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Director's Report to the National Advisory Council on Drug Abuse - September, 2008

Research Findings - Prevention Research

Universal Childhood Prevention Effects Developmental Course of Antisocial Personality Disorder and Violent and Criminal Behavior

Antisocial personality disorder (ASPD), violent and criminal behavior, and drug abuse disorders often share the common antecedent of early aggressive, disruptive behavior. In the 1985-1986 school year teachers implemented the Good Behavior Game (GBG), a classroom behavior management strategy targeting aggressive, disruptive behavior and socializing children to the student role. From first through seventh grade the developmental trajectories of 2311 students from 19 Baltimore City Public Schools were examined. GBG impact on these trajectories and ASPD and violent and criminal behavior by age 19-21 is reported. In five urban, poor to lower middle class predominately African-American areas, three to four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a reading achievement program, or (3) the standard program. Classrooms and teachers were randomly assigned to intervention or control. Measures at 19-21 included self reports and juvenile court and adult incarceration records. GBG impact was assessed via General Growth Mixture Modeling based on repeated measures of aggressive, disruptive behavior. Three trajectories of aggressive, disruptive behavior were identified. By young adulthood, GBG significantly reduced the rates of ASPD and violent and criminal behavior among males in the persistent high aggressive, disruptive trajectory. A replication was implemented with the following cohort of first-grade children using the same teachers, but with diminished mentoring and monitoring. Beneficial impact was found among persistent high males through seventh grade. By young adulthood GBG effects on ASPD and violent and criminal behavior were non-significant, but generally in the hypothesized direction. This study demonstrated strongest effects on high risk males, suggesting the need to understand the shared and non-shared developmental processes within and across genders. Petras, H., Kellam, S.G., Brown, C.H., Muthen, B., Ialongo, N., and Poduska, J. Developmental Epidemiological Courses Leading to Antisocial Personality Disorder and Violent and Criminal Behavior: Effects By Young Adulthood of a Universal Preventive Intervention in First- and Second-Grade Classrooms. Drug Alcohol Depend., 95S1 pp. S45-S59, 2008.

Universal Classroom-Based Preventive Intervention Impacts Young Adult Service Use for Drugs, Alcohol and Other Problem Behaviors

The Good Behavior Game (GBG) is a classroom behavior management strategy focused on socializing children to the role of student and aimed at reducing early aggressive, disruptive behavior, a confirmed antecedent to service use. The GBG was tested in a randomized field trial in 19 elementary schools with two cohorts of children as they attended first and second grades. This article reports on the impact of the GBG on service use through young adulthood. Three or four schools in each of five urban areas were matched and randomly assigned to one of three conditions: (1) GBG, (2) an intervention aimed at academic achievement, or (3) the standard program of the school system. Children were assigned to classrooms to ensure balance, and teachers and classrooms were randomly assigned to intervention conditions. A positive impact of the universal preventive intervention on later service use for problems with emotions, behavior, or drugs or alcohol was found for males, but not females. For both cohorts, males in GBG classrooms who had been rated as highly aggressive, disruptive by their teachers in the fall of first grade had a lower rate of school-based service use than their counterparts in control classrooms. The design employed two cohorts of students. Although both first- and second-grade teachers received less training and support with the second cohorts of students than with the first cohort, the impact of GBG was similar across both cohorts. Poduska, J., Kellam, S.G., Wang, W., Brown, C.H., Ialongo, N., and Toyinbo, P. Impact of the Good Behavior Game, a Universal Classroom-Based Behavior Intervention, on Young Adult Service Use for Problems with Emotions, Behavior, or Drugs or Alcohol. Drug Alcohol Depend., 95S1 pp. S29-S44, 2008.

Prevention of Behavior Problems for Children in Foster Care: Outcomes and Mediation Effects

Parent training for foster parents is mandated by federal law and supported by state statues in nearly all states; however, little is known about the efficacy of that training, and recent reviews underscore that the most widely used curricula in the child welfare system (CWS) have virtually no empirical support. On the other hand, numerous theoretically based, developmentally sensitive parent training interventions have been found to be effective in experimental clinical and prevention intervention trials. One of these, Multidimensional Treatment Foster Care (MTFC) has been used with foster parents of youth referred from juvenile justice. The effectiveness of a universal intervention, KEEP (Keeping Foster Parents Trained and Supported) based on MTFC (but less intensive) was tested in a universal randomized trial with 700 foster and kinship parents in the San Diego County CWS. The goal of the intervention was to reduce child problem behaviors through strengthening foster parents' skills. The trial was designed to examine effects on both child behavior and parenting practices, allowing for specific assessment of the extent to which improvements in child behavior were mediated by the parenting practices targeted in the intervention. Child behavior problems were reduced significantly more in the intervention condition than in the control condition, and specific parenting practices were found to mediate these reductions, especially for high-risk children in foster families reporting more than six behavior problems per day at baseline. Chamberlain, P., Price, J., Leve, L., Laurent, H., Landsverk, J., and Reid, J. Prevention of Behavior Problems for Children in Foster Care: Outcomes and Mediation Effects. Prev. Sci., 9(1), pp. 17-27, 2008.

