What stage of the scientific method will someone be at if they make a prediction that drinking alcohol?

Objective  To review the latest studies on risk and protective factors for the development of substance abuse and the effectiveness of prevention interventions for the pediatric population.

Data Sources  Multiple bibliographic databases, including MEDLINE and ERIC, were used to develop a comprehensive review of the literature on substance abuse prevention during the last 10 years. Selected indexing terms included substance abuse prevention, risk factors, and protective factors . Research monographs from the National Institute on Drug Abuse and the Center for Substance Abuse Prevention were used, along with information from authors of prevention curricula.

Study Selection  Study populations included children from birth through adolescence who were enrolled in controlled, prospective, and/or longitudinal studies of either protective or risk factors for the development of substance abuse or response to substance abuse prevention programs. Studies of adult patients that investigated predisposing risk factors for substance abuse (eg, genetic implications) were also used. Care was taken to ensure studies included children from diverse racial and social backgrounds.

Data Extraction  Information was abstracted and summarized from peer-reviewed publications. Controlled random-designed studies were used to determine prevention program efficacy.

Data Synthesis  Main results of the review are summarized in a qualitative format.

Conclusions  Factors that contribute to the emergence of substance abuse in the pediatric population are multifactorial. Behavioral, emotional, and environmental factors that place children at risk for the development of substance abuse may be remediated through prevention and intervention programs that use research-based, comprehensive, culturally relevant, social resistance skills training and normative education in an active school-based learning format.

THE DIRECT and indirect effects of alcohol and other drugs on children lead to many adverse health and safety risks for the child, family, and community. Understanding risk and protective factors that may affect the development of substance abuse is a first step in ameliorating the problem of drug use in the pediatric population. This article reviews the literature on the prediction, protection, and prevention of substance abuse in the pediatric population, including a list of available prevention programs for children across the age continuum.

The younger a child initiates alcohol and other drug use, the higher the risk for serious health consequences and adult substance abuse.1-4 Fatalities, accidental and intentional, that are associated with drug and alcohol use in the adolescent population represent one of the leading preventable causes of death for the 15- to 24-year-old population.5-7 Alcohol and other drug use in the adolescent population carries a higher risk for school underachievement, delinquency, teenage pregnancy, and depression.8-16 Inadvertent passive drug exposure in infants and toddlers has resulted in multiple medical complications including respiratory illnesses, seizures, altered mental status, and death.17-23

Illicit drug use is associated with an increased risk of contracting human immunodeficiency virus (HIV). The sharp rise in pediatric HIV infection from 1985 to 1990 paralleled the occurrence of the crack cocaine epidemic. In 1990, 68% of perinatally acquired HIV infection was attributable to intravenous drug abuse in one or both of the child's parents.24 Even without a history of intravenous drug use, an alcohol- and drug-abusing lifestyle places the abuser, partners, and unborn children at risk for HIV infection due to impaired judgment, reduction of inhibitions, and sex-for-drugs.1,7,25

The American Academy of Pediatrics Committee on Substance Abuse recommends that pediatricians have the skills to detect drug-related problems in their patients and their patients' family members and are knowledgeable about the extent of drug use and availability of drug treatment resources (including those for alcohol and tobacco) in their community.26 Pediatric health care providers are often called on to be a consultant for parents, schools, and the community on topics related to alcohol and other drug use. In this capacity, knowledge about available drug and alcohol prevention curricula and their researched effectiveness is of utmost importance. Some of the more widely available curricula have had modest to no significant improvements in drug use patterns yet, through sophisticated marketing, have been implemented in many school districts. Many prevention curricula targeted for the preschool population have limited random-design prospective research to document the programs' efficacy. Proactive approaches by pediatric health care providers to recommend the use of effective validated universal, selective, and indicated prevention curricula will assist community, public health, and school officials in their decisions to select and implement prevention programs.

The trend of drug use derived from the analysis of the 10th annual survey of 147077 students by the National Parents' Resource Institute for Drug Education for the 1996-1997 school year showed a increase in the monthly use of marijuana, cocaine, stimulants, sedatives, hallucinogens, and heroin among sixth- to eighth-graders when compared with the previous academic year.27 Conversely, drug use among high school students did not show an increase for the first time since the 1991-1992 school year. The most recent data from the 23rd national survey from the University of Michigan's Monitoring the Future study also demonstrated that, although marijuana use continues to rise in older adolescents, the use of other illicit drugs has begun to level off.28 Monitoring the Future data is derived from the 1997 survey of 51000 eighth-, 10th-, and 12th-grade students located in 429 secondary schools across the nation. This study reported that, for the first time in 6 years, marijuana and other illicit drug use was unchanged among eighth-graders; in addition, there was a concurrent increase in disapproval of marijuana use among these students. Binge drinking, defined as 5 or more drinks on one occasion, remains problematic, occurring in 15%, 25%, and 31% of the 8th-, 10th-, and 12th-graders, respectively. According to the Drug Use Among Racial/Ethnic Minorities 1995 data from the National Institute on Drug Abuse, rates of drug use are higher for white students for all categories of drug use, with the exception of 12th-grade Hispanic youth, who had the highest annual prevalence of cocaine use from 1984 to 1994.29

