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Director's Report to the National Advisory Council on Drug Abuse - May, 2009

Research Findings - Prevention Research

Changes in Marijuana Outcome Expectancies Over Time Translate to Changes in Use Intentions

An evaluation of the National Youth Anti-Drug Media Campaign revealed that greater Campaign exposure was associated with weaker anti-drug norms and higher rates of marijuana initiation. There are many possible reasons for these effects, including the possibility that the typical campaign often is designed to develop expectancies regarding marijuana use outcomes that may not be experienced by the initiate. Indeed drug prevention media campaigns commonly seek to change outcome expectancies associated with substance use, but the effects of violating such expectancies are rarely considered. This study details an application of the expectancy violation framework in this real world context by investigating whether changes in marijuana expectations were associated with subsequent future marijuana intentions. Using data from a cohort of adolescents (N = 1,344; age range = 12-18 years) collected as part of the National Survey of Parents and Youth, nonusers at baseline were assessed 1 year later. Changes in expectancies were significantly associated with changes in intentions (p < .001). Moreover, in most cases, changes in expectancies and intentions had the strongest relationship among those who became users. The final model accounted for 31% of the variance (p < .001). Consistent with laboratory studies, changes in marijuana expectancies were predictive of changes in marijuana intentions. These results counsel caution when describing negative outcomes of marijuana initiation. If adolescents conclude that the harms of marijuana use are not as grave as they had been led to expect, intentions to use may intensify. Skenderian J, Siegel J, Crano W, Alvaro E, Lac A. Expectancy change and adolescents' intentions to use marijuana. Psychol Addict Behav. 2008;22(4):563-9.

Infrequent Use of Evidence-based Prevention Programs in America's High Schools

Despite a substantial proportion of high school students who initiate substance use following middle school, the implementation of universal evidence-based prevention curricula appears to be scant. This study on school-based substance use prevention practices reports on data collected in 2005 from a nationally representative sample of 1,392 school district-based drug prevention coordinators. Overall, only 10.3% of districts with high schools reported administering one of six prevention programs rated as effective by the Substance Abuse and Mental Health Services Administration's National Registry of Effective Programs and Practices or Blueprints for Violence Prevention, and only 5.7% reported that they used one of these effective programs most. Strikingly only 56.5% of the nation's high school districts administered any substance use prevention programming at all in at least one of their constituent high schools. This study highlights the very infrequent use of evidence-based prevention programs in America's high schools, despite increasing requirements for use of evidence based practices and the increasing availability of efficacious and effective prevention programs. Ringwalt C, Hanley S, Vincus A, Ennett S, Rohrbach L, Bowling J. The prevalence of effective substance use prevention curricula in the nation's high schools. J Prim Prev. 2008;29(6):479-88.

Majority of America's Middle Schools Administer Drug Prevention Programs with Limited Evidence of Effectiveness

Since the dissemination of its Principles of Effectiveness in 1998, the Office of Safe and Drug-Free Schools of the U.S. Department of Education has promoted the use of evidence-based drug prevention programs in the nation's schools. This paper reports on a 2005 survey of a nationally representative sample of 1,721 schools with middle school grades. Respondents included the middle school staff identified as most knowledgeable about each school's drug prevention programs. The survey asked questions concerning which drug use prevention curricula the schools used, and if they used more than one, which program they used most frequently. Three federally-sponsored registries were used to characterize which curricula were considered evidence-based programs (EBP): "model" or "effective" programs from the Substance Abuse and Mental Health Services Administration (SAMHSA) NREPP (National Registry of Evidence-based Programs and Practices ), "model" or "promising" programs listed by "Blueprints for Violence Prevention" (Center for the Study and Prevention of Violence), or "exemplary" programs identified by the Office of Safe and Drug-Free Schools (Safe, Disciplined, and Drug-Free Schools Expert Panel). Findings from this 2005 survey were then compared to earlier estimates based on a similar 1999 survey. Results showed that 42.6% of the nation's schools with middle school grades were using an evidence-based curriculum, an increase of 8% from the 1999 estimate. The two most prevalent programs in use, at 19% each, were Life Skills Training and Project ALERT. However, only 8% of Life Skills Training users and 9% of Project ALERT users reported using these programs the most, and only 23% of schools reported that they used an EBP the most. This study points to the need for more information on why over three-quarters of the nation's middle schools continue to administer programs that may have limited evidence of effectiveness. Ringwalt C, Vincus A, Hanley S, Ennett S, Bowling J, Rohrbach L. The prevalence of evidence-based drug use prevention curricula in U.S. middle schools in 2005. Prev Sci. 2009;10(1):33-40.