A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls

Despite growing evidence that child welfare youth are at increased risk for juvenile delinquency, little is known about gender-specific processes and effective treatment programs for girls. Multidimensional Treatment Foster Care (MTFC), an empirically validated intervention for child welfare and juvenile justice populations, has demonstrated efficacy in reducing arrest rates in delinquent boys and girls. In this study, the efficacy of MTFC on school attendance and homework completion was examined in juvenile justice girls who were referred to out-of-home care (N = 81). Results from this randomized intervention trial suggest that MTFC was more effective than group care in increasing girls' school attendance and homework completion while in treatment and at 12 months post baseline. In addition, the previously reported effect of MTFC on reducing girls' days in locked settings was mediated by homework completion while girls were enrolled in the intervention setting. Implications for policy and practice are described. Leve, L.D., and Chamberlain, P.A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls. Res. Soc. Work Pract., 17(6), pp. 657-663, 2007.

Impact of First and Second Grade Universal Prevention on Young Adult Behavioral, Psychiatric and Social Outcomes

The Good Behavior Game (GBG), a method of classroom behavior management used by teachers, was tested in first- and second-grade classrooms in 19 Baltimore City Public Schools beginning in the 1985-1986 school year. The intervention was directed at the classroom as a whole to socialize children to the student role and reduce aggressive, disruptive behaviors, confirmed antecedents of later substance abuse and dependence disorders, smoking, and antisocial personality disorder. This article reports on impact to ages 19-21. In five poor to lower-middle class, mainly African American urban areas, three or four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a curriculum-and-instruction program directed at reading achievement, or (3) the standard program. Balanced assignment of children to classrooms was made, and then, within intervention schools, classrooms and teachers were randomly assigned to intervention or control. By young adulthood significant impact was found among males, particularly those in first grade who were more aggressive, disruptive, in reduced drug and alcohol abuse/dependence disorders, regular smoking, and antisocial personality disorder. These results underline the value of a first-grade universal prevention intervention. A replication was implemented with the next cohort of first-grade children with the same teachers during the following school year, but with diminished mentoring and monitoring of teachers. The results showed significant GBG impact for males on drug abuse/dependence disorders with some variation. For other outcomes the effects were generally smaller but in the predicted direction. Kellam, S., Brown, C., Poduska, J., Ialongo, N., Wang, W., Toyinbo, P., Petras, H., Ford, C., Windham, A., and Wilcox, H. Effects of a Universal Classroom Behavior Management Program in First and Second Grades on Young Adult Behavioral, Psychiatric, and Social Outcomes. Drug Alcohol Depend., 95 Suppl 1 pp. S05-S28, 2008.

Impact of Two Universal School-Based Preventive Interventions On Young Adult Suicide Ideation and Attempts

This paper reports the impact of two first- and second-grade classroom based universal preventive interventions on the risk of Suicide Ideation (SI) and Suicide Attempts (SA) by young adulthood. The Good Behavior Game (GBG) was directed at socializing children for the student role and reducing aggressive, disruptive behavior. Mastery Learning (ML) was aimed at improving academic achievement. Both were implemented by the teacher. The design was epidemiologically based, with randomization at the school and classroom levels and balancing of children across classrooms. The trial involved a cohort of first-grade children in 19 schools and 41 classrooms with intervention at first and second grades. A replication was implemented with the next cohort of first grade children with the same teachers but with little mentoring or monitoring. In the first cohort, there was consistent and robust GBG-associated reduction of risk for suicide ideation by age 19-21 years compared to youths in standard setting (control) classrooms regardless of any type of covariate adjustment. A GBG-associated reduced risk for suicide attempt was found, though in some covariate-adjusted models the effect was not statistically robust. No statistically significant impact on these outcomes was found for ML. The impact of the GBG on suicide ideation and attempts was greatly reduced in the replication trial involving the second cohort. In conclusion, a universal preventive intervention directed at socializing children and classroom behavior management to reduce aggressive, disruptive behavior may delay or prevent onset of suicide ideation and attempts. The GBG must be implemented with precision and continuing support of teachers. Wilcox, H.C., Kellam, S.G., Brown, C.H., Poduska, J., Ialongo, N., Wang, W., and Anthony, J.C. The Impact of Two Universal Randomized First-And Second-Grade Classroom Interventions on Young Adult Suicide Ideation and Attempts. Drug Alcohol Depend., 95S pp. S60-S73, 2008.