Although the use of illicit drugs has leveled off in some of the adolescent population for the first time since the early 1990s, we must, as stated in the words of Lloyd D. Johnston, PhD, principal investigator for the Monitoring the Future Study,

learn[ed] from the relapse in the drug epidemic in the 1990s that drug use among kids is a persistent and recurring problem—one which needs consistent and unremitting attention. It is a long-term problem, which means that we must institutionalize prevention efforts....28

The importance of this early use is that it places the child on a deleterious trajectory for future drug use. If a child smoked tobacco or drank alcohol, they were 65 times more likely to use marijuana than a child who never smoked or drank. Children who used marijuana were 104 times as likely to use cocaine compared with their peers who never used marijuana.29

Addiction develops from a complex interplay between the individual, the agent (drugs and alcohol), and the environment. The initiation of first drug use is determined by interactions between social, cognitive, cultural, attitudinal, personality, and developmental factors. The earliest influences to smoke, drink alcohol, or use drugs may come from the family. Factors that are related to drug use during adolescence include poor self-image, low religiosity, poor school performance, parental rejection, family dysfunction, abuse, under- or over-controlling by parents, and divorce.10,15,30-34

Behavior, Affect, and Temperament

Risk factors for the development of externalizing disorders are found in the preschool years. McMahon35 describes the development of conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder (ADHD) in the preschool years as continuous throughout the child's developmental stages. These disorders may initially present with relatively mild behavior problems and progress to severe symptoms such as stealing, aggression, and substance abuse.

Temperament difficulties may exacerbate childhood troublesome behaviors and result in an insecure attachment with the child's primary caregiver. Difficult temperament, characterized by moodiness, negativity, poor compliance, and provocativeness, may lead to the child being criticized and ostracized by parents. The resultant parent-child interactions may lead to the coercive model of parenting that is often present in families who have children with substance abuse and delinquency.35

Hyperactivity in childhood imparts a higher risk of later development of adult alcoholism and substance abuse.36-39 High activity level in infancy was found to predict later substance abuse in both sexes in a large prospective study of African American subjects.40 Some preliminary studies suggest that children who were treated for ADHD were less likely to initiate drug and alcohol use in early adolescence.41-44 In a recent study by Biederman et al,39 rates of substance abuse in adolescents with ADHD (without comorbid conduct disorder) were not significantly different from rates of substance abuse in a control cohort without ADHD. Childhood aggression has been reported to place a child at risk for adolescent substance abuse.45 High novelty-seeking and low harm-avoidance behaviors place boys at risk for early drug initiation.46 In a longitudinal study, frequent early use of drugs was associated with violent behavior.9

Peer influence plays a pivotal role in the initiation of tobacco and drug usage.10,47 Peer pressure may be a factor not only in drug use but also in drug abstinence. Peer cross-pressure,48 that is, the opposing influences on individuals exerted by the choices they make or by their socioeconomic standing or social group membership, may play a role in initiation of drug use. The study by Robin and Johnson49 on peer cross-pressure found adolescents believed their peers' general attitude was against drug use. With the exception of alcohol, there was a direct relationship between peer cross-pressure and subsequent drug use; the lower the acceptance of drug use, the less frequent the drug use. The higher the perceived risk, the lower the drug use.28 Other studies suggest that children predisposed to use drugs may seek out others with similar inclinations. Adolescents whose drug use is influenced by peer pressure, in the absence of psychological dysfunction, are more likely to stop using drugs.50-52

Biological children of alcohol-dependent parents who have been adopted continue to have an increased risk (2- to 9-fold) of developing alcoholism.53-57 Researchers discovered differences in inheritance patterns between type I, "milieu-limited," adult-onset alcoholism (that is associated with a passive-dependent personality) vs type II, "male-limited," early-onset alcoholism (that is more associated with criminal behavior). The transmission of type II alcoholism, from father to son, demonstrated a high heritability despite environmental factors.58 Behaviors such as frequency of drinking and amount consumed demonstrate moderate heritability of 0.39 and 0.36, respectively.59 Further, studies of siblings and twins born to parents who are drug dependent have confirmed the existence of a genetic predisposition not only for alcohol abuse but also for other drugs of abuse.60-62 Researchers have found a relationship between the presence of the A1 allele of the dopamine D2 receptor gene and alcoholism.63 The presence of the A1 allele correctly identified 77% of the alcoholics in a study of brain tissue taken from 70 nonalcoholic and alcoholic cadavers. It was hypothesized that this receptor gene, located on the q22-q23 region of chromosome 11, may confer increased probability for the development of alcoholism. Other studies suggest that the dopamine D2 receptor locus may serve as a gene that modifies expression of severe psychiatric disorders, rather than being a marker for alcoholism.64

Illicit drug use by men has twice the reported prevalence rate of women's drug use.29 Heavy alcohol use is almost 3 times more frequent in men. The trajectory for these patterns of drug use may be found in childhood, where drug use is generally higher in boys than in girls.65 Heavy alcohol and tobacco use is found more frequently in male students than in their female peers.65

In their long-term study, Block et al30 found that there were remediable psychosocial and behavioral risk factors in 3- and 4-year-olds that predicted drug use during adolescence. Notably, risk factors differed by sex. In short, for girls, the absence of resiliency (ie, skills that allow a person to cope with adverse situations) and the lack of self-control during early childhood predict both marijuana and hard drug use in adolescence. In boys, lack of self-control is strikingly important. Involvement with harder drugs seemed to represent an extension of the behavioral characteristics that predisposed to marijuana use in boys, while in girls additional psychopathological characteristics were usually present when harder drug use was evidenced. In another study, Luthar et al66 reported that women who abused drugs had a higher incidence of internalizing problems, eg, depression, anxiety, and withdrawn behaviors, during childhood and had more severe psychiatric symptoms as adults. Conduct disorders were found more frequently in men who were in treatment for drug abuse.