College Substance Use: Being Caught and Reprimanded Leads to Behavior Change

Studies evaluating the efficacy of brief interventions with mandated college students have reported declines in drinking from baseline to short-term follow-up regardless of intervention condition. A key question is whether these observed changes are due to the intervention or to the incident and/or reprimand. This study evaluates a brief personalized feedback intervention (PFI) for students (N = 230) who were referred to a student assistance program because of infractions of university rules regarding substance use to determine whether observed changes in substance use are attributable to the intervention. Half the students received immediate feedback (at baseline and after the 2-month follow-up), and half received delayed feedback (only after the 2-month follow-up). Students in both conditions generally reduced their drinking and alcohol-related problems from baseline to the 2-month follow-up and from the 2-month to the 7-month follow-up; however, there were no significant between-group differences at either follow-up. Therefore, it appears that the incident and/or reprimand are important instigators of mandated student change and that written PFIs do not enhance these effects on a short-term basis but may on a longer term basis. White H, Mun E, Morgan T. Do brief personalized feedback interventions work for mandated students or is it just getting caught that works? Psychol Addict Behav. 2008;22(1):107-16.

Morning Cortisol Levels in Preschool-Aged Foster Children

Maltreated foster children are subjected to a range of early adverse experiences, including neglect, abuse, and multiple caregiver disruptions. Research suggests that such disturbances alter the development and subsequent functioning of the hypothalamic-pituitary-adrenocortical system. The current study was designed to investigate morning cortisol levels in 117 foster children and 60 low-income, nonmaltreated children. Maltreatment and foster care placement experiences were coded from official records. Analyses revealed that the foster children were significantly more likely than the nonmaltreated children to have low morning cortisol levels. Additionally, specific maltreatment experiences were significantly associated with foster children's morning cortisol levels. Foster children with low morning cortisol levels experienced more severe physical neglect than the other foster children. In contrast, foster children with high morning cortisol levels experienced more severe emotional maltreatment. These results suggest that specific early adverse experiences have differential effects on the functioning of the hypothalamic-pituitary-adrenocortical system. Bruce J, Fisher P, Pears K, Levine S. Morning cortisol levels in preschool-aged foster children: differential effects of maltreatment type. Dev Psychobiol. 2009;51(1):14-23.

Risk Factors Stronger Predictors of Adolescent Substance Use Than Protective Factors

To compare the relative influence of risk and protective factors across several domains on adolescent substance use in a large sample of youth cross-sectional survey, data were collected from students in grades 6, 8, 10, and 12 in Pennsylvania (N = 91,778). Generalized linear mixed models were estimated for each grade level to examine associations among indices of three risk factors (individual, peer, and family) and three protective factors (family, school, and community) and both recent and lifetime substance use. The risk factors were stronger predictors of substance use outcomes compared with the protective factors, regardless of grade level or substance use type. In particular, the individual and peer risk factors were strongly related to lifetime and recent use of cigarettes, alcohol, and marijuana. Among the protective factors, the strongest associations with substance use were found in the community domain. Several age-related differences in the associations were also found, suggesting that family and community factors were more salient among younger adolescents whereas peer and school factors were stronger among older adolescents. These findings provide support for the social development model (SDM), which proposes that adolescent substance use is associated with factors across multiple spheres of influence. Age-related differences in these associations suggest that effective interventions to reduce adolescent substance use may need to emphasize different domains of risk and protective factors at different stages of adolescent development. Cleveland M, Feinberg M, Bontempo D, Greenberg M. The role of risk and protective factors in substance use across adolescence. J Adolesc Health. 2008;43(2):157-64.

HealthWise Intervention Shows Promise for Reducing Sexual and Drug Risks Among South African Youth

Sexual behavior and substance use represent major threats to the health and well-being of South African adolescents, especially in light of the high prevalence of HIV infection in this population. However, there is currently a lack of evidence-based school programs designed to address health risk behaviors. The current study details the evaluation of HealthWise South Africa, a leisure, life skills, and sexuality education intervention for eighth and ninth grade students currently being evaluated in South Africa. The investigators hypothesized that, compared to controls, HealthWise participants would have delayed sexual initiation, reduced rates of current sexual activity, increased use of and perceived access to condoms, and lower rates of lifetime and past use of drugs. Longitudinal data were analyzed using logistic regression of multiply imputed data. Results indicate that HealthWise was effective in increasing the perception of condom availability for both genders. Compared to HealthWise participants, control participants had steeper increases in recent and heavy use of alcohol, and recent and heavy cigarette use. Significant gender by intervention interactions were identified indicating that the program may have differentially affected girls and boys. Specifically, the program produced reduced sexual initiation favoring boys, and reductions in past month drinking, past month cigarette use, and smoking initiation favoring girls. These results suggest that HealthWise had a moderate, positive effect on multiple health risk behaviors among the population of school-going South African adolescents. Smith E, Palen L, Caldwell L, Flisher A, Graham J, Mathews C, Wegner L, Vergnani T. Substance use and sexual risk prevention in Cape Town, South Africa: an evaluation of the HealthWise Program. Prev Sci. 2008; 9(4):311-21.