Efficacy of the Parents Who Care Prevention Program at 24 Month Follow-Up

This study was designed to test the efficacy of Parents Who Care (PWC), a seven-session universal prevention program which includes parenting, youth, and family components designed to prevent substance use and other problem behaviors. Using an intent-to-treat experimental design, this study tests the program efficacy across race within a balanced sample of European American and African American youth and their parents (n = 331). Families were recruited and randomly assigned to three conditions: a) group-administered intervention (PA), b) self-administered intervention with telephone support (SA), and c) no-treatment control. The intervention was administered when the adolescents were in the eighth grade. The investigators examined the 24-month impact of the intervention on perceptions of drug use harm, favorable attitudes about drug use, delinquent and violent behavior, and initiation into cigarette, alcohol, other drug use, or sexual activity. Regression analyses with multiple imputations for missing data detected group differences in means at 24-month follow-up. Both program formats reduced favorable attitudes toward drug use among youth (SA d = 0.39, PA d = 0.22); and African American youth in the self-administered intervention reported significantly less violent behavior than their control counterparts (d = 0.45). No effects were found for drug use harm or delinquency. Finally, logistic regression predicting a combined outcome measure of initiation of alcohol, tobacco, drug use, and/or sexual activity found African American youth in both the group- and self-administered intervention conditions significantly less likely to initiate substance use and/or sexual activity than those in the control condition. Odds ratios indicated the chances of initiating sex or substance use were reduced by almost 70% (OR = 0.31) for African American teens in the SA condition compared to controls, and 75% (OR = 0.25) for the African American teens in the PA compared to controls. Haggerty, K., Skinner, M., Mackenzie, E., and Catalano, R. A Randomized Trial of Parents Who Care: Effects on Key Outcomes at 24-Month Follow-up. Prev. Sci., 8(4), pp. 249-260, 2007.

Engagement in Family-Centered Intervention Reduces Problem Behaviors

This research extends previous research on the efficacious Adolescent Transitions Program family prevention program to examine the effects of the program through adolescence and to study the process of treatment engagement and the impact of treatment engagement on adolescent problem behavior. For these analyses the investigator used Complier Average Causal Effect analysis techniques (CACE; see G. Imbens & D. Rubin, 1997) to examine program effects on rates of substance use and antisocial behavior among students ages 11-17. Students were randomly assigned to a family-centered intervention (N = 998) in 6th grade and offered a multilevel intervention that included (as needed) (a) a universal classroom-based intervention, (b) a selective intervention, the Family Check-Up and (c) indicated family management treatment. All services were voluntary, and approximately 25% of the families engaged in the selected and indicated levels. Participation in the Family Check-Up was significantly related to the likelihood of biological fathers being absent from the home, youth reports of elevated family conflict, and teacher reports of elevated risk behaviors at school, suggesting that highly vulnerable families were likely to agree to participate in the intervention. Relative to randomized matched controls, adolescents whose parents engaged in the Family Check-Up exhibited less growth in alcohol, tobacco, and marijuana use and problem behavior during ages 11 through 17, along with decreased risk for substance use diagnoses and police records of arrests by age 18. Connell, A., Dishion, T., Yasui, M., and Kavanagh, K. An Adaptive Approach to Family Intervention: Linking Engagement in Family-Centered Intervention to Reductions in Adolescent Problem Behavior. J. Consult. Clin. Psychol., 75(4), pp. 568-579, 2007.

Therapeutic Interactive Voice Response for Chronic Pain Reduction and Relapse Prevention

Therapeutic Interactive Voice Response (TIVR) is an automated, telephone-based tool for maintenance enhancement following group cognitive-behavioral therapy for chronic pain. TIVR has four components: a daily self-monitoring questionnaire, a didactic review of coping skills, pre-recorded behavioral rehearsals of coping skills, and monthly personalized feedback messages from the cognitive behavioral therapy provider based on a review of the patient's daily reports. The first three components are pre-recorded and all four can be accessed remotely by patients via touch-tone telephone on demand. Following 11 weeks of group therapy, 51 subjects with chronic musculoskeletal pain were randomized to one of two study groups. Twenty-six subjects participated in 4 months of TIVR, while a control group of 25 subjects received standard care only. The TIVR group showed significant improvement (p<.001) over baseline at the 8-month follow-up for seven of the eight outcome measures. Between group analysis of covariance revealed significantly greater improvement for the experimental group at both 4- and 8-month follow ups for most outcomes. Results demonstrate that TIVR can be used to decrease pain, improve coping, and decrease likelihood of relapse into pain behavior. Preliminary analysis of medication usage suggests that the superior outcome of the TIVR group was unlikely to be a consequence of differential medication use. Naylor, M.R., Keefe, F.J., Brigidi, B., Naud, S., and Helzer, J.E. Therapeutic Interactive Voice Response for Chronic Pain Reduction and Relapse Prevention. Pain, 134(3), pp. 335-345, 2008.

Differences in Marijuana and Alcohol Use Trajectories Between Rural and Urban Youth

This study investigated differences in the development of heavy drinking and marijuana use among students in urban and rural areas and assessed whether any such differences can be accounted for by locality differences in racial/ethnic makeup, social disorganization/low social bonding, feelings of despondency and escapism, and the availability of drugs. Drawn from 62 South Dakota middle schools involved in a drug prevention field trial, participating students were assigned to a locality category based on the location of their seventh-grade school. Schools in metropolitan areas were distinguished from schools in nonmetropolitan areas. Schools in nonmetropolitan areas were further distinguished into those in micropolitan (medium and large towns) and noncore (rural areas without towns and with small towns) areas. Latent growth curve analysis was used to model the influence of locality on the development of heavy drinking and marijuana use from ages 13 to 19 and to determine whether differences in development across locality were attributable to location-based differences in race/ethnicity, social disorganization/ bonding, feelings of despondency and escapism, and alcohol and marijuana availability. Heavy drinking increased at a faster rate among youth living in micropolitan areas compared with youth living in metropolitan areas. Marijuana use increased at a faster rate among youth living in metropolitan and micropolitan areas compared with youth living in noncore areas. Differences in the rate of change in heavy drinking were attributable to differences in the racial/ethnic composition of metropolitan and micropolitan areas. Differences in the rate of change in marijuana use were attributable to differences in residential instability and marijuana availability. This study underscores the diversity of drug use within rural communities, suggesting that living in a very rural area is protective against some forms of drug use but that living in a rural area that includes a medium or large town is not. Martino, S., Ellickson, P., and McCaffrey, D. Developmental Trajectories of Substance Use from Early to Late Adolescence: A Comparison of Rural and Urban Youth. J. Stud. Alcohol Drugs, 69(3), pp. 430-440, 2008.