Childhood abuse has been implicated as a significant risk factor for later substance abuse.67,68 Women who were physically abused were 1.58 times as likely to abuse drugs than their nonabused adult counterparts, even after controlling for family history of substance abuse.68

Girls seem to be more influenced by environmental factors in the home. Unkempt, crowded, noisy, disorderly conditions where there is little emphasis on conventions and religion are very potent predictors of later drug use in girls.30 For boys, family environment had only chance association with later marijuana use.30

Eighth-graders who took care of themselves after school had a significantly higher risk of using alcohol, tobacco, and marijuana.69 Risk increased with longer duration of self-care, such that the relative risk for alcohol use for children in self-care for 11 hours per week or more was 2 for alcohol, 2.1 for tobacco, and 1.7 for marijuana. Children who were quick to anger, perceived themselves to be stressed, were resentful of parents' absence, or from families with conflicts had high drug use rates. These findings were confirmed by later studies including that of Chilcoat and Anthony70 who studied 926 youths and found children in the lowest quartile of parent monitoring initiated drug use at earlier ages.

The percentage of children aged 12 to 17 years who have seen people selling drugs is higher in the African American community than in communities with a majority of white or Hispanic children (41.2% vs 7.4% and 23.9%, respectively). More African American children aged 12 to 17 years are exposed to people who are high or drunk (55.7%) than children of other ethnic groups.29 The percentage of children reporting that obtaining illicit drugs is fairly or very easy is higher among African American and Hispanic youth when compared with their white peers. Despite this exposure, African American adolescents have a lower reported rate of drug use than their white peers.29 The work of Crum et al71 found an association between neighborhood disadvantage and exposure to cocaine. Youths living in the most disadvantaged areas were more than 5 times as likely to be offered cocaine as compared with those in more advantaged areas.

Protective factors are characteristics within the individual, the family, and the environment that advance one's ability to resist adverse outcomes. Protective factors for the pediatric population include growing up in a nurturing home with open communication with parents and positive parental support.72-74 Teacher commitment to didactics and maintenance of low dissension are also protective.75 Positive self-esteem, self-concept, self-control, assertiveness, social competence, and academic achievement all promote resistance to drug use.74,76,77 In addition, regular church attendance and a sense of morality have been shown to be protective against drug abuse.78,79

Protective factors instill the individual with resiliency. Resiliency is the property of an individual to overcome a negative set of life circumstances. Adolescent resiliency is associated with high intelligence, low novelty-seeking behaviors, and avoidance of friendships with delinquent peers.80

The Challenge Model81,82 uses the principles of resiliency to focus on individuals' capacity to respond and manage their lives. A chaotic family environment does not necessarily cause a child to be forever damaged. Where the risk-protective equation implies the tallying of factors, the Challenge Model asserts that individuals can achieve beyond the negative factors in their lives; in essence, resiliency. The Challenge Model delineates 7 principles that facilitate an individual's adaptive and healthy development. These include insight, independence, relationships, initiative, humor, creativity, and morality. As conceptualized in the work of Newcomb and Felix-Ortiz,83 consideration and attention to both protective factors and risk factors are fundamental in developing effective prevention strategies.

Prevention efforts prior to 1970 were based on an information-deficit approach. The assumption was that children lacked adequate knowledge regarding the effects of drug use. Thus, prevention efforts involved the dissemination of information. During the 1970s through 1980s, prevention efforts focused on social and interpersonal influence models. The theory underlying this approach postulated that youth experimented with drugs and alcohol because they had not fully developed their own internal value system to resist external pressures. The prevention programs of the 1990s offer a comprehensive systems approach. They are research-based, age-appropriate, culturally relevant interactive resistance models. These prevention programs promote protective factors while reducing risk factors using school-based curricula that include social resistance skills training and normative education.84-92 Social resistance skills training seems to be readily adapted for multiple ethnic groups.85,93-95 Normative education teaches students that most youngsters do not use drugs. Active learning techniques are the primary teaching modality, as opposed to passive didactics. Small-group, role-playing, and interactive learning techniques are imperative in these programs.

Prevention curricula have been developed for children from preschool ages to young adulthood. Young children are increasingly likely to feel pressure to drink alcohol and use drugs.96 Children are also increasingly vulnerable to the temptation of drug usage during periods of transition. The adolescence period represents the greatest risk for substance abuse.97

Programs in prevention have developed a new nomenclature to denote the target audience and focus of the program. Programs are designated as universal, selective, or indicated . Universal interventions are designed to address a general population, such as a community or school. Selective curricula target an at-risk population, such as those curricula that are designed for children whose parents have drug or alcohol dependence. Indicated programs target individuals who already demonstrate the problem behavior or have other high-risk behaviors related to initiating the target behavior.