Brief Family Intervention for High Risk Toddlers Improves School Readiness

This study examined the longitudinal effects of the Family Check-Up (FCU) on parents' positive behavior support and children's school readiness competencies in early childhood. It was hypothesized that the FCU would promote language skills and inhibitory control in children at risk for behavior problems as an indirect outcome associated with targeted improvements in parents' positive behavior support. High-risk families in the Women, Infants, and Children (WIC) federal nutrition program participated in a multisite preventive intervention study (N = 731) with 3 yearly assessments beginning at child age 2 years. Positive behavior support was measured using 4 indicators derived from at-home observations of parent-child interaction during semi structured tasks. Longitudinal structural equation models revealed that parents in families randomly assigned to the FCU showed improvements in positive behavior support from child age 2 to 3, which in turn promoted children's inhibitory control and language development from age 3 to 4, controlling for child gender, ethnicity, and parental education. These findings suggest that a brief, ecological preventive intervention supporting positive parenting practices can indirectly foster key facets of school readiness in children at risk. Lunkenheimer E, Dishion T, Shaw D, Connell A, Gardner F, Wilson M, Skuban E. Collateral benefits of the family check-up on early childhood school readiness: indirect effects of parents' positive behavior support. Dev Psychol. 2008;44(6):1737-52.

Peer Health Advocates Reduce HIV Risk in Injection Drug and Crack Users

The Risk Avoidance Partnership (RAP) Project tested a program to train active drug injectors and crack cocaine users as "Peer Health Advocates" (PHAs) to deliver a modular HIV, hepatitis, and STI prevention intervention to hard-to-reach drug users in their networks and others in an urban area. The intervention was designed to diffuse health promotion and risk-reduction interventions by supporting PHAs to model prevention practices and deliver risk- and harm-reduction materials and information. They compared change in behaviors and attitudes between baseline and 6-month follow-up of 112 primarily African-American and Latino PHAs, 223 of their drug-user network contact referrals, and 118 other study recruits (n = 523). Results indicated significant HIV risk reduction among all study participants, associated with significant health advocacy action conducted by PHAs, and a relationship between exposure to the RAP peer-delivered intervention and risk reduction among all study groups. Findings suggest that the engagement of active drug users in peer health advocacy can set in motion a feedback and diffusion process that supports both the continued work of the PHAs and the adoption of harm reduction and mimicking of health advocacy by their peers. Weeks M, Li J, Dickson-Gomez J, Convey M, Martinez M, Radda K. The risk avoidance partnership. Subst Use Misuse. 2009;44(2):253-81.

Mandated Interventions Contribute to Reductions in College Alcohol Use

Little is known about the effects of alcohol-related infractions and resulting reprimands for invoking behavioral change among mandated college students. The primary aim of this study was to assess the extent to which students significantly reduce their drinking between the time of an alcohol-related violation and the sanctioned intervention. Data came from 175 (70% male) students mandated to the Rutgers University Alcohol and Other Drug Assistance Program for Students because of infractions of university rules about alcohol and drug use. At intake, students reported on their alcohol consumption for the 30 days before the violation and the 30 days before the intake assessment. Mandated students significantly reduced peak blood alcohol concentration (BAC) levels, total weekly drinks, and frequency of alcohol use after the violation and before any intervention was delivered. Those students who had received a legal or medical referral (i.e., a serious infraction) reduced their alcohol consumption (BAC and total drinks) significantly more than those referred by residence hall advisors. The alcohol-related violation (including the event itself, getting caught, and/or getting mandated to an intervention) contributed to reductions in alcohol use for mandated college students. The finding that the seriousness of the infraction resulted in greater reductions in alcohol use suggests that the students' cognitive self-appraisal and affective response to the incident may be underlying mechanisms for their changes. Knowing if mandated students have already made significant changes in their drinking before intake would provide counselors with a valuable opportunity to identify and reinforce successful harm reduction strategies and could inform the type or intensity of intervention needed. Morgan T, White H, Mun E. Changes in drinking before a mandated brief intervention with college students. J Stud Alcohol Drugs. 2008;69(2):286-90.

Brief Interventions for Adolescents May Impact Multiple Health Behaviors

This study examined whether brief intervention strategies founded on the Behavior-Image Model that addresses positive images of college and career success have an impact on multiple health behavior habits of high-risk adolescents transitioning into adulthood. Participants included 375 11th and 12th grade students from a large, relatively diverse suburban school in northeast Florida. Students were stratified by grade level and drug use and individually randomized to one of the three "Plan for Success" interventions: (1) Goal Survey, (2) Goal Survey plus Contract, or (3) Goal Survey plus Consult. Data on multiple health risk, health promotion, and personal development behaviors, as well as image and beliefs measures were collected at baseline and 1 month post intervention. Findings from MANOVAs tests were significant for alcohol use, marijuana use, exercise, college preparation, and career preparation, with most behaviors improving over time. Group-by-time interaction effects were found for nutrition habits and career preparation, favoring the consultation. These results suggest that brief interventions founded on the Behavior-Image Model may have potential to improve selected health and personal development habits among older adolescents. Werch C, Bian H, Ames S, DiClemente, C, Thombs D, Pokorny S. Brief multiple behavior health interventions for older adolescents. Am J Health Promot. 2008;23(2):92-6.