Media Resistance Skills Related to Reduced Alcohol Use Among Inner-City Adolescents

This longitudinal study examined the impact of media resistance skills on subsequent drinking among adolescents residing in inner-city regions of New York City. The study also tested whether drug skill refusal techniques (knowing how to say no to alcohol and other drugs) mediated the relationship between media resistance skills and adolescent drinking. A panel sample of baseline, one-year and two-year follow-ups (N = 1318) from the control group of a longitudinal drug abuse prevention trial participated. A series of structural equations models showed that media resistance skills directly negatively predicted alcohol use 2 years later and that drug skill refusal techniques mediated this effect. Baseline media resistance skills were associated with one-year drug skill refusal techniques, which in turn negatively predicted two-year alcohol use. These findings provide empirical support for including media resistance skills and drug skill refusal techniques in alcohol prevention programs. Epstein, J., and Botvin, G. Media Resistance Skills And Drug Skill Refusal Techniques: What Is Their Relationship With Alcohol Use Among Inner-City Adolescents? Addict. Behav., 33 pp. 528-537, 2008.

Random Drug Testing in US Public High Schools

This study of random drug testing in high schools was conducted within a larger study of the diffusion of evidence-based drug prevention programs in US middle schools. Estimates of the proportion of the nation's public school districts that have high school grades in which random drug testing is conducted were generated. Data were collected in the spring of 2005 from 1343 drug prevention coordinators in a nationally representative sample of school districts with schools that have high school grades. Of these districts, 14% conducted random drug testing. Almost all districts randomly tested athletes, and 65% randomly tested other students engaged in extracurricular activities; 28% randomly tested all students. Ringwalt, C., Vincus, A., Ennett, S., Hanley, S., Bowling, J., Yacoubian, G., and Rohrbach, L. Random Drug Testing in US Public School Districts. Am. J. Public Health, 98(5), pp. 826-828, 2008.

Sexual Risk Behavior in College and Non-College Youth

This study examined sexual risk behavior among a community sample of youth in the fall after their senior year of high school. The primary goal was to examine associations between college and residential status and 3 behaviors: casual sex, inconsistent condom use, and high-risk sex. Data were from 834 participants in the Raising Healthy Children project who were surveyed annually during high school and in the fall of the post-high school year. Thirty percent of participants reported inconsistent condom use, 23% reported casual sex, and 11% reported high-risk sex in the fall after high school. Youth in college were less likely than non-college youth to report sexual risk behavior. The protective association between college attendance on one hand and casual sex and intermittent condom use on the other was fully explained by high school substance use, risky sex, and academic performance. The protective effect of college attendance on high-risk sex was partly explained by high school predictors. Living with parents at age 18-19 years was not related to sexual risk behavior. Results from this study indicate that the higher prevalence of sexual risk behavior among non-college youth is largely a continuation of patterns of higher risk behavior and lower academic performance during high school. Findings suggest that human immunodeficiency virus and sexually transmitted infection prevention efforts are needed among young adults who are not attending college and among high school students who have earned poor grades, used drugs, or engaged in sexual risk behavior. Bailey, J., Fleming, C., Henson, J., Catalano, R., and Haggerty, K. Sexual Risk Behavior 6 Months Post-High School: Associations with College Attendance, Living with a Parent, and Prior Risk Behavior. J. Adolesc. Health, 42(6), pp. 573-579, 2008.

Factors Affecting the Implementation of an Indicated School-Based Prevention Program for Adolescents

This paper presents the organizational factors and program characteristics that promote or hinder the implementation of a school-based drug prevention program, Reconnecting Youth, designed to address academic, substance use and mood management goals among adolescents at risk of dropping out of high school. A randomized controlled effectiveness trial was conducted in 10 schools in two school districts in the United States. Data were collected using surveys and interviews from teachers and school and district staff who participated in the implementation of the program in the study schools. Results suggest that certain program characteristics made it difficult to implement. Small class size, resource-intensive procedures for student selection and recruitment and special training, qualities and skills needed to be an effective Reconnecting Youth teacher meant that schools had to significantly change their usual practices to implement the program. Organization barriers included a lack of financial resources and leadership support for program implementation. Thaker, S., Steckler, A., Sanchez, V., Khatapoush, S., Rose, J., and Hallfors, D.D. Program Characteristics and Organizational Factors Affecting the Implementation of a School-Based Indicated Prevention Program. Health Educ. Res., 23(2), pp. 238-248, 2008.

