|
Items in cart [0] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 47
3
INDIVIDUAL-ENVIRONMENT INTERACTIONS:
FOCUS ON THE INDIVIDUAL
This chapter describes three avenues of research into antecedents of the heavy use of
alcohol and possible interventions to prevent such use. The three perspectives share a
common focus on the individual.
There are obviously many possible approaches to prevention research from the point of
view of the individual alone. A number of these research avenues are presented in IOM's
1987 report, Causes and Consequences of Alcohol Problems. The approaches chosen by
the committee for inclusion in Part I are illustrative of the interactive perspective the
committee believes would be most fruitful for prevention research in alcohol-related
problems: that is, the individual in the context of the environment, both the specific
drinking environment and the broader, total developmental setting.
The first research approach uses life-course development and individual vulnerability as a
framework for research to identify individuals, early in their lives, who may be at high risk
of heavy alcohol use during adolescence. The section also discusses indicators of future
problems with alcohol. Conclusions from this line of research could be used to design
prevention efforts targeted to populations that are identified as being vulnerable. A second
research avenue involves the use of social learning models, which can accommodate genetic,
developmental, and environmental factors in their investigation of etiology and antecedents.
The committee suggests several lines of intervention using this approach that may prevent
problems with alcohol by teaching individuals to alter their behavior. The final research
perspective, the genetic influences on the risk of developing severe alcohol problems or
dependence, is discussed briefly; the committee notes that understanding of these effects is
in an early stage and refers the reader to the first phase of this study (IOM, 1987) for a
more complete treatment of the subject.
Despite their common focus on the individual, some differences among the three
perspectives will be obvious to the reader. Nevertheless, it will become clear that they
are complementary and that insights from each can be useful in preventing the heavy use
of alcohol.
LIFE-COURSE DEVELOPMENT, VULNERABILITY, AND PREVENTION RESEARCH
The perspective on prevention research described in this section is derived primarily from
epidemiological and developmental research and builds on advances in biological,
behavioral, and sociological research. Its main tool is the prospective study, which follows
cohorts or samples of individuals to map, in this case, developmental pathways to the heavy
use of alcohol.
This approach to alcohol problem prevention, with its focus on the development of the
individual, is based on research that searches for those physiological and psychological
factors that interact with life events to produce "high-risk" populations who may be
especially vulnerable to alcohol-related problems. The research findings on which the
-47
OCR for page 48
life-course developmental approach rests--and the implications of this model for preventive
interventions--are presented here with research suggestions that may assist in future
prevention program design and policy development.
The Developmental Approach: Rationale and Definitions
The research avenue described in this section stems from the assumption that a
developmental perspective may be fruitful both for risk-factor research and for preventive
trials in the areas of alcohol and substance use. As stated by Zucker and Noll (1982:316~:
A developmental view of behaviors, including that related to alcohol use and abuse, in its
simplest form implies the ability to link age to drinking phenomena in an orderly way. The
complexity of the problem, however, lies in the ability to trace out the vagaries of this
process, and to specitr the exact pathways and interactions that both anticipate and produce
the drinking behavior and problem or nonproblem sequelae. This implies the ability to
trace out unfolding and maturational phenomena for the individual, as well as ongoing
physiological, psychological, social, and sociocultural events as they affect the unfolding and
are in turn affected by it.
Development is seen as a life-long process that occurs as a result of biological and
environmental determinants and their interaction. Researchers have used this concept to
construct analytical frameworks for the investigation of individual vulnerability to the heavy
use of alcohol. A number of these frameworks are described briefly below.
The Life-Course Events Approach
This perspective (Baltes, Reese, and Lipsitt, 1980) sees behavioral development as shaped
by three major systems of influence:
1. normative age-graded, or ontogenetic, influences--events that occur in very similar
ways for all individuals in a culture or subculture (e.g., biological maturation,
age-determined socialization events involving aspects of the family life cycle, entrance
into and progression through the educational system, entrance into the work force, etc.),
2. normative histoty-graded influences, or cohort effects-- events that occur to most
members of a given generation (a cohort) in a similar manner, although the actual
experience of a history-graded event (e.g., a war or economic depression) may differ for
members of the same as well as different generations, and
3. nonnormative life events--events vary across individuals and that are not shared
across a population (e.g., divorce, loss of a job, having an alcoholic parent).
These three types of influences--age-graded, history-graded, and nonnormative--vary in their
relative effect on an individual at different stages in the life span.
The life-event perspective posits that behavior involving the heavy use of alcohol will be
influenced by all three categories of events. Such normative events as entering high school
or college, leaving home to live on one's own, retirement, and death of a spouse may have
a measurable effect on an individual's substance use. Similarly, history-graded events may
have an impact on a subpopulation or a particular cohort. For example, Prohibition and
its subsequent repeal in the United States during the early part of the twentieth century
influenced the population's use of alcohol. In contrast, the cohort of teenagers and young
-48
OCR for page 49
adults during the late 1960s, the "Woodstock generation," experienced greater acceptance
of drug experimentation and usage, an effect that was not as strongly felt by individuals
who were older or younger. Finally, an individual's use of alcohol will be influenced by
nonnormative or stressful life events that put severe burdens on his or her capacity to cope
with life circumstances and change.