Research on the effectiveness of prevention curricula have generally focused on universal programs that target children in junior high and high school. One researched intervention that targets the elementary school child is the Seattle Social Development Project. Based on the theory that the greater the number of childhood risk factors the greater the likelihood of child delinquency and drug use, the Seattle Social Development Project employed a model of intervention focusing on both family- and school-based interventions in grades 1 through 4 to enhance protective factors against delinquency and substance abuse. The study by Hawkins et al98 supports the presence of reduced incidents of drug use, antisocial and disruptive behaviors, and improved school performance following the implementation of the Seattle Social Development Project.

Among the most widely disseminated and promoted curricula are the Drug Abuse Resistance Education curricula (DARE). Despite DARE's popularity in US schools, studies have found little difference in drug use patterns among students who have participated in the curriculum compared with cohorts who have not received the DARE program.99,100 Significant differences, however, were noted in students' attitudes toward drug use, knowledge regarding drugs, social skills, and attitudes regarding police officers.100 Though the data on drug use patterns following the initiation of the DARE program are disappointing, a solution to this dilemma may be to integrate DARE with broad-based, research-proven prevention programs.

Life Skills Training was found to be effective in lowering tobacco, alcohol, and marijuana use in a 6-year long-term randomized field trial involving 3597 New York State students in 56 high schools.101-103 Beginning in the seventh grade and continuing until the ninth grade, Life Skills Training integrates up to 18 sessions in the initial year, 10 booster sessions in the second year, and 5 booster sessions in the third year of implementation. Life Skills Training uses resistance skill training in a broader framework of self-improvement and interpersonal social skills development. Recent studies supported the effectiveness of the program in minority inner-city populations.93-95,104,105 Project ALERT106 and STAR107,108 are universal prevention programs that have demonstrated efficacy in the reduction of drug use. Project ALERT includes normative education and resistance skills development to promote drug abstinence. Project ALERT spans seventh and eighth grade with 8 and 3 sessions, respectively. Project STAR , using a resistance skills model, was integrated into 15 Kansas City, Mo, communities, involving more than 22000 adolescents. Interestingly, the programs both have a classroom component. In addition, Project STAR endeavors to involve the media, community organizations, and health policy officials as well as parents in a comprehensive network of activities.

Efficacy of preschool prevention curricula are largely undocumented in controlled randomized outcome studies. Curricula that target elementary school students have not been studied with the same fervor as curricula designed for adolescents. Included in Table 1 are a representative sample of some of the more widely available and used prevention materials as noted in Center for Substance Abuse Prevention and National Institute on Drug Abuse publications. An asterisk has been placed by curricula that have proven efficacy in peer-reviewed outcome studies. There are many sources for obtaining information regarding available prevention materials for children and adolescents. Recommended federal resources include the Substance Abuse and Mental Health Services Administration's National Clearinghouse for Alcohol and Drug Information (1-800-729-6686 [http://www.health.org]); National Institute on Drug Abuse (1-800-729-6686 [http://www.nida.nih.gov]); and National Institute on Alcohol Abuse and Alcoholism (1-800-729-6686 [http://www.niaaa.nih.gov]). Inclusion of prevention programs in Table 1 is not meant to represent endorsement or approval of programs by the authors or this journal.

Table 1a. 

Pediatric Substance Abuse Prevention Programs

Table 1b. 

Pediatric Substance Abuse Prevention Programs

Knowledge development and dissemination in the field of substance abuse prevention relies, in part, on the review of studies outside general pediatric literature. Multiple disciplines, including public health, psychiatry, psychology, education, and criminal justice have participated in developing a body of knowledge on the risk and protective factors and the effectiveness of prevention programs. This review provides a synopsis of pertinent studies and available prevention programs for the pediatric population.

Although much is known about the risk factors that lead to initiation of drug abuse, early intervention strategies targeting preschool and elementary school students are underrepresented in research literature. Further studies are necessary to develop alcohol and drug prevention programs that will have sustained effects across the age continuum. Understanding the risk factors that lead to substance abuse is paramount for the early identification and prevention of substance abuse in children. Active participation by pediatric health care providers in promotion of programs that enhance protective factors and social skills development through interactive child and parent curricula, while collaborating with communities and schools, will indemnify children against drug abuse. Careful evaluation of prevention program effectiveness for preschool to high school students is of utmost importance. Finally, to echo the words of Johnston, substance abuse in children is a complex multifactorial challenge that requires "consistent and unremitting attention."28

Accepted for publication March 23, 1998.

This work was supported by grant SAMHSA/CSAP, 5 T26 SP07777 from the Substance Abuse and Mental Health Services Administration Substance Abuse Faculty Development Program, Baltimore, Md.

Reprints: Harolyn M. E. Belcher, MD, The Kennedy Krieger Institute, 707 N Broadway, Baltimore, MD 21205 (e-mail: ).

1.

Fergusson  DMLynskey  MT Alcohol misuse and adolescent sexual behaviors and risk taking.  Pediatrics. 1996;9891- 96Google Scholar

3.

Tennant  FSDetels  R Relationship of alcohol, cigarette, and drug abuse in adulthood with alcohol, cigarette, and coffee consumption in childhood.  Prevent Med. 1976;570- 77Google ScholarCrossref

4.