Self-Regulation Moderates the Association Between Peer Deviance and Antisocial Behavior

This study tests the hypothesis that self-regulation serves as a resiliency factor in buffering youth from negative influences of peer deviance in middle to late adolescence. The interactive effects between peer deviance and self-regulation were investigated on change in antisocial behavior from age 17 to 19 years in an ethnically diverse sample of adolescents recruited for a prevention trial. The current analysis includes data from 655 youth. A multi-agent construct was created using adolescent, parent, and teacher reports of self-regulation and peer deviance. Antisocial behavior was assessed through a 9 item self-report measure of problem behaviors reported in the month prior to the interview. Results indicated that self-regulation shows convergent validity and covaries as expected with developmental patterns of adolescent antisocial behavior. Self-regulation moderated the association of peer deviance with later self-reported adolescent antisocial behavior after controlling for prior levels of antisocial behavior. Gardner, T., Dishion, T., and Connell, A. Adolescent Self-Regulation as Resilience: Resistance to Antisocial Behavior within the Deviant Peer Context. J Abnorm Child Psychol., 36(2), pp. 273-284, 2008.

Defining the At-risk Adolescent Marijuana Nonuser

This research expands the user/nonuser dichotomy commonly used in research on marijuana. By conceptualizing nonusers as homogeneous, vital nuances in susceptibility to risk and protective factors may be overlooked. Research operations tested the predictive validity of a brief measure that divided nonusers into resolute and vulnerable subcategories; determined whether variables that distinguished nonusers and users were more informative when a tripartite classification was used; and with an eye on future prevention, examined variables on which resolute nonusers were similar to vulnerable nonusers or users, and on which they differed from both. A nationally representative sample of respondents (N = 2,111; ages 12-16 years) from the National Survey of Parents and Youth was used in this secondary analysis. Panel data gathered yearly over four rounds included information on intentions and use of marijuana and other illicit substances, along with social, demographic, intrapersonal, and parental variables. The three groups differed significantly on associates' marijuana use, participants' approval of others' use, and cigarette and alcohol use. Resolute nonusers differed from vulnerable nonusers and users alike on religiosity, delinquency (self and friends'), refusal strength, sensation seeking, parental monitoring and warmth, and adult supervision. Results support the utility of distinguishing vulnerable from resolute nonusers, counsel against considering nonusers as a homogeneous group, and provide insight into variables that might prove useful in future prevention efforts. Crano, W., Siegel, J., Alvaro, E., Lac, A., and Hemovich, V. The At-risk Adolescent Marijuana Nonuser: Expanding the Standard Distinction. Prev. Sci., 9(2), pp. 129-137, 2008.

Methods For Integrating Person, Place and Time in Randomized Prevention Trials

Randomized trials in real world settings provide unique opportunities to examine effectiveness and to test and extend both theory of etiology and theory of intervention. These trials are designed not only to test for overall intervention impact but also to examine how impact varies as a function of individual level characteristics, context, and across time. Examination of such variation in impact requires analytical methods that take into account the trial's multiple nested structure and the evolving changes in outcomes over time. The models described in this paper merge multilevel modeling with growth modeling, allowing for variation in impact to be represented through discrete mixtures-growth mixture models-and nonparametric smooth functions-generalized additive mixed models. These methods are part of an emerging class of multilevel growth mixture models, and are illustrated with models that examine overall impact and variation in impact. Intent-to-treat analyses in group-randomized multilevel field trials are defined and appropriate ways to identify, examine, and test for variation in impact without inflating the Type I error rate are discussed. Descriptions are provided for how to make causal inferences more robust to misspecification of covariates in such analyses and how to summarize and present these interactive intervention effects clearly. Practical strategies for reducing model complexity, checking model fit, and handling missing data are discussed using six randomized field trials to show how these methods may be used across trials randomized at different levels. Brown, C.H., Wang, W., Kellam, S.G., Muthen, B., Petras, H., Toyinbo, P., Poduska, J., Ialongo, N., Wyman, P., Chamberlain, P., Sloboda, Z., Mackinnon, D.P., and Windham, A. Methods for Testing Theory and Evaluating Impact in Randomized Field Trials: Intent-To-Treat Analyses for Integrating the Perspectives of Person, Place, and Time. Drug Alcohol Depend., 95S1 pp. 74-104, 2008.

After-School Activities May Predict Delinquency in Youth

The social development model hypothesizes that antisocial behavior in one developmental time period leads to less involvement in activities and interactions that have positive socializing influence in the subsequent developmental period. As a test of the model, analyses were conducted on data from 776 students who participated in the Raising Healthy Children study. Annual survey data from sixth through ninth grade were used to study the relationships among after-school activities, misbehavior in school, and delinquency. Overall correlations between structured activities and both misbehavior in school and delinquency did not suggest a strong protective effect of structured activities. However, results from a cross-lagged model adjusting for prior activity and behavior patterns supported the hypothesis. Consistent with prior research, unstructured activity involvement and delinquent behavior in the first year of high school were positively correlated. These findings point to the beginning of middle school as a crucial time when prior patterns of behavior predict levels of involvement in activities that in turn predict behavioral outcomes. Fleming, C.B., Catalano, R.F., Mazza, J.J., Brown, E.C., Haggerty, K P., and Harachi, T.W. After-School Activities, Misbehavior in School, and Delinquency from the End of Elementary School Through the Beginning of High School. J. of Early Adoles., 28(2), pp. 277-303, 2008.