Two-month Follow-up Outcomes for a Mother-Daughter Computer-Mediated Drug Prevention Program

This study evaluated a computer-mediated intervention program to prevent underage drinking among early adolescent girls. Study participants were 202 pairs of adolescent girls (mean age = 12.2 years; ethnicity: 68% white, 14% Latina, 9% black, 1% Asian, 8% other) and their mothers (mean age = 41.1 years). Participants completed pretests online, were randomly divided between intervention and control arms, and completed posttest measures two months following the intervention. Program girls and their mothers interacted with a computer program aimed to enhance mother-daughter relationships and to teach girls skills for managing conflict, resisting media influences, refusing alcohol and drugs, and correcting peer norms about underage drinking, smoking, and drug use. Two months following program delivery and relative to control, girls and mothers in the program had improved their mother-daughter communication skills and their perceptions and applications of parental monitoring and rule-setting relative to girls' alcohol use. Also at follow-up, intervention-arm girls had improved their conflict management and alcohol use-refusal skills; reported healthier normative beliefs about underage drinking; demonstrated greater self-efficacy about their ability to avoid underage drinking; reported less alcohol consumption in the past 7 days, 30 days, and year; and expressed lower intentions to drink as adults. Study findings modestly support the viability of a mother-daughter, computer-mediated program to prevent underage drinking among adolescent girls. Schinke S, Cole K, Fang L. Gender-specific intervention to reduce underage drinking among early adolescent girls: a test of a computer-mediated, mother-daughter program. J Stud Alcohol Drugs. 2009;70(1):70-7.

Outcomes of the 5th Grade Version of the Keepin' It REAL Prevention Intervention

This study examined the immediate and short-term outcomes of adapting the culturally-grounded middle school program, keepin' it REAL, for elementary school students. Ten schools were randomly assigned to the intervention in 5th grade with follow-up boosters in 6th grade; 13 schools were randomly assigned to the control condition, implementing the school's pre-existing substance use prevention programming. Students (n = 1,566) completed a questionnaire prior to curriculum implementation and follow-up questionnaires toward the end of 5th and 6th grade. The 5th grade kiR curriculum generally appeared no more effective than the control schools' programming in changing students' resistance or decision-making skills, substance use intentions, expectancies, normative beliefs, or lifetime and recent substance use. Hecht ML, Elek E, Wagstaff DA, Kam JA, Marsiglia F, Dustman P, Reeves L, Harthun M. Immediate and short-term effects of the 5th grade version of The Keepin' It REAL substance use prevention intervention. J Drug Educ. 2008;38(3):225-51.

Measuring Quality of Delivery of Evidence-Based Drug Abuse Prevention

The purpose of this study was to develop and validate an observational measure designed to capture teachers' use of interactive teaching skills within the delivery of the All Stars substance use prevention program. This work was conducted within a larger study testing the relative effects of two training conditions to support implementation of the All Start program by teachers. Teachers in the standard condition received initial training, technical assistance on request, online video instruction on the program, and Internet-based support. Teachers in the enhanced condition received onsite coaching, proactive technical assistance and assessments of fidelity. In this study on the development of a measure of quality of delivery, coders counted the number of times teachers praised and encouraged students, accepted and used students' ideas, asked questions, self-disclosed personal anecdotes, and corrected student misbehavior. In a factor analysis teacher behaviors loaded onto three factors: classroom management, acknowledgment, and student-centered methods. Classroom management was negatively related to student engagement. Acknowledgment was negatively related to students' normative beliefs. Student-centered methods were positively related to student idealism and normative beliefs, and marginally predicted decreases in student marijuana use. This study provides a promising approach to studying pedagogical prevention approaches that also link teaching processes to student outcomes. Giles S, Jackson-Newsom J, Pankratz M, Hansen W, Ringwalt C, Dusenbury L. Measuring Quality of Delivery in a Substance Use Prevention Program. J Prim Prev. 2008;29(6):489-501.

Factors Associated with Prevention Program Implementation

Teacher- and school-level factors influence the fidelity of implementation of school-based prevention and social character and development (SACD) programs. Using a diffusion of innovations framework, the relationships among teacher beliefs and attitudes towards a prevention/SACD program and the influence of a school's administrative support and perceptions of school connectedness, characteristics of a school's climate, were specified in two cross-sectional mediation models of program implementation. Implementation was defined as the amount of the programs' curriculum delivered (e.g., lessons taught), and use of program-specific materials in the classroom and in relation to school-wide activities. Teachers from 10 elementary schools completed year-end process evaluation reports for year 2 (N = 171) and 3 (N = 191) of a multi-year trial. Classroom and school-wide material usage were each favorably associated with the amount of the curriculum delivered, which were associated with teachers' attitudes toward the program which, in turn, were related to teachers' beliefs about SACD. These, in turn, were associated with teachers' perceptions of school climate. Perceptions of school climate were indirectly related to classroom material usage and both indirectly and directly related to the use of school-wide activities. Program developers need to consider the importance of a supportive environment on program implementation and attempt to incorporate models of successful school leadership and collaboration among teachers that foster a climate promoting cohesiveness, shared visions, and support. Beets M, Flay B, Vuchinich S, Acock A, Li K, Allred, C. School climate and teachers' beliefs and attitudes associated with implementation of the positive action program: a diffusion of innovations model. Prev Sci. 2008;9(4):264-75.