Wu  TCTashkin  DPDjahed  BRose  JE Pulmonary hazards of marijuana as compared with tobacco.  N Engl J Med. 1988;318347- 351Google ScholarCrossref

5.

Not Available, Advance Report of Final Mortality Statistics, 1989.  Hyattsville, Md National Center for Health Statistics1992;81- 52Vital and Health Statistics, No. 40

6.

Schwartz  RHHayden  GFGetson  PRDiPaola  A Drinking patterns and social consequences: a study of middle-class adolescents in two private pediatric practices.  Pediatrics. 1986;77139- 143Google Scholar

7.

Smith  DESchwartz  RHMartin  DM Heavy cocaine use by adolescents.  Pediatrics. 1989;83539- 542Google Scholar

8.

Cornelius  MDTaylor  PMGeva  DDay  NL Prenatal tobacco and marijuana use among adolescents: effects on offspring gestational age, growth, and morphology.  Pediatrics. 1995;95738- 743Google Scholar

9.

Friedman  ASKramer  SKreisher  CGranick  S The relationships of substance abuse to illegal and violent behavior in a community sample of young adult African American men and women (gender differences).  J Subst Abuse. 1996;8379- 402Google ScholarCrossref

10.

Jessor  RJessor  SL Problem Behavior and Psychological Development: A Longitudinal Study of Youth.  New York, NY Academic Press1977;

11.

Kokotailo  PKAdger  HDuggan  AKRepke  JJoffe  A Cigarette, alcohol, and other drug use by school-age pregnant adolescents: prevalence, detection, and associated risk factors.  Pediatrics. 1992;90328- 334Google Scholar

12.

Pletsch  P Substance use and health activities of pregnant adolescents.  J Adolesc Health Care. 1988;938- 45Google ScholarCrossref

13.

Ringwalt  CLPalmer  JH Cocaine and crack users compared.  Adolescence. 1989;24851- 859Google Scholar

14.

Schwartz  RHLuxenberg  MGHoffman  NG "Crack" use by American middle-class adolescent polydrug abusers.  J Pediatr. 1991;118150- 155Google ScholarCrossref

15.

Smith  GMFogg  CP Psychological predictors of early use, late use, and nonuse of marijuana among teenage students. Kandel  DBed. Longitudinal Research on Drug Use New York, NY John Wiley & Sons Inc1978;101- 113Google Scholar

16.

Zuckerman  BAmaro  HBeardslee  W Mental health of adolescent mothers: the implications of depression and drug use.  J Dev Behav Pediatr. 1987;8111- 116Google ScholarCrossref

18.

Bateman  DAHeagarty  MC Passive freebase cocaine ("crack") inhalation by infants and toddlers.  AJDC. 1989;14325- 27Google Scholar

20.

Chasnoff  IJLewis  DESquires  L Cocaine intoxication in a breast-fed infant.  Pediatrics. 1987;80836- 838Google Scholar

21.

Kharasch  SJGlotzer  DVinci  RWeitzman  MSargent  J Unsuspected cocaine exposure in young children.  AJDC. 1991;145204- 206Google Scholar

22.

Rivkin  MGilmore  HE Generalized seizures in an infant due to environmentally acquired cocaine.  Pediatrics. 1989;841100- 1101Google Scholar

23.

Rosenberg  NMMeert  KLKnazik  SRYee  HKauffman  RE Occult cocaine exposure in children.  AJDC. 1991;1451430- 1432Google Scholar

24.

Centers for Disease Control, AIDS in the Pediatric Population [slide presentation].  Atlanta, Ga Centers for Disease Control1990;

25.

Stall  RMcKusick  LWiley  J Alcohol and drug use during sexual activity and compliance with safe sex guidelines for AIDS: the AIDS Behavioral Research Project.  Health Educ Q. 1986;13359- 371Google ScholarCrossref

26.

Heyman  RBJoffe  AAnglin  TM Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse.  Pediatrics. 1998;101125- 128Google ScholarCrossref

27.

Not Available, Survey shows rising drug use among students in junior high.  Subst Abuse Lett. 1997;47Google Scholar

28.

Johnston  LD Monitoring the Future Study [press release].  Ann Arbor, Mich NewsInfo1997;

29.

Not Available, National Institute on Drug Abuse: Drug Use Among Racial/Ethnic Minorities 1995.  Rockville, Md National Institute of Drug Abuse1995;NIH publication No. 95-3888

30.

Block  JBlock  JKeyes  S Longitudinally foretelling drug use in adolescence: early childhood personality and environmental precursors.  Child Dev. 1988;59336- 355Google ScholarCrossref

31.

Blum  RRichards  L Youthful drug use. Dupont  RIGoldstein  AO'Donnell  Jeds. Handbook on Drug Abuse Washington, DC US Government Printing Office1979;257- 267Google Scholar

32.

Bry  B Empirical foundations of family-based approaches to adolescent substance abuse. Glynn  TJLeukefeld  CGLudford  JPeds. Preventing Adolescent Drug Abuse: Intervention Strategies Washington, DC US Government Printing Office1983;154- 171DHHS publication No. ADM 83-1280Google Scholar

33.

Jessor  RJessor  SL Adolescent development and the onset of drinking.  J Stud Alcohol. 1975;3627- 51Google Scholar

34.