Enhancing Prediction of Inhalant Abuse Risk Among Adolescents

The theory of reasoned action (TRA) was used to estimate adolescents' vulnerability to inhalant abuse, operationalized by intentions to use or avoid inhalants. The sample consisted of 596 6th and 7th grade children from southwest Arizona. It was drawn from a larger group of 4th through 12th grade schoolchildren that was the basis of Ramirez et al.'s (2004) earlier research on inhalant and marijuana use. Only 6th and 7th graders are included in the present study, as the goal was to identify predictive features of drug use for early adolescents. The gender breakdown was relatively even: 304 (51%) males and 292 (49%) females. Forty two percent of the sample was 6th graders. Most respondents described themselves as White (62.4%), followed by Hispanic (18.8%). The remaining 18.8% reported their ethnicity as Black, Asian, American Indian, or "other." The model correctly differentiated 78% of all respondents (N=596). A second analysis highlighted variables that discriminated properly identified from misclassified youth. False positives, those defined as being at-risk, but who repudiated inhalants, were significantly less likely than their at-risk peers to have used inhalants; they used inhalants and marijuana less frequently; were monitored more closely by parents; and were less rebellious (all p<.05). False negatives, defined as not at-risk, but who had not unequivocally rejected inhalants, were significantly more likely than their similarly classed peers to have used inhalants and marijuana, and to have used both more frequently; also, they were less highly acculturated. This study reaffirmed the utility of the TRA and underscored factors that might improve classification accuracy. This approach may facilitate prevention efforts, and may be extrapolated to any context in which risk categorization is used as a basis for prevention or amelioration. Crano, W., Gilbert, C., Alvaro, E., and Siegel, J. Enhancing Prediction of Inhalant Abuse Risk in Samples of Early Adolescents: A Secondary Analysis. Addict. Behav., 33(7), pp. 895-905, 2008.

Family Functioning and Identity Confusion Affect Substance Use and Sexual Behavior of Hispanic Adolescents

This study examined adolescent-reported family functioning and identity confusion as they relate to onset of substance use and sexual behavior in a sample of 250 Hispanic adolescents from immigrant families ranging in age between 12 and 16 years. Participants were part of a family-centered adolescent HIV prevention trial and completed assessments at baseline, 6 months, 1 year, 2 years, and 3 years. The sample for this study came from families who provided data during at least two of the five time points. Results indicated that adolescents whose identity confusion scores increased over time were most likely to initiate cigarette use, alcohol use, and sexual behavior during the course of the study. Adolescents whose identity confusion scores remained stable over time were less likely to initiate, and adolescents whose identity confusion scores decreased over time were least likely to initiate. Thus, increases in identity confusion during early and middle adolescence may place youth at risk for substance use and sexual risk behavior. In these analyses, family functioning predicted identity confusion and also predicted substance use and sexual behavior initiation. Schwartz, S.J., Mason, C.A., Pantin, H., and Szapocznik, J. Effects of Family Functioning and Identity Confusion on Substance Use and Sexual Behavior in Hispanic Immigrant Early Adolescents. Identity: An International Journal of Theory and Research, 8, pp. 107-124, 2008.

A New Statistical Procedure to Examine Behavioral Transitions

The set of statistical methods available to researchers is continually being expanded, allowing for questions about change over time to be addressed in new, informative ways. Indeed, new developments in methods to model change over time create the possibility for new research questions to be posed. Latent transition analysis, a longitudinal extension of latent class analysis, is a method that can be used to model development in discrete latent variables, for example, stage processes, over 2 or more times. The current article illustrates this approach using a new SAS procedure, PROC LTA, to model change over time in adolescent and young adult dating and sexual risk behavior. Gender differences are examined, and substance use behaviors are included as predictors of initial status in dating and sexual risk behavior and transitions over time. Lanza, S., and Collins, L. A New SAS Procedure for Latent Transition Analysis: Transitions in Dating and Sexual Risk Behavior. Dev. Psychol., 44(2), pp. 446-456, 2008.

Ten Year Follow Up of a Preventive Intervention: Locating Children of Drug Abusers

Longitudinal studies require high follow-up rates in order to maintain statistical power, reduce bias, and enhance the generalizability of results. This study reports on locating and survey completion for a 10-year follow-up of the Focus on Families project, an investigation of 130 families headed by parents who were enrolled in methadone treatment for opiate addiction. Despite having no contact with participants in the study for at least 10 years, the project successfully located nearly 99% of parent participants and 98% of their children. Twenty-four percent of the parents and one child had died before the follow-up. Of the surviving sample, 91% of parents and 86% of the children completed the follow-up interview. Multiple techniques were used to locate study participants, including internet searches, researching court and public records, collaborating with government and service agencies, and contacting family and social networks. For more than half of the sample, costly efforts were required to locate individual participants. Haggerty, K., Fleming, C., Catalano, R., Petrie, R., Rubin, R., and Grassley, M. Ten Years Later: Locating and Interviewing Children of Drug Abusers. Eval. Program Plann. 31(1), pp. 1-9, 2008.