Child Maltreatment Profiles Predict Psychosocial and Cognitive Functioning

Up to 90% of child welfare system cases involve multiple types of maltreatment; however, studies have rarely incorporated multiple dimensions of maltreatment. The present study employed a latent profile analysis to identify naturally occurring subgroups of children who had experienced maltreatment. Reports of maltreatment incidents for 117 preschool-aged foster children were classified along two dimensions: type (e.g., physical abuse, sexual abuse, physical neglect, supervisory neglect, or emotional maltreatment) and severity within type. The analyses revealed four distinct profiles showing moderate to high levels of maltreatment: (a) supervisory neglect/emotional maltreatment; (b) sexual abuse/emotional maltreatment/neglect (when not otherwise specified neglect refers to both supervisory and physical neglect); (c) physical abuse/emotional maltreatment/neglect; and (d) sexual abuse/physical abuse/emotional maltreatment/neglect. Profile membership was examined with respect to children's' cognitive functioning and externalizing and internalizing problems: lower cognitive functioning was related to profiles with neglect or physical abuse (or both), externalizing was highest in the sexual abuse/physical abuse/emotional maltreatment/neglect profile, and internalizing was highest in the profiles with physical or sexual abuse (or both). There appear to be distinct profiles of maltreatment among preschoolers that have differential associations to measures of adjustment. Using different profiles of maltreatment to understand specific vulnerabilities may guide in tailoring interventions to the needs of maltreated children. Pears K, Kim H, Fisher P. Psychosocial and cognitive functioning of children with specific profiles of maltreatment. Child Abuse Negl. 2008;32(10):958-71.

Maternal Depression as a Mediator of Parenting Efficacy

Parenting self-efficacy (PSE) has been positively linked to children's adjustment and negatively associated with maternal depression. The present study investigated: (1) how PSE changes over time, (2) the relationship between PSE when the child is age 2 and children's behavior problems 2 years later, and (3) the potential mediating role of maternal depression in relation to the association between PSE and child problem behavior. Participants were 652 ethnically and geographically diverse mothers and their children, at high risk for conduct problems. PSE increased while children were between ages 2 and 4 and higher initial levels predicted lower caregiver-reported conduct problems at age 4 after controlling for problem behavior at age 2. The relationship between PSE and later conduct problems was mediated, however, by maternal depression. These results point to the role of maternal depression as a potential disruptor of caregiver confidence in early childhood, and as a possible target for intervention. Weaver C, Shaw D, Dishion T, Wilson M. Parenting self-efficacy and problem behavior in children at high risk for early conduct problems: the mediating role of maternal depression. Infant Behav Dev. 2008;31(4):594-605.

Factors Associated with Methamphetamine Injection

In addition to the ill health effects of drug use, methamphetamine users are at risk for HIV and Hepatitis C (HCV) through drug injection and unsafe sex. The potential risks of injecting methamphetamine versus injecting other drugs are similar, that is, through shared needles and shared injecting equipment, as well as the possibility of unsafe sex while under the influence. This empirically based study compared injectors of methamphetamine with non-methamphetamine injectors to determine if these two groups differ in ways that put them at risk. From 2004-2006, 439 injection drug users were recruited in Denver, Colorado, to participate in a study of drug use and HCV risk. Over two-thirds were male, more than half were white, and 28% were methamphetamine injectors. Demographics, drug use, and HIV risk behaviors were assessed via the Risk Behavior Assessment. A logistic regression model was built using forward stepwise method to determine independent associations between variables of interest and methamphetamine injection. In comparing methamphetamine injectors to non-methamphetamine injectors, this study found injectors to be younger, more likely to be white and to have more education than non-injectors. This demographic, as well as the finding that methamphetamine injectors were more likely to report being gay/lesbian or bisexual than non-MA IDUs, mirrors the national profile of methamphetamine users. Having this information may allow for targeting intervention and prevention efforts to the most vulnerable segments of the population before they contract HIV or HCV. Corsi K, Kwiatkowski C, Booth R. Predictors of methamphetamine injection in out-of-treatment IDUs. Subst Use Misuse. 2009;44(3):332-42.

Substance Use Involvement Among Youth in Child Welfare

This study examined risk factors for substance use involvement for adolescents involved with the child welfare system. Participants included 214 adolescents 13 to 18, randomly sampled from active child welfare rolls in San Diego County, California. Severity of substance use involvement was assessed via structured diagnostic interviews determining lifetime substance use, abuse, and dependence. Hierarchical regression analyses revealed that both common and child welfare-specific risk factors were associated with severity of youth substance involvement. Multiple-placement changes, later entry into the child welfare system, and multiple-placement changes at an older age were associated with higher risk for more serious substance involvement for youths in child welfare. Aarons G, Monn A, Hazen A, Connelly C, Leslie L, Landsverk J, Hough R, Brown S. Substance involvement among youths in child welfare: the role of common and unique risk factors. Am J Orthopsychiatry;78(3):340-9.