Kellam  SGBrown  CHRubin  BREnsminger  ME Paths leading to teenage psychiatric symptoms and substance abuse: developmental epidemiological studies in Woodlawn. Guze  SMEarls  FJBarrett  JEeds. Childhood Psychopathology and Development New York, NY Raven Press1983;17- 47Google Scholar

35.

McMahon  RL Diagnosis, assessment and treatment of externalizing problems in children: the role of longitudinal data.  J Consult Clin Psychol. 1994;62901- 917Google ScholarCrossref

36.

Kramer  JLoney  J Childhood hyperactivity and substance abuse: a review of the literature. Gadow  KDBialer  Ieds. Advances in Learning and Behavioral Disabilities. Vol 1 Greenwich, Conn JAI Press1981;Google Scholar

37.

Kramer  JLoney  JWhaley-Klahn  MA The role of prescribed medication in hyperactive youths' substance abuse.  Paper presented at: American Psychological Association Annual Meeting August 24, 1981 Los Angeles, Calif

38.

Weiss  GHechtman  L Hyperactive Children Grown-Up.  New York, NY Guilford Press1986;

39.

Biederman  JFaraone  SVTaylor  ASienna  MWilliamson  SFine  C Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample.  J Am Acad Child Adolesc Psychiatry. 1998;37305- 313Google ScholarCrossref

40.

De Obaldia  RParsons  OA Relationship of neuropsychological performance to primary alcoholism and self-reported symptoms of childhood minimal brain dysfunction.  J Stud Alcohol. 1984;45386- 392Google Scholar

41.

Greenfield  BHechtman  LWeiss  G Two subgroups of hyperactives as adults: correlation of outcome.  Can J Psychiatry. 1988;33505- 508Google Scholar

42.

Horner  BRScheibe  KE Prevalence and implications of attention-deficit hyperactivity disorder among adolescents in treatment for substance abuse.  J Am Acad Child Adolesc Psychiatry. 1997;3630- 36Google ScholarCrossref

43.

Tarter  RMcBride  HBuonpane  NSchneider  D Differentiation of alcoholics according to childhood history of minimal brain dysfunction, family history and drinking pattern.  Arch Gen Psychiatry. 1977;34761- 768Google ScholarCrossref

44.

Friedman  ASGranick  SBransfield  SKreisher  CKhalsa  J Gender differences in early life risk factors for substance use/abuse: a study of an African American sample.  Am J Drug Alcohol Abuse. 1995;21511- 531Google ScholarCrossref

45.

Brook  JSWhiteman  MFinch  SJCohen  P Young adult drug use and delinquency: childhood antecedents and adolescent mediators.  J Am Acad Child Adolesc Psychiatry. 1996;351584- 1592Google ScholarCrossref

46.

Masse  LCTremblay  RE Behavior of boys in kindergarten and the onset of substance use during adolescence.  Arch Gen Psychiatry. 1997;5462- 68Google ScholarCrossref

47.

Kandel  DBSimcha-Fagan  ODavies  M Risk factors for delinquency and illicit drug use from adolescence to young adulthood.  J Drug Issues. 1986;1667- 90Google Scholar

48.

Berelson  BRSteiner  GA Human Behavior: An Inventory of Scientific Findings.  New York, NY Harcourt Brace & World1964;

49.

Robin  SSJohnson  EO Attitude and peer cross pressure: adolescent drug and alcohol use.  J Drug Educ. 1996;2669- 99Google ScholarCrossref

51.

Kandel  DBLogan  JA Patterns of drug use from adolescence to young adulthood: periods of risk initiation, continued use and discontinuation.  Am J Public Health. 1984;74660- 666Google ScholarCrossref

52.

Kandel  DBRavies  VH Cessation of illicit drug use in young childhood.  Arch Gen Psychiatry. 1989;46109- 116Google ScholarCrossref

53.

Bohman  MCloninger  CRSigvardsson  Svon Knorring  AL The genetics of alcoholism and related disorders.  J Psychiatr Res. 1987;21447- 452Google ScholarCrossref

54.

Cloninger  CRBohman  MSigvardsson  S Inheritance of alcohol abuse.  Arch Gen Psychiatry. 1981;38861- 868Google ScholarCrossref

55.

Goodwin  DWSchulsinger  FHermansen  LGuze  SBWinokur  G Alcohol problems in adoptees raised apart from alcoholic biological parents.  Arch Gen Psychiatry. 1973;28238- 243Google ScholarCrossref

56.

Goodwin  DWSchulsinger  FKnop  JMednick  SAGuze  SB Alcoholism and depression in adopted-out daughters of alcoholics.  Arch Gen Psychiatry. 1977;34751- 775Google ScholarCrossref

57.

Hrubek  ZOmenn  GS Evidence of genetic predisposition to alcoholic cirrhosis and psychosis: twin concordances for alcoholism and its biologic end-points by zygosity among male veterans.  Alcohol Clin Exp Res. 1981;5207- 215Google ScholarCrossref

58.

Cloninger  CRSigvardsson  SGilligan  SBvon Knorring  ALReich  TBohman  M Genetic heterogeneity and the classification of alcoholism. Gordis  ETabakoff  BLinnoila  Meds. Alcohol Research From Bench to Bedside New York, NY Haworth2989;3- 16Google Scholar

59.