Substance Abuse is Associated with HCV Viremia and HCV Transmission Potential

Co-infection with hepatitis C virus (HCV) is common among HIV-infected women. To further the understanding of risk factors for HCV viremia and the predictors of HCV viral load among women, sociodemographic, immunologic, and virologic factors associated with presence and level of HCV viremia were investigated among 1049 HCV-seropositive women, 882 of whom were HIV-infected and 167 HIV-uninfected at their entry into the Women's Interagency HIV Study. Plasma HCV RNA was detected in 852 (81%) of these 1049 women (range: 1.2-7.8 log(10)copies/ml). HCV-viremic women were more likely to have an HIV RNA level >100,000 copies/ml (p = 0.0004), to have reported smoking (p =0.01), or to be Black (p = 0.005). They were less likely to have current or resolved hepatitis B infection. HCV RNA levels were higher in women who were >35 years old, or HIV-infected. Current smoking and history of drug use (crack/freebase cocaine, marijuana, amphetamines, or heroin) were each associated with both presence and level of viremia. Substance abuse counseling aimed at eliminating ongoing use of illicit drugs and tobacco may reduce clinical progression, improve response to treatment, and decrease HCV transmission by lowering levels of HCV viremia in women. Operskalski, E., Mack, W., Strickler, H., French, A., Augenbraun, M., Tien, P., Villacres, M., Spencer, L., Degiacomo, M., and Kovacs, A. Factors Associated With Hepatitis C Viremia in a Large Cohort of HIV-Infected and -Uninfected Women. J. Clin. Virol., 41(4), pp. 255-263, 2008.

Experienced Consequences of Drinking and Changes in Plans to Drink

This study examined experienced consequences of alcohol use and short-term changes in alcohol use plans and perceptions of the importance of alcohol-related consequences. Participants were 176 traditionally aged first-year university students who completed a 10-week telephone diary study (total weeks=1735). In multi-level models, men and students who experienced more positive and negative consequences on average planned to drink more and rated avoiding negative consequences as less important. Students who experienced more positive consequences rated them as more important (between-person analyses). Following weeks of experiencing relatively more positive drinking consequences, students planned to drink more and rated experiencing positive consequences as more important for the subsequent week (within-person analyses). Challenges for intervening in the ongoing formation of anticipatory cognitions regarding alcohol use are discussed. Patrick, M., and Maggs, J. Short-Term Changes in Plans to Drink and Importance of Positive and Negative Alcohol Consequences. J. Adolesc., 31(3), pp. 307-321, 2008.

Modeling Confidence Intervals Without Distributional Assumptions

Confidence intervals for the intraclass correlation coefficient (ICC) have been proposed under the assumption of multivariate normality. In this study, confidence intervals which do not require distributional assumptions are proposed. A simulation study to assess the coverage rates of normal theory (NT) and asymptotically distribution free (ADF) intervals was performed and the results showed that ADF intervals performed better than NT intervals when kurtosis was greater than 4. When violations of distributional assumptions were not too severe, both the intervals performed about the same. The point estimate of the ICC was robust to distributional violations. Codes for computing the ADF confidence intervals for the ICC are provided. Coffman, D.L., Maydeu-Olivares, A., and Arnau, J. Asymptotic Distribution Free Estimation for an Intraclass Correlation Coefficient with Applications to Longitudinal Data. Methodology, 4(1), pp. 4-9, 2008.

Engaging Communities to Prevent Youth Use of Harmful Legal Products

This study applied the Community Readiness Model (CRM) as part of a multi-stage community mobilization strategy to engage community leaders, retailers, parents, and school personnel in preventing youth use of inhalants and other harmful legal products in rural Alaska. The CRM is designed to assess readiness to address a single social problem, based on a limited set of key informant interviews. In this study, researchers conducted 32 baseline and 34 post-intervention community readiness assessment interviews in four rural Alaskan communities. The aggregate results were analyzed using hierarchical linear modeling (HLM), and the individual community scores were analyzed in the context of the overall study. Significant positive changes in community readiness were found across six readiness dimensions as well as for the overall readiness score. Variation in the degree of changes in readiness across the four communities is attributed to differences in the implementation of the intervention. The implications of these results include the potential for CRM assessments to serve as an integral component of a community mobilization strategy and also to offer meaningful feedback to communities participating in prevention research. Ogilvie, K., Moore, R., Ogilvie, D., Johnson, K., Collins, D., and Shamblen, S. Changing Community Readiness to Prevent the Abuse of Inhalants and Other Harmful Legal Products in Alaska. J. Community Health, 33(4), pp. 248-258, 2008.