Case Study of Process in a Brief Family Intervention for Toddlers

This article describes a case study in the use of the Family Check-Up (FCU), a family-based and ecological preventive intervention for children at risk for problem behavior. The FCU is an assessment-driven intervention that utilizes a health maintenance model; emphasizes motivation for change; and offers an adaptive, tailored approach to intervention. The FCU is currently under study in a randomized control trial (RCT) in 3 geographically diverse communities where 731 families with children at high risk for conduct problems were identified through local Women Infants and Children (WIC, federal food and nutrition) programs. This case study follows one Caucasian family through their initial assessment and subsequent intervention for their toddler daughter's conduct problems over a 2-year period. Clinically meaningful improvements in child and family functioning were found despite the presence of child, parent, and neighborhood risk factors. Gill A, Hyde L, Shaw D, Dishion T, Wilson M. The family check-up in early childhood: a case study of intervention process and change. J Clin Child Adolesc Psychol. 2008;37(4):893-904.

Needs Assessment of a Social Service Referral Telephone Program for High Risk Youth

This paper reports on a needs assessment study of a social service resource telephone program component among high risk youth who participated in Project Towards No Drug Abuse (TND), a classroom-based program, approximately 1 year earlier. Results supported youths' overwhelming receptiveness of a social service referral program. The vast majority of respondents indicated a strong desire for resource and referral information on vocational, educational, recreational, transportation, and mental health and drug counseling. Further research is needed to investigate the effectiveness of the provision of social service resource information on drug use among emerging adults. Sussman S, Skara S, Pumpuang P. Project Towards No Drug Abuse (TND): needs assessment of a social service referral telephone program for high risk youth. Subst Use Misuse. 2008;43(14):2066-73.

A Practical Guide for Estimating Causal Effects in Nonrandomized Intervention Trials

In a well-designed experiment, random assignment of participants to interventions makes causal inference straightforward. However, if participants are not randomized (as in observational study, quasi-experiment, or nonequivalent control-group designs), group comparisons may be biased by confounders that influence both the outcome and the alleged cause. Traditional analysis of covariance, which includes confounders as predictors in a regression model, often fails to eliminate this bias. In this article, the authors review Rubin's definition of an average causal effect (ACE) as the average difference between potential outcomes under different treatments. The authors distinguish an ACE and a regression coefficient. The authors review 9 strategies for estimating ACEs on the basis of regression, propensity scores, and doubly robust methods, providing formulas for standard errors not given elsewhere. To illustrate the methods, the authors simulate an observational study to assess the effects of dieting on emotional distress. Drawing repeated samples from a simulated population of adolescent girls, the authors assess each method in terms of bias, efficiency, and interval coverage. Throughout the article, the authors offer insights and practical guidance for researchers who attempt causal inference with observational data. Schafer J, Kang, J. A practical guide on computing average causal effects from nonrandomized intervention studies. Psychol Methods. 2008;13(4):279-313.

STIs More Related to Sexual Risk than Substance Use Among Meth Using Thai Youth

Cross-sectional data were collected in Chiang Mai, Thailand in 2005--2006 among 658 sexually active participants aged 18 to 25 years, the majority having a history of recent methamphetamine use. Data were collected by interview and sexually transmitted infections (STI) were detected using standard laboratory assays. At least one laboratory confirmed STI was found in 38% of participants. Herpes simplex virus and Chlamydia were significantly more common among women, whereas hepatitis B virus was significantly more common among men. Men reported a greater number of sexual partners than women, and condom use at last sex was infrequent. Most participants reported using methamphetamine at least weekly, with men more frequent users than women, and more often giving reports of frequent drunkenness and lifetime arrests. Behavioral correlates of prevalent STI were similar to the published literature. In multivariate analysis, women > or =20 years of age, with > or =2 heterosexual partners in the past year and a younger age at sexual debut were significantly more likely to have a prevalent STI. Men > or =20 years of age, with > or =2 heterosexual partners in the past year and who enrolled both sex and drug network members were significantly more likely to have a prevalent STI, whereas men who used a condom at last sex were significantly less likely to have a prevalent STI. Substance abuse was associated with behavioral risks but not with prevalent STI. Sexual risks and substance abuse are substantially elevated among young Thai methamphetamine users, but only sexual risks are associated with prevalent STI. Celentano D, Sirirojn B, Sutcliffe C, Quan V, Thomson N, Keawvichit R, Wongworapat K, Latkin C, Taechareonkul S, Sherman S, Aramrattana A. Sexually transmitted infections and sexual and substance use correlates among young adults in Chiang Mai, Thailand. Sex Transm Dis. 2008;35(4):400-5.