Partanen  JBruun  KMarkanen  T Inheritance of Drinking Behavior.  Helsinki, Finland Gound Alcohol Studies1966;

60.

Comings  DE Genetic aspects of childhood behavioral disorders.  Child Psychiatry Hum Dev. 1997;27139- 150Google ScholarCrossref

61.

Miller  NSGold  MSBelkin  BMKlahr  AL The diagnosis of alcohol and cannabis dependence in cocaine dependents and alcohol dependence in their families.  Br J Addict. 1989;841491- 1498Google ScholarCrossref

62.

Schuckit  MAGoodwin  DAWinokur  G A study of alcoholism in half siblings.  Am J Psychiatry. 1972;1281132- 1136Google Scholar

63.

Blum  KNobel  EPSheridan  PJ Allelic association of human dopamine D2receptor gene in alcoholism.  JAMA. 1990;2632055- 2060Google ScholarCrossref

64.

Comings  DEComings  BGMuhleman  D The dopamine D2 receptor locus as a modifying gene in neuropsychiatric disorder.  JAMA. 1991;2661793- 1799Google ScholarCrossref

65.

O'Malley  PMJohnston  LDBachman  JG Adolescent substance use: epidemiology and implications for public policy.  Pediatr Clin North Am. 1995;42241- 260Google Scholar

66.

Luthar  SSCushing  GRounsaville  BJ Gender differences among opioid abusers: pathways to disorder and profiles of psychopathology.  Drug Alcohol Depend. 1996;43179- 189Google ScholarCrossref

67.

Bennett  EMKemper  KJ Is abuse during childhood a risk factor for developing substance abuse problems as an adult?.  J Dev Behav Pediatr. 1994;15426- 429Google ScholarCrossref

68.

Wilsnack  SCVogeltanz  NDKlassen  ADHarris  TR Childhood sexual abuse and women's substance abuse: national survey findings.  J Stud Alcohol. 1997;58264- 271Google Scholar

69.

Richardson  JLDwyer  KMcGuigan  K Substance use among eighth-grade students who take care of themselves after school.  Pediatrics. 1989;84556- 566Google Scholar

70.

Chilcoat  HDAnthony  JC Impact of parent monitoring on initiation of drug use through late childhood.  J Am Acad Child Adolesc Psychiatry. 1996;3591- 100Google ScholarCrossref

71.

Crum  RMLillie-Blanton  MAnthony  JC Neighborhood environment and opportunity to use cocaine and other drugs in late childhood and early adolescence.  Drug Alcohol Depend. 1996;43155- 161Google ScholarCrossref

72.

Climent  CEdeAragon  LVPlutchik  R Prediction of risk for drug use in high school students.  Int J Addict. 1990;25545- 556Google Scholar

73.

Kafka  RRLondon  P Communication in relationships and adolescent substance use: the influence of parents and friends.  Adolescence. 1991;26587- 598Google Scholar

74.

Wills  TAVaccaro  DMcNamara  G The role of life events, family support, and competence in adolescent substance use: a test of vulnerability and protective factors.  Am J Community Psychol. 1992;20349- 374Google ScholarCrossref

75.

Brook  JSNomura  CCohen  P A network of influences on adolescent drug involvement: neighborhood, school, peer, and family.  Genet Soc Gen Psychol Monogr. 1989;115123- 145Google Scholar

76.

Werner  EE Resilient offspring of alcoholics: a longitudinal study from birth to age 18.  J Stud Alcohol. 1986;4734- 40Google Scholar

78.

Hawkins  JDCatalano  RFMiller  JY Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention.  Psychol Bull. 1992;11264- 105Google ScholarCrossref

79.

Selnow  GWCrano  WD Formal vs informal group affiliations: implications for alcohol and drug use among adolescents.  J Stud Alcohol. 1986;4748- 52Google Scholar

80.

Fergusson  DMLynskey  MT Adolescent resiliency to family adversity.  J Child Psychol Psychiatry. 1996;37281- 292Google ScholarCrossref

81.

Wolin  SWolin  S The Resilient Self: How Survivors of Troubled Families Rise Above Adversity.  New York, NY Villard Books1993;

82.

Wolin  SWolin  S Resilience among youth growing up in substance-abusing families.  Pediatr Clin North Am. 1995;42415- 429Google Scholar

83.

Newcomb  MDFelix-Ortiz  M Multiple protective and risk factors for drug use and abuse: cross-sectional and prospective findings.  J Pers Soc Psychol. 1992;63280- 296Google ScholarCrossref

84.

Bangert-Drowns  RL The effects of school-based substance abuse education: a meta-analysis.  J Drug Educ. 1988;18243- 264Google ScholarCrossref

85.

Botvin  GJBotvin  EM School-based and community-based prevention approaches. Lowinson  JRuiz  PMillman  Reds. Comprehensive Textbook of Substance Abuse Baltimore, Md Williams & Wilkins1992;910- 927Google Scholar

86.

Bruvold  WH A meta-analysis of the California school-based risk reduction program.  J Drug Educ. 1990;20139- 152Google ScholarCrossref

87.

Bruvold  WH A meta-analysis of adolescent smoking prevention programs.  Am J Public Health. 1993;83872- 880Google ScholarCrossref

88.