Social Fields
At each stage of life, individuals are involved- in a few major social fields. In the early
years, the dominant field of influence is the family of orientation, followed by school and
classroom influences, and shortly thereafter by the peer group. The intimate social field
develops through adolescence and becomes the marital social field later in the life course.
In adulthood, the work field develops in importance, as does the individual's family of
procreation. There are, altogether, a fairly small number of such social fields, and their
influences vary at each stage of life.
Within each social field, significant people, or Natural raters" (e.g., schoolteacher, parent,
spouse, work supervisor), define social tasks, evaluate efforts, and give feedback to an
individual based on performance expectations. These natural raters can be asked by
researchers to gauge an individual's social adaptational status (SAS), which can be defined
as adequacy of performance in a particular social field at a particular stage of life (Kellam
et al., 1975~. Some childhood SAS ratings have been shown to predict later teenage
outcomes involving the use of alcohol and other substances (Kellam et al., 1983~. Examples
of SAS predictors of later heavy alcohol use include poor school achievement and shy and
aggressive classroom behavior, as rated by teachers (Kellam et al., 1975, 1983~.
Risk Factors: Intraindividual and Environmental Domains
A number of researchers have considered prevention from the vantage of intraindividual
differences that are associated with the heavy use of alcohol. These differences can be
broken down into more specific risk-factor categories:
· neurophysiological variables (Tarter, Alterman, and Edwards, 1985; Heibrun et al.
1986; Baribeau, Ethier, and Braun, 1987~;
· temperament (Tarter, Alterman, and Edwards, 1985~;
· personality variables (Goodwin et al., 1975; Cantwell, 1978; Gaines and Connors,
1982; Folsom et al., 1985; Brooks et al., 1986; Labouvie and McGee, 1986~;
· behavior variables (McCord and McCord, 1960, 1962; Robins, 1966; Jones, 1968.
1971; Vaillant, 1983~; and
· social adaptational status variables (Kellam, Ensminger, and Simon, 1980; Knop et
al., 1985~.
It is also possible to make more fine-grained distinctions within each of these groupings.
Furthermore, some research has indicated that there may be a genetic contribution to the
etiology of alcoholism, possibly mediated through one or more neurophysiological,
temperament, personality, or behavioral variables (Partanen, Bruun, and Markkanen, 1966;
Goodwin et al., 1973, 1974; Begleiter et al., 1984; Cadoret, Troughton, and O'Gorman,
1987; Cloninger, 1987~.
-49
OCR for page 50
Factors that may influence drinking behavior have also been linked to various
environmental domains:
· the family (Zucker and Barron, 1973; Ablon, 1976; Wolin, Bennett, and Noonan,
1979; Wolin and Bennett, 1980; Barnes, Farrell, and Cairns, 1986; Beardslee, Son, and
Vaillant, 1986; Burnside et al., 1986; MacDonald and Blume, 1986; Needle et al., 1986~;
· the peer group (Straus and Bacon, 1953; Alexander and Campbell, 1967; Needle et
al., 1986; Selnow and Crano, 1986~;
· the work setting (Smart, 1979~;
· the community (Gibbons et al., 1986~; and
· broader societal culture (Berger and Snortum, 1986; Dawkins, 1986; Gliksman and
Rush, 1986; Linsky, Colby, and Straus, 1986; Vaillant, 1986~.
Individual -Environment Interaction
Recently, researchers have suggested that certain interactions between risk factors in an
individual and factors in the environment may contribute to the etiology of alcoholism. For
example, a poor match between a child's temperament and parental behavior and style may
heighten the risk for later alcoholism (Tarter, Alterman, and Edwards, 1985~. A genetic
vulnerability combined with particular environmental influences could also determine
whether an individual exhibits problem drinking (Tarter, Alterman, and Edwards, 1985;
Zucker and Gomberg, 1986; Cadoret, Troughton, and O'Gorman, 1987; McCord, 1988a).
Indeed, the diathesis-stress concept that hypothesizes an etiology of schizophrenia spectrum
disorders based on the notion of individual-environment interaction may be relevant to an
understanding of the development of alcohol problems in some individuals.
A further area of research in individual-environment interactions involves the role of
developmental transitions (e.g., entrance into college) in creating conditions that may lead
to problem drinking (see Jessor and Jessor, 1975, 1977~. The majority of individuals
progress through developmental transitions without complications. Why some individuals
are susceptible to episodes of problem drinking or other adverse outcomes during periods
of heightened stress and change is a research question that can be addressed within a
conceptual framework of individual-environment interaction. To carry out this kind of
research, information about both the individual and his or her environment must be
gathered during the planning stage of a study to detect interactions between the two.
Developmental transitions should be seen as potential periods during which environmental
influences may have more pronounced additive or interactive effects on individual
characteristics.