The Use of Harmful Legal Products among Pre-adolescent Alaskan Students

This study examined pre-adolescent use of harmful but legally obtainable products (HLPs) "in order to get high" in 4 communities in northwest and southeast Alaska. These products include inhalants, over-the-counter medications, prescription medications taken without a doctor ''s prescription and common household products. A student survey was administered to the 447 students whose parents consented and who agreed to participate. The lifetime overall use of HLPs among fifth, sixth and seventh grade students in 4 Alaskan communities was 17.4%. The lifetime use of inhalants (6.8%) and prescription medications taken without a doctor's prescription (8.0%) appear to be comparable to use rates from other studies. The use of over-the-counter medications (5.7%) appears to be slightly higher than in other U.S. surveys. The use of common household products was 6.1%. No significant differences in the lifetime or 30-day use were found correlated to region, gender, and ethnicity or student grade. There was a strong association between 30-day or lifetime use of some HLPs and the (30-day or lifetime) use of alcohol, cigarettes and smokeless tobacco. The use of harmful everyday legal products by fifth, sixth and seventh graders in Alaska appears to be similar to data collected in other parts of the country. The possibility that there may be a link between the use of available legal substances and alcohol, tobacco and marijuana deserves additional attention. Saylor, B., Fair, M., Deike-Sims, S., Johnson, K., Ogilvie, K., and Collins, D. The Use of Harmful Legal Products among Pre-Adolescent Alaskan Students. Int. J. Circumpolar Health, 66(5), pp. 425-436, 2007.

HIV Disclosure Among Adults Living with HIV

Research on disclosure among heterosexual adult person(s) living with HIV (PLH) was reviewed, omitting disclosure of parental HIV to children. Disclosure has been studied within five additional relational contexts: with partners, family members, friends, healthcare professionals and in work settings. Disclosure is higher among women than men, among Latino and white compared to African-American families, and among younger compared to older HIV-positive adults. Most PLH disclose to their sexual partners and family members, yet there is a significant minority who do not disclose. Similarly, rates of disclosure to employers range from 27-68%, suggesting broad variability in perceived consequences of employment disclosures. Of concern, 40% of PLH do not consistently disclose to their healthcare professionals. Rather than examine HIV disclosures in the context of relationships, it is possible to understand disclosures around personal identity. Disclosure decisions are often made to tell everyone (making HIV status a central attribute of one's identity), no one (requiring strategies for securing social support while remaining anonymous) or some people (requiring strategic decisions based on context). Given that disclosure decisions are central to personal identity, future data on disclosure and interventions designed to increase disclosure or comfort with disclosure must focus on communication strategies adopted by PLH to present a coherent identity. Arnold, E.M., Arnold, E.M.E.R., Flannery, D., and Rotheram-Borus, M.J. HIV Disclosure Among Adults Living with HIV. AIDS Care, 20(1), pp. 80-92, 2008.

Tobacco Use Among Indian Students Attending Government Schools Versus Private Schools

This study examined whether the distribution of tobacco use and related psychosocial risk factors among youth in urban India vary by socioeconomic status (SES). Data were derived from a cross-sectional survey of students enrolled in the 6th and 8th grades in 32 schools in Delhi and Chennai (N = 11,642). The survey was conducted in 2004. Mixed-effect regression models were used (a) to determine the prevalence of tobacco use among private (higher SES) and government (lower SES) school students, (b) to investigate whether certain psychosocial factors were associated with increased tobacco use, and (c) to determine how these factors varied by school type. Ever-use of multiple forms of tobacco (e.g., gutkha, bidis, and cigarettes) was more prevalent among government school students than private school students. After adjusting for city, gender, grade, and age, the authors found the prevalence rate for ever-use of any tobacco product to be 18.9% for government school students, compared with 12.2% for private school students (p<.01). Students in government schools scored lower than private school students on most psychosocial risk factors for tobacco use studied here, indicating higher risk. Government school students scored the lowest for refusal skills, self-efficacy, and reasons not to use tobacco. Social susceptibility to chewing tobacco and social susceptibility to smoking were strong correlates of current tobacco use among government school students. Exposure to tobacco advertising was also a strong correlate of current tobacco use for government school students but not private school students. In two large cities of India, the psychosocial risk profile of government school students suggests they are more vulnerable to initiation and use and to outside influences that encourage use. Mathur, C., Stigler, M., Perry, C., Arora, M., and Reddy, K. Differences in Prevalence of Tobacco Use Among Indian Urban Youth: The Role of Socioeconomic Status. Nicotine Tob. Res., 10(1), pp. 109-116, 2008.

The Association of Tobacco Marketing to Tobacco Use Among Urban Youth in India

This study examined whether receptivity and exposure to tobacco marketing were correlated with tobacco use and psychosocial risk factors for tobacco use among a sample of urban Indian youth. In 2004, sixth and eighth graders (n = 11,642) in 32 schools in Delhi and Chennai, completed a cross-sectional survey from Project MYTRI, a group randomized intervention trial. Analyses indicated that exposure to tobacco advertisements and receptivity to tobacco marketing was significantly related to increased tobacco use among students. This association suggests the need to strengthen policy and program-based interventions in India to reduce the influence of such exposures. Arora, M., Reddy, K., Stigler, M., and Perry, C. Associations Between Tobacco Marketing and Use Among Urban Youth in India. Am. J. Health Behav, 32(3), pp. 283-294, 2008.


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