Bruvold  WHRundall  TG A meta-analysis and theoretical review of school-based risk reduction programs.  Psychol Health. 1988;253- 78Google ScholarCrossref

89.

Hansen  WB School-based substance abuse prevention: a review of the state of the art in curriculum, 1980-1990.  Health Educ Res. 1992;7403- 430Google ScholarCrossref

90.

Hansen  WB School-based alcohol prevention programs.  Alcohol Health Res World. 1993;1754- 60Google Scholar

92.

Tobler  NS Meta-analysis of adolescent drug prevention programs: results of the 1993 meta-analysis. Bukoski  WJed. National Institute on Drug Abuse Research Monograph Series: Meta-analysis of Drug Prevention Programs Rockville, Md National Institute on Drug Abuse1997;5- 68NIH publication No. 97-4146Google Scholar

93.

Botvin  GJDusenbury  LBaker  EJames-Ortiz  SKerner  J A skills training approach to smoking prevention among Hispanic youth.  J Behav Med. 1989;12279- 296Google ScholarCrossref

94.

Botvin  GJBatson  HWWitts-Vitale  SBess  VBaker  EDusenbury  L A psychosocial approach to smoking prevention for urban black youth.  Public Health Rep. 1989;104573- 582Google Scholar

95.

Botvin  GJSchinke  SPEpstein  JADiaz  T Effectiveness of culturally focused and generic skills training approaches to alcohol and drug abuse prevention among minority youths.  Psychol Addict Behav. 1994;8116- 127Google ScholarCrossref

96.

US Department of Education, Children and drugs: how drug use develops.  What Works: Schools Without Drugs Washington, DC US Dept of Education1992;7Google Scholar

97.

US Department of Health and Human Services, National High School Senior Survey [press release].  Washington, DC US Dept of Health and Human Services1991;

98.

Hawkins  JDCatalano  RFMorrison  DMO'Donnell  JAbbott  RDDay  LE The Seattle social development project: effects of the first four years on protective factors and problem behaviors. McCord  JTemblay  Reds. The Prevention of Antisocial Behavior in Children New York, NY Guilford Press1992;139- 161Google Scholar

99.

Clayton  RRCattarello  AMJohnstone  BM The effectiveness of drug abuse resistance education (Project DARE): 5-year follow-up results.  Prev Med. 1996;25307- 318Google ScholarCrossref

100.

Ennet  STTobler  NSRingwalt  CLFlewelling  RL How effective is drug abuse resistance education? a meta-analysis of Project DARE outcome evaluations..  Am J Public Health. 1994;841394- 1401Google ScholarCrossref

101.

Botvin  GJBaker  EDusenbury  LTortu  SBotvin  E Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: results of a three-year study.  J Consult Clin Psychol. 1990;58437- 446Google ScholarCrossref

102.

Botvin  GJBaker  EFilazzola  ADBotvin  EM A cognitive-behavioral approach to substance abuse prevention: one-year follow-up.  Addict Behav. 1990;1547- 63Google ScholarCrossref

103.

Botvin  GJBaker  EDusenbury  LBotvin  EMDiaz  T Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population.  JAMA. 1995;2731106- 1112Google ScholarCrossref

104.

Botvin  GJDusenbury  LDBaker  E Smoking prevention among urban minority youth: assessing effects on outcome and mediating variables.  Health Psychol. 1992;11290- 299Google ScholarCrossref

105.

Botvin  GJSchinke  SPEpstein  JA Effectiveness of culturally focused and generic skills training approaches to alcohol and drug prevention among minority adolescents: two-year follow-up results.  Psychol Addict Behav. 1995;9183- 194Google ScholarCrossref

106.

Ellickson  PLBell  RMHarrison  ER Changing adolescent propensities to use drugs: results from Project ALERT.  Health Educ Q. 1993;20227- 242Google ScholarCrossref

107.

Pentz  MADwyer  JHMacKinnon  DP A multi-community trial for primary prevention of adolescent drug abuse: effects on drug use prevalence.  JAMA. 1989;2613259- 3266Google ScholarCrossref

108.

Pentz  MA The school-community interface in comprehensive school education. Stansfield  Sed. 1996 Institute of Medicine Annual Report, Committee on Comprehensive School Health Programs Washington, DC National Academy Press1995;Google Scholar

109.

Kumpfer  KLMolraard  VSpoth  R The "Strengthening Families Program" for the prevention of delinquency and drug use. Peters  RMcMahon  R Preventing Childhood Disorders, Substance Abuse, and Delinquency Thousand Oaks, Calif Sage Publications1996;Google Scholar

110.

Dusenbury  LFalco  M Eleven components of effective drug abuse prevention curricula..  J Sch Health. 1995;65420- 425Google ScholarCrossref

111.

National Institute on Drug Abuse, Preventing drug use among children and adolescents: a research-based guide. Available athttp://www.nida.nih.govAccessed April 12, 1997

112.

US Department of Health and Human Services, Prevention Resource Guide: Preschool Children.  Rockville Md National Clearinghouse for Alcohol and Drug Information1990;

113.

US Department of Health and Human Services, Prevention Resource Guide: Elementary Youth.  Rockville, Md National Clearinghouse for Alcohol and Drug Information1991;