Social adaptational status (SAS) ratings reflect a different kind of individual-environment
interaction. An individual's behavioral response to social task demands within a specific
social field will influence a natural rater's evaluation of performance adequacy. Poor SAS
ratings can serve as markers of an etiologic process that may be leading to a problem
outcome.
The Prospective Study: Characteristics and Advantages
The goal of the life-course developmental approach to prevention is to identitr specific risk
factors that may be useful in devising effective primary prevention programs. Prospective
-50
OCR for page 51
epidemiological studies that follow a cohort of individuals as they progress through
developmental stages in the life course are a particularly important research strategy for
risk-factor identification. Such studies also allow a more complete understanding of the
developmental progression from antecedents to first use, to initiation, to heavy use, to
abuse or dependency on a substance. Earlier work in this area (Kellam et al., 1975,1983;
Kellam, Ensminger, and Simon, 1980; Kellam, Brown, and Fleming, 1982; Kellam and
Werthamer-Larsson, 1986; Kellam, in press) has combined the advantages of a life-course,
developmental orientation and epidemiologically based research to map the developmental
paths to the heavy use of alcohol within defined populations over significant portions of
the life course. Kellam and colleagues have termed this approach developmental
epidemiology.
The prospective study of a cohort of individuals is a major methodological advance over
earlier studies that examined only clinical populations, either at a single point in time or
through retrospective reports (e.g., Vaillant, 1966; Ball and Chambers, 1970; Stephens and
Cottrell, 1972; El-Guebaly and Offord, 1977~. As Kandel (1980) has pointed out, clinical
populations of addicted individuals seen in hospitals or even outpatient clinics represent
very special subgroups of the population of alcohol and other substance users; the risk
factors identified among such groups may not be generalizable to other groups or
populations.
The primary objective of a prospective epidemiological study involving a cohort is to
identify, along developmental pathways, risk factors that heighten the probability of a
problem outcome. A prospective epidemiological research strategy first requires that a
researcher gain the cooperation of an epidemiologically defined population. If possible,
participants should be enrolled early in their development--before initiating alcohol use--to
facilitate the disentanglement of cause from effect. The temporal sequence of such factors
as aggressive or antisocial behavior and heavy alcohol use, which has been hard to
determine in cross-sectional or retrospective studies, is easier to discern when the
prospective method is used and begins with a childhood cohort.
The prospective research strategy also allows for follow-up of multiple-problem outcomes.
In the area of alcohol and other substance use, this capability is especially important
because the heavy use of multiple substances combined with other problem outcomes is not
uncommon (e.g., the co-occurrence of alcohol and drug abuse, of heavy alcohol use and
major depression, and of substance abuse with schizophrenia spectrum disorders).
Multiple-problem follow-up allows researchers to assess the specificity of an antecedent for
a particular outcome; it can also help in gauging the impact of a preventive trial.
A prospective epidemiological methodology eliminates some of the problems of
cross-sectional studies by enabling the same sample to be studied as it progresses through
different developmental stages. Factors that are related to the initiation of alcohol use may
not be the same as factors related to continuing problem use and abuse (Zucker and
Gomberg, 1986~. Continuities and discontinuities over time, both in the development of
attitudes about drinking and in drinking behavior, can be described with the prospective
approach (Christiansen, Goldman, and Brown, 1985~; furthermore, factors that predict
which subgroups will progress through different stages of drinking behavior leading to
alcohol-related problems can be isolated. Multiple pathways leading to similar-appearing
outcomes probably exist, and various theoretical models may be necessary to explain these
different developmental paths (McCord, 1988b).
-51
OCR for page 52
Findings from Prospective Risk-Factor Research
The few available prospective studies that examine the antecedents of heavy alcohol use or
problem drinking have made important contributions to our understanding of the etiology
of these problems. Based on the review by Zucker and Gomberg (1986), consistent findings
that have emerged from this research are noted below.
Antisocial behavior during childhood has been shown to be related to adult alcohol
problems (McCord and McCord, 1960; Robins, Bates, and O'Neal, 1962; Robins, 1966;
Jones, 1968, 1971; Monnelly, Hartl, and Elderkin, 1983; Vaillant, 1983~. In studies of the
Woodlawn community in Chicago, aggressive behavior and the combination of aggressive
and shy behavior in the first grade both were found to predict heavy alcohol use at ages
16 and 17 (Kellam, Brown, and Fleming, 1982; Kellam et al., 1983~. In a finding analogous
to those results, McCord (1988b) found that males who were judged to be shy as children
were least likely to become heavy alcohol users or to engage in criminal behavior as adults,
but those who were rated as both shy and aggressive as children were most likely to
become heavy alcohol users or criminals. In a similar finding, Block, Block, and Keyes
(1988) report an increased risk of later teenage drug use among 3-to 4-year-old children
who displayed aggressive behavior.