Factors Associated with Methamphetamine Use Initiation in Thailand

Methamphetamine has become the leading drug of abuse in northern Thailand over the past several years, particularly among youth. The current qualitative study examines factors associated with initiation of methamphetamine use. Between March 2002 and January 2003, 48 in-depth interviews with young methamphetamine users were conducted in advance of a randomized, methamphetamine harm reduction, peer outreach intervention trial. The interviews were conducted in the city of Chiang Mai and the surrounding district. Participants were 57% male and had a median age of 20 years (range 15-31 years). A culture of methamphetamine ubiquity characterized participants' initiation stories. Drug ubiquity encompassed three elements: the extent of methamphetamine use within peer networks; the availability of methamphetamine; and exposure to methamphetamine before initiation. All participants were introduced to methamphetamine by people close to them, most often by their friends. Internal reasons for trying methamphetamine were curiosity, a way to lose weight or to enhance hard work, and a way to "forget life's problems." With the prevalence of methamphetamine use among participants' peers, initiation seemed inevitable. Initiation was characterized as ubiquitous in terms of peer networks' use and availability. Because of the prevalent norm of methamphetamine use, these data indicate that interventions targeting social networks and young Thais before methamphetamine initiation are needed. Sherman S, German D, Sirirojn B, Thompson N, Aramrattana A, Celentano D. Initiation of methamphetamine use among young Thai drug users: a qualitative study. J Adolesc Health. 2008;42(1):36-42.

Meth Using Young Women in Thailand Have Varied Level of HIV Sexual Risk

Given high rates of methamphetamine use among young people in Thailand and evidence of an association between methamphetamine and increased sexual risk behavior, the associations among women's recent sexual partnerships, social network characteristics and drug and alcohol use were examined. Female participants (n=320) in an HIV behavioral trial among young (18-25 years) methamphetamine users in Chiang Mai completed a drug and sexual behavior survey and social network inventory. Multinomial regression analyses accounting for clustered data examined individual and network characteristics associated with recent sexual partnership category. Women with only one male partner in the past year (39%) were compared to those with multiple male partners (37%) and those with only female partners (24%). Differences in levels of drug and alcohol use and social and sexual network characteristics were dependent on recent sexual partnership profiles. The multiple partner group reported an average of five male partners in the past year; 12% reported consistent condom use in the past 30 days. Compared to both groups, women with multiple male partners used methamphetamine more frequently, had larger non-sex networks with more methamphetamine users, were more likely to have a methamphetamine-using sex partner, and received less emotional support from their partners. Women with multiple male partners and only female partners reported more frequent alcohol use. These data point to the need for targeted prevention approaches that take into account the varying characteristics and social influences of these different groups of women. German D, Sherman S, Latkin C, Sirirojn B, Thomson N, Sutcliffe C, Aramrattana A, Celentano D. Young Thai women who use methamphetamine: intersection of sexual partnerships, drug use, and social networks. Int J Drug Policy. 2008;19(2);122-9.

Daily Context Analysis of Methamphetamine Use in Thailand

Methamphetamine is the leading illicit drug in Thailand among youth and young adults. Sexual risk behaviors are associated with methamphetamine use, but few data are available on the daily context of methamphetamine use. The authors developed an inductive behavioral typology that young Thais engage in while using methamphetamine. A cross-sectional study in Chiang Mai, Thailand was conducted in 2005-2006 among 1,162 street-recruited methamphetamine smokers 18-25 years of age. Data collected included sociodemographic characteristics, sexual behaviors, and drug use patterns. Latent class analysis was used to describe patterns of activities in which participants reported engaging directly after using methamphetamine. Logistic regression was used to examine univariate correlates of class membership, separately by gender. Participants were 75% male with a median age of 19 years. More than half of participants reported frequent alcohol use (>or=4 days/week) and half of the sample reported smoking methamphetamine >or=2 days/ week. Three classes of activities emerged for male participants (n = 863): "work" (job related); "high-risk behaviors" (motorcycle riding, fighting, sex); and "combined" (all activities). Two classes emerged for the women (n = 299): "work" (housework) and "high-risk behaviors." "High-risk behaviors" and "combined" (men only) classes were associated with more frequent alcohol and methamphetamine use compared with the "work" class. This study found a distinct typology of behaviors associated with substance abuse among young adults in Thailand. Sherman S, Sutcliffe C, German D, Sirirojn B, Aramrattana A, Celentano D. Patterns of risky behaviors associated with methamphetamine use among young Thai adults: a latent class analysis. J Adolesc Health. 2009;44(2):169-75.

Processes of Substance Use Among Youth of Mexican Heritage

This study examined the theory of planned behavior to explain normative processes in substance use among Mexican-heritage youth. The theory identifies norms, attitudes, and perceived behavioral control as predictors of intentions, which in turn, predict behaviors. It was hypothesized that norms are multidimensional, consisting of parental approval/disapproval, peer approval/disapproval, descriptive, and personal substance use norms. Second, it was hypothesized that parental approval/disapproval, peer approval/disapproval, and descriptive norms indirectly affect substance use intentions through attitudes, personal norms, and perceived behavioral control. Third, it was hypothesized that the model would operate differently based on Mexican-heritage youths' country of origin. Mexican-heritage youth (N = 1,499) from 30 elementary schools in Phoenix, AZ completed questionnaires in three waves over 18 months as part of a larger study. The findings supported the first hypothesis, showing the multidimensionality of norms. The second hypothesis was partially supported by findings from a multi-group multilevel path analysis using Mplus. Descriptive norms' association with intentions was partially mediated by attitudes, personal norms, and perceived behavioral control, while parental and peer approval/disapproval norms were fully mediated, partially supporting the second hypothesis. Contrary to the third hypothesis, the mediation model did not differ based on Mexican-heritage youths' country of origin. Kam JA, Matsunaga M, Hecht ML, Ndiaye K. Extending the theory of planned behavior to predict alcohol, tobacco, and marijuana use among youth of Mexican heritage. Prev Sci. 2009;10(1):41-53.