Other factors that have consistently predated alcohol problems across many of these
prospective studies include difficulty in school achievement (Robins, Bates, and O'Neal,
1962; Robins, 1966; Jones, 1968, 1971; Monnelly, Hartl, and Elderkin, 1983; Vaillant, 1983),
inadequate parenting (McCord and McCord, 1960; Robins, Bates, and O'Neal, 1962; Robins,
1966; Jones, 1968, 1971; Monnelly, Hartl, and Elderkin, 1983; Vaillant, 1983), marital
conflict in the childhood home (McCord and McCord, 1960; Robins, Bates, and O'Neal,
1962; Robins, 1966; Jones, 1968, 1971; Vaillant, 1983), ethnicity (McCord and McCord,
1960; Robins, Bates, and O'Neal, 1962; Robins, 1966; Vaillant, 1983), hyperactive behavior
(McCord and McCord, 1960; Jones, 1968, 1971), and among males, weak interpersonal ties
(Robins, Bates, and O'Neal, 1962; Robins, 1966; Jones, 1968, 1971; Monnelly, Hartl, and
Elderkin, 1983; Hagnell et al., 1986~. Finally, in their prospective study, Hagnell and
colleagues (1986) found a greatly increased relative risk of alcoholism among men in their
thirties who had used alcohol with their peers 20 years earlier--when they were less than
14 years of age.
Limitations in Existing Prospective Research
There are several important limitations in the prospective studies noted above. Often, the
study samples were not drawn from a representative community population. This problem
limits the generalizability of results, particularly with regard to women and minorities who
have traditionally been underrepresented in such samples. In addition, most samples were
not followed from early childhood; thus, the etiologic role of a host of factors that predate
adolescence is unclear. Moreover, the relative importance and interrelationships of the
various risk factors remain unclear.
Another problem in these studies has been that follow-up contact has not occurred with
sufficient regularity to document continuity or discontinuity in developmental course prior,
during, and subsequent to heavy use. In a recent review of the literature concerning
"spontaneous remission" from alcohol problems, Fillmore and colleagues (1988) describe
variability across the life course by age and sex and suggest that cultural factors may play
-52
OCR for page 53
an important role in structuring observed patterns over multiple generations. Generally,
this observation is consistent with research that suggests that early problems with alcohol
are not necessarily predictive of later problems with alcohol; periodic problem drinking is
much more common than continuous abuse (Vaillant, 1983; Fillmore and Midanick, 1984~.
Certain childhood factors are definitely associated with increased risk either for heavy
drinking in adolescence or for serious alcohol problems in adult life. Yet in the majority
of cases there is no continuity between adolescent problem drinking and alcohol problems
later in life. About 50 to 60 percent of adolescent males and about 75 percent of
adolescent females have been found to "remit" or "mature out" of their problem drinking
patterns. It remains to be learned what the factors are that determine which adolescents
remain vulnerable to continued difficulty with alcohol (Temple and Fillmore, 1985~.
The theories, research approaches, and preventive interventions described in other parts of
this report will generally focus on variables during adult life that are determinants of
drinking behavior, whether or not an enduring vulnerability exists in the drinking individual.
Naturally, when such a vulnerability to problems with alcohol is present, these determinants
(e.g., situational factors) will be all the more powerful.
Research on Preventive Trials: Implications from Prospective Research
Although more sophisticated prospective studies are needed to better understand the
etiology of alcohol problems, there is already sufficient knowledge to direct preventive
trials at specific modifiable antecedents of, and risk factors for, heavy alcohol use and other
substance-related problem outcomes. These preventive trials can test the efficacy of specific
interventions in field settings and, like prospective cohort research, can inform etiologic
theory by experimentally testing plausible causal models.
Chapter 1 of this report presented a threefold model for preventive interventions composed
of universal preventive interventions (directed at the entire population), selected
interventions (directed at a subgroup presumed to be at greater risk for a problem
outcome), and indicated interventions (directed at specific individuals who exhibit indices
of preclinical dysfunction). Universal and selected interventions are considered primary
prevention; indicated preventive interventions are considered secondary prevention (see
Chapter 10~.
The life-course development approach suggests that targeting subgroups which are at
greater risk to receive a preventive intervention may make that intervention more efficient.
(A preventive intervention becomes more efficient as the percentage of program recipients
increases who, but for the intervention, would have developed the disorder.) The
identification of a risk factor that can be linked to a large proportion of cases with the
problem outcome (i.e. a risk factor with a high attributable risk) is a prerequisite for an
efficient, selected prevention study.
Under the selected intervention assumptions, the life-course developmental approach
suggests certain principles that should be applied to the design of interventions to be tested
for the prevention of alcohol and substance-use disorders: (1) interventions should be
designed to conform to the developmental pathways taken by cohorts at each major stage
of life; (2) vulnerable or high-risk individuals may need to participate in more than one
intervention, both within a particular life stage (e.g., adolescence) and across life stages
(e.g., adolescence-young adulthood); and (3) interventions should be embedded within or
-53
OCR for page 54
influence the social fields of family, school, work, and community in which a target
population is active.
A number of studies suggest that there are potentially modifiable targets for selective
approaches to preventive intervention. Tarter, Alterman, and Edwards (1985) integrate
various psychological and biological characteristics associated with vulnerability to alcohol
abuse, using a multidimensional concept of temperament. Variables that characterize the
temperament dimensions linked to heightened risk for alcohol abuse include (1) a high
activity level, (2) a deficit in attention-span persistence, (3) low soothability, (4) high
emotionality, and (5) a disinhibited, impulsive manner of sociability.
Tarter's findings (1985) also present research evidence supporting the hypothesis that there
may be a central nervous system (CNS) dysfunction present in some individuals prior to
the onset of alcohol problems, that influences behavior. If such a CNS dysfunction is part
of a developmental path leading to heavy alcohol use for these individuals, the potential
effectiveness of traditional preventive interventions is questionable. Rather than attempt
to modify the implicated risk factor directly, a "prosthetic" preventive approach could be
taken. This approach would involve development (and testing) of a set of skills and
cognitive coping strategies that a vulnerable individual would be taught or given, much like
a prosthesis, to help compensate for or counteract a temperamental predisposition to abuse
alcohol. Specific temperamental traits that an individual could be taught to control include
impulsive behavior, activity level, and emotional arousal. Additionally, individuals could
learn relaxation and other stress management techniques, as well as problem-solving skills,
that might help prevent the heavy use of alcohol during periods of heightened stress.
As noted earlier, early aggressive behavior in the classroom has consistently been found to
predict heavy alcohol use in late adolescence and early adulthood (Kellam, Brown, and
Fleming, 1982; Kellam et al., 1983), and childhood antisocial behavior has been found to
be a risk factor for alcohol abuse (McCord and McCord, 1960; Robins, Bates, and O'Neal,
1962; Robins, 1966; Jones, 1968, 1971; Monnelly, Hartl, and Elderkin, 1983; Vaillant, 1983~.
Should it be the case for the majority of individuals vulnerable to heavy alcohol use that
these behaviors are learned responses rather than the product of a CNS dysfunction, it
would be possible to develop and test preventive interventions that could be directed at
modification of the behaviors themselves, modification of the environmental contingencies
that reinforce and maintain the behaviors, or both.
Apart from individual characteristics that play a role in the development of alcohol-related
problems, there are influences from various environmental domains. The family is an
important source of influence, as well as an important setting within which preventive
intervention could occur. Wolin, Bennett, and Noonan (1979) and Wolin and Bennett
(1980) have found evidence to support the hypothesis that children from alcoholic families
that have not maintained important family rituals during periods in which there is severe
parental drinking are more likely to develop alcohol problems than are children from
families with an alcoholic parent that have been able to maintain their rituals.
In a prospective study, McCord (1988b) examined the intergenerational transmission of
alcoholism and found evidence that men with alcoholic fathers were more likely to become
alcoholics themselves if the mother seemed to accept her husband's intoxicated behavior
and to hold him in high esteem. These findings suggest that one developmental path to
alcoholism in children of alcoholics may stem, in part, from family acceptance of an
alcoholic parent's intoxicated behavior. Preventive interventions targeted to children who
are at risk by virtue of having an alcoholic parent could be designed to modify those family
-54
OCR for page 55
dynamics that lead to the disruption of important family rituals and to family
overacceptance or unwillingness to confront intoxicated behavior in a parent.
The peer group is another source of environmental influence for alcohol and other
substance use that is most salient during the adolescent stage of development (Alexander
and Campbell, 1967; Biddle, Bank, and Marlin, 1980; Needle et al., 1986~. Research
findings suggest that membership in structured, goal-directed groups may protect teenagers
against adolescent substance use (Selnow and Crano, 1986~. The element that appears to
be critical to the protective influence of formal groups is a group norm that does not
expect or approve of substance use. Adolescent participation in nonstructured, informal
peer groups without such a norm appears to increase the risk of substance use.
Pronounced sex differences in vulnerability to alcohol and other substance use remain
unexplained and may have major importance in understanding the origins and paths leading
to problem outcomes. Femaleness as well as shyness appear to be strong inhibitors of both
adolescent delinquency and substance use, and both variables are important to an
understanding of the evolution of these outcomes.
lithe following are opportunities for the next stage of prospective research into the etiology
of heavy alcohol use from a developmental/epidemiological perspective:
· The next stage of prospective research on heavy alcohol use and alcohol-related
problems should be integrated with research into other problem outcomes (e.g., drug use,
suicide, delinquency, mental disorders). This integration would foster the development of
theoretical models that explain the appearance of both single and multiple problem
outcomes. These models can then be used for planning targeted prevention strategies for
specific subgroups.
· Prospective studies should define and assess intermediate outcomes and stages along
the developmental paths of cohort members. For example, observation at the preschool
stage of development could assess genetic, family, and temperament variables. At the
grade-school stage, researchers might investigate the behavioral responses that are either
known or hypothesized to be antecedents of later alcohol-related problems. At follow-
up in the preadolescent stage, a relevant outcome for assessment could be the initial use
of alcohol; at the adolescent stage, it might be heavy use, whereas in young adulthood the
outcomes of interest might include heavy use, abuse, and dependence. This approach
entails repeated waves of follow-up study and multivariate modeling.