Ego Development and Parenting: Potential Application to Substance Abusing Mothers

This study examined maternal ego development in relation to psychopathology and parenting problems in a sample of substance abusing mothers. Given the tendency for introspection and guilt at higher levels of ego development, the authors expected mothers at higher levels to report more psychopathology. Given the tendency for dichotomous perceptions and limited conceptions of causation at lower levels of ego development, the authors expected mothers at low levels to report more problematic parenting behaviors. Intelligence was expected to correlate but not overlap with ego development. Participants were 182 mothers who expressed interest in a randomized clinical trial for a new parenting intervention. Measures included the Washington University Sentence Completion Task--Short Form, the Parental Acceptance-Rejection Questionnaire, the Brief Symptom Inventory and the Kaufman Brief Intelligence Test. Results of correlation and multivariate analyses of variance confirmed predictions. Suchman N, McMahon T, Decoste C, Castiglioni N, Luthar S. Ego Development, psychopathology, and parenting problems in substance-abusing mothers. Am J Orthopsychiatry. 2008;78(1):20-8.

Correlates of Early Alcohol and Drug Use Among Hispanic Adolescents

This study examined associations of multiple contexts (e.g., family, school, and peers) and of attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD) to adolescent alcohol and drug use in a sample of 217 eighth-grade adolescents with behavior problems from Hispanic/Latino immigrant families. Data for this study come from baseline assessments (collected prior to randomization) of adolescents and families participating in a randomized clinical trial testing the efficacy of an HIV and substance use prevention intervention. Adolescents and their families were recruited from three large predominantly Hispanic middle schools located in a single urban low-income school district in Miami-Dade County, Florida. The results from structural equation modeling analyses suggest that conduct disorder in youth with high levels of hyperactivity symptoms, poor school functioning, and peer alcohol and drug use was directly related to early adolescent alcohol and drug use. Attention deficit/hyperactivity disorder with comorbid conduct disorder and family functioning was indirectly related to early alcohol and drug use through poor school functioning and through peer alcohol and drug use. Lopez B, Schwartz SJ, Prado G, Huang S, Rothe EM, Wang W, Pantin H. Correlates of early alcohol and drug use in Hispanic adolescents: examining the role of ADHD with comorbid conduct disorder, family, school, and peers. J Clin Child Adolesc Psychol. 2008;37(4):820-32.

Longitudinal Effects of Student Mobility on Elementary School Engagement

This study examined the effects of student mobility during the elementary school years on longitudinal school engagement. Also of focus was how school engagement outcomes are influenced by school and home environmental factors. Data collected from second through fifth grades were drawn from the Raising Healthy Children (RHC) project, an ongoing longitudinal intervention study, which retained a high percentage of study participants despite a high degree of mobility. Data were collected annually from district records and from parent-child and teacher surveys. The sample was predominantly Caucasian, contained roughly equal numbers of boys and girls, and approximately one third low income. The students came from 10 public elementary schools in the Pacific Northwest suburban school district, which had high aggregate measures of risk relative to other schools in the district. Growth curve analyses were used to examine mobility effects within the context of other factors (e.g., behavior problems, school relationships, and family circumstances). Growth curve models showed that school changes predicted declines in academic performance and classroom participation but not positive attitude toward school. Time-varying factors such as peer acceptance and teacher support had a positive influence on the trajectories of child outcomes. Additionally, teacher support had a particularly strong influence on positive attitudes toward school among children who had more school changes. Gruman DH, Harachi TW, Abbott RD, Catalano RF, Fleming, CB. Longitudinal effects of student mobility on three dimensions of elementary school engagement. Child Dev. 2008;79(6):1833-52.

Tobacco Industry Targeting Youth in Argentina

This study examined whether and how the tobacco industry promotes cigarettes to adolescents in Argentina by conducting a systematic search of tobacco industry documents available through the internet dated between 1995 and 2004 using standard search terms to identify marketing strategies in Argentina. A selected review of the four leading newspapers and nine magazines with reported high readership among adolescents was completed. The selected print media were searched for tobacco images and these were classified as advertisements if associated with a commercial product or as a story if not. For example, British American Tobacco (BAT) undertook a young adult psychographic study and classified them as "progressives," "Jurassics" or "conservatives" and "crudos" or "spoiled brats." Philip Morris promoted Marlboro by sponsoring activities directed at young people and they launched the 10 cigarettes packet as a starter vehicle. The tobacco industry used psychographic segmentation of the population and developed advertising strategies focused on youth. Tobacco control researchers and advocates must be able to address these strategies in counter-marketing interventions. Braun S, Mejia R, Ling P, Pérez-Stable E. Tobacco industry targeting youth in Argentina. Tob Conrol. 2008;17(2):111-7.


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