· The factors that influence the heavy use of alcohol should be considered within
intraindividual domains and across environmental domains for their separate and joint
contributions to the etiology of alcohol-related problems. Research should focus not only
on measuring intraindividual and environmental factors that influence an individual's use
of alcohol but also on the interaction of these two categories of influence.
· Particular attention should be paid to transitions among stages of development (e.g.,
transition to school, leaving home, entrance into the work force) as times when
intraindividual factors may interact with conditions in certain environmental domains to
produce alcohol-related problems. Researchers will need to examine how the development
of drinking-related behavior is influenced by such age-graded, normative influences as the
transition to high school and college, as well as such life events as the loss of a job or
divorce.
· Cohort effects (e.g., a period of greater cultural tolerance or intolerance of substance
use) must be taken into account to understand the etiology of alcohol and other
55
OCR for page 56
substance-use problems for a specific cohort of a particular culture in a given historical
period.
· Multistage sampling provides the needed bridge for linking large-scale, prospective
research to studies based on more frequent or precise observations of smaller samples.
Probability samples can be drawn from a defined population, or the entire population or
cohort may be used for assessment, followed by a second sample drawn from the first. This
second-stage sample can be drawn to represent the strata of the first sample, as well as the
total population that was originally sampled. A third-stage sample can be drawn from the
second sample, which represents strata-from the second and the first. This method allows
increasingly intensive assessments to be done on suitably small but representative
subsamples.
Importance of Longitudinal Data Bases
The longitudinal data on which life-course developmental research now rests are extremely
important as a national resource for the next stage of prevention research. Yet some
longitudinal data sets are in immediate jeopardy of disappearing due to a lack of funding.
There is now no mechanism other than the individual research grant by which to ensure
the continued survival of these data. One proposal that has been discussed is to send data
tapes to a central repository. However, this approach would not include information
concerning documentation, specification of constructs, software languages, and the
conditions under which the data were collected, all of which are necessary for researchers
to be able to draw the most accurate inferences. Therefore, it seems most prudent to find
mechanisms to support and maintain--as well as expand--existing longitudinal data bases,
and to find ways of increasing their accessibility to the research community.
In the search for predictors of future problems with alcohol, there are other possible
sources of data that could be exploited and correlated with longitudinal data bases. For
example, most prevention intervention trials have been carried out separately from
prospective epidemiological research. Yet these prevention trials have yielded data that can
be further analyzed to determine which subgroups are affected by particular kinds of
interventions and how they are affected.
experimentally test the effects of specific
to be targeted for preventive interventions
Further analysis would add to our ability to
predictors. Moreover, the particular subgroups
~ , could be identified by early predictors that have
already been found in prospective epidemiological research.
The following are opportunities for research with expanded longitudinal data bases:
· Analyses of potential predictors of later risk behaviors should be extended to as early
in the life span as possible. Sex differences should be investigated much more intensively,
and the populations that are studied should be described better.
· Researchers should actively seek opportunities to use a profile of multiple outcomes
rather than the single outcome of problematic alcohol use. To construct such a profile,
data bases other than those specifically related to alcohol use should be included, and
parallel agencies to NIAAA should be enlisted for help whenever possible.
-56
OCR for page 57
SOCIAL LEARNING MODELS
As discussed in the section concerning life-course development and vulnerability, theoretical
models that account for the behavior of individuals may be useful in designing
population-based prevention programs because, ultimately, individual behavior change is
necessary for prevention. Prevention research should therefore be directed toward
elucidating those factors within an individual that underlie the drinking behavior and that
may aid or retard the processes of change (Prochaska and DiClemente, 1982; Miller and
Heather, 1986~.
There are several useful models of alcohol use and abuse that focus on the individual and
derive from biological and psychological Drocesses (Blanc and Leonard. 19871. To varying
C7 ~ ~ C, ~ ~ ' ~ ~ ~
. . . . . . .
degrees, these models are based on blobenavloral, cognltlve-emotlonal, and perceived
sociocultural factors that contribute to the development of alcohol-related problems. These
same factors can be used as a guide to intervention strategies.
A variety of antecedent variables have been proposed as predictors or mediators of behavior
in the context of broader theoretical models. These models include problem behavior
theory (Jessor and Jessor, 1977; Jessor, 1984), drug-use stress and drug-use coping skills
hypotheses (Kandel, Kessler, and Margulies, 1978; Abrams, 1983), and models based on
cognitive social learning theory (Bandura, 1977, 1986; Blane and Leonard, 1987~.
Alcohol-related problems have been conceptualized as resulting from low self-esteem and
poor self-concept; moral deficiencies; underlying biochemical imbalances: inanDrooriate
social norms within subcultures; or deficiencies in knowledge, attitudes, intentions, and
alternative coping behaviors (Azjen and Fishbein, 1980; Perry, 1986~. Yet the various
biopsychosocial factors involved in alcohol-related problems, factors that could become
important targets for prevention research and intervention design, are often
underemphasized in prevention program planning. Those who design and implement
intervention programs are often more explicit about their objectives than about the cause
of the process in which they want to intervene (Goodstadt, 1986~.
~ A ~
· . · · ~
Among existing conceptual models, those based on a social learning perspective have
generated a great deal of interest and are discussed in this section. Because social learning
approaches delineate the processes by which individuals acquire and maintain behavior, they
are useful for conceptualizing alcohol prevention research.
. . . .
. . ..
In addition, social learning
models can be coordinated with other models because they incorporate (a) the innate
biological vulnerabilities of the individual, as well as the experience he or she acquires
during the course of development; (b) immediate (proximal) environmental antecedents and
consequences of behavior; and (c) cognitive-behavioral processes that are relevant to an
individual's understanding of how to self-regulate alcohol use and alcohol-related behaviors
(Abrams, 1983; Pomerleau and Pomerleau, 1984~.
A number of studies have focused on social learning theory as it relates to alcohol use and
abuse (Bandura, 1969, 1977, 1986; P. M. Miller, 1976; W. R. Miller, 1980; Marlatt and
Gordon, 1985; Abrams and Niaura, 1987; Blane and Leonard, 1987; Nathan and Niaura,
1987; Wilson, 1987, 1988; Marlatt et al., 1988~. The central concept of the social learning
perspective is reciprocal determinism. Like the life-course developmental approach,
reciprocal determinism emphasizes the interaction between individuals and their
environment and can provide a bridge between microlevel (individual) and macrolevel
(social network, organizational, community, and population) models. Abrams and Niaura
(1987) have summarized the way social learning theorists view the development of problems
of alcohol abuse:
-57
OCR for page 64
norms (Abrams et al., 1986~. The processes of diffusion and cultural change can be
accelerated to modify individual behavior and to select the behaviors that society deems
acceptable for drinking frequency, volume, and comportment (MacAndrew and Edgerton,
1969; Abrams et al., 1986; Abrams and Niaura, 1987~.
Research is also needed to facilitate choosing between different interventions that vale in
cost, complexity, and degree of impact on the target population. In contrast to universal
prevention programs targeted to the whole community or the society. selected preventive
~ntenent~ons could be pnor~t~zed on the basis of (a) prior screening or knowledge of
individual risk factors; (b) intensity of the intervention (including such factors as cost,
degree of individualized skills training, and amount of professional involvement per
a _ ,
individual); and (c) their importance (i.e., in terms of the prevalence of the target behaviors
to be modified and the degree of individual/societal risk or damage caused by them).
Because the matching process could be very costly, matching subgroups to interventions
must first be demonstrated to be superior to universal interventions designed for larger
populations. Perhaps optimal prevention using community-based interventions should
consist of multilevel, multifaceted universal intervention components with a few, selected
individual and small group programs for those who fail to benefit from the more
standardized sets of interventions. Thus, individuals or subgroups are "stepped up" to more
intensive and costly interventions only when less costly approaches have been attempted
and have failed.
The committee recommends controlled trials to test the efficacy of matching versus
mismatching or no matching. Suggested questions for testing include the following: Is it
necessary to have special programs for adolescent children of alcoholics, or could they
benefit as much as other adolescents from general coping skills training programs given to
all adolescents as part of a brief, standardized curriculum package? Is it necessary to
provide skills training that is directed specifically toward alcohol, or can such training
include other drugs and tobacco? To what extent should skills training focus on presumed
underlying vulnerabilities (e.g., low self-esteem or poor self-concept) that may mediate the
risk of alcohol or drug abuse? Research should be encouraged to identity program
components (or combinations of components) that have the largest sustained impact with
the least cost and use of human resources.
Life-Style Change
Prevention research should also consider the process of life-style change over time.
Naturalistic studies and the methods of anthropology could be useful in this area. It is
important to test theories of how changes in life-style are adopted, how they diffuse to
others, and how they either become embedded in cultural norms (maintained) or fade away
(Abrams et al., 1986; Bandura, 1986~. Selected theory-driven questions include these:
What specific factors promote diffusion and cultural norm change? How should individual,
group, organizational, and community-level theoretical models and principles become
integrated into a comprehensive, synergistic blueprint to accelerate the development of
healthy life-style norms? How do individuals influence their social network members, and
how do these network members reciprocally influence individuals? What factors determine
when and how a critical mass is achieved that results in a more permanent normative
change in cultural practices (i.e., the maintenance of desired changes because of reciprocal
reinforcement) (Rogers and Shoemaker, 1971~?
-64
OCR for page 65
Recent developments in motivational constructs, such as models of stages of readiness to
change and associated processes to accelerate change, should be considered and adapted for
alcohol prevention research (Prochaska and DiClemente, 1982, 1985, 1986~. The results
of life-span developmental research indicating the importance of transition periods should
also be integrated into models of the process of change over time. What factors determine
resilience, and what mechanisms allow individuals to "grow out of" acute problem behaviors
over time?
A variety of specific preventive interventions can be developed and evaluated in controlled
trials. The goals of such interventions can vary, ranging from controlled or moderate
alcohol use, to modification of cognitive and behavioral factors that might reduce
alcohol-related problems, to total abstinence in those populations in which abstinence is
indicated (e.g., pregnant women or individuals with chronic alcohol dependence syndrome).
Once there is a clear conceptual model that identifies critical mediating mechanisms and
accurately measures desired changes in endpoints, effective preventive interventions can be
designed based on the principles of individual psychology. Theo~y-driven research provides
the opportunity for testing specific theoretical models and predictions about how and why
prevention interventions work or do not work.
The following are opportunities for research based on social learning models:
· There is a need for synthetic efforts among researchers that could explicate the
multidetermined and reciprocal interactions among behavioral, cognitive, and environmental
processes that bear on the development of alcohol-related problems.
· The role of cognitive-behavioral mediators of drinking and drinking-related behaviors
should be explored to better understand the mechanisms that control these behaviors and
the interventions required to set processes of change in motion.
· Emphasis should be placed on understanding the role of beliefs and expectations in
the acquisition and maintenance of problem drinking practices and behaviors. The
relevance of self-efficacy for prevention should also be explored.
· The use of role modeling and vicarious learning factors should be more thoroughly
explored in prevention research at both the individual and the community levels (em..
media influences).
~, ~
~ ,
· Morel effort needs to be directed toward developing and evaluating coping skills
training for primary and secondary prevention targets.
· Research should focus more on the motivational factors underlying the processes and
stages of readiness to change. How can the process of change be accelerated by considering
stages-of-change models? How can immotive and precontemplative individuals be
persuaded to want to change their practices?
· More research should be done to examine the matching hypothesis and to gather data
to examine the feasibility of cost-effective, stepped-care approaches to prevention. Are
screenings for individual differences and tailored (but costly) treatments worthwhile? If so,
for which subgroups, at what developmental stages, and in which settings?
· Research should attempt to bridge the gap between individual and sociocultural
models and understand how innovations diffuse through society. Studies should focus on
advancing theoretical models of diffusion by extending individual change concepts to group,
social network, organizational, community, and higher levels of social structure.
· Basic assessments, analogue research, and clinical trials are required that will focus
on promising targets for preventive interventions and on understanding their mediating
mechanisms-- when and why treatments work and on whom. What mediating mechanisms
How generalizable are
are crucial for facilitating change? Is timing important?
inte~ventions--to what groups, at what time, and in what contexts?
-65
OCR for page 66
· Research should focus on answering specific questions that test underlying theory
rather than on "racehorse" studies that are eclectic in nature. Do different theoretical
models apply to different targets or stages of individual change?
GENETIC DETERMINANTS OF RISK
Considerable effort continues to be devoted to identifying those genetic factors that may
predispose an individual to alcohol dependence (alcoholism). The types of effort being
employed, the relative success of venous avenues of research, and future research
opportunities are discussed in detail in Causes and Consequences of Alcohol Problems
(IOM, 1987:93~. Consequently, the committee includes only a short summary below.
Briefly, researchers are looking for chromosomal markers, including restriction
fragment-length polymorphisms (RFLPs), and specific genes that predispose an individual
to alcohol dependence; they are also pursuing family studies and linkage analysis and
searching for physiological indicators of susceptibility (IOM, 1987~. This work is promising,
and its results may, in the future, enable health care providers to identify specific
individuals who are genetically at risk and to provide appropriate counseling. However,
these investigations have not yet progressed to the point at which it is possible to
recommend that prevention efforts based on them should be undertaken. At present,
family history is the single best predictor of severe alcohol problems or dependence. As
a group, children of alcoholics are considered to be at high risk, but they are not all
equally at risk. Research should continue to allow more specific identification of those
individuals among the children of alcoholics who are or are not genetically susceptible.
CONCLUSION
This chapter has focused on factors in the individual that may influence the development
of alcohol-related problems. The first concerns individual vulnerabilities from a life-course
perspective; the second describes observational theories derived from a social learning
. . . . .
c,
.
perspective that suggest potential interventions for the prevention of alcohol-related
probRems; and the third briefly notes current work on genetic factors that may predispose
an individual to problems. It is clear that each approach offers promising avenues of
research that can lead to more effective interventions than are now available. Yet a
relatively unexplored issue is how the general principles of social learning can be made
more specific to be useful for individuals of varying susceptibility. Future researchers may
find the matching of particular patterns of susceptibility vulnerability to specific preventive
interventions a very fruitful avenue of investigation.
REFERENCES
Ablon, J. Family structure and behavior in alcoholism: A review of
the literature. In B. Kissin and H. Begleiter, eds. The Biology of Alcoholism, vol. 4,
Social Aspects of Alcoholism. New York: Plenum, 1976.
Abrams, D. B. Assessment of alcohol-stress interactions: Bridging the gap between
laboratory and treatment outcome research. Pp. 61-86 in L. Pohorecky and J. Brick, eds.
Stress and Alcohol Use. New York: Elsevier, 1983.
OCR for page 67
Abrams, D. B., and R. Niaura. Social learning theory of alcohol abuse. Pp. 131-178 in H.
T. Blane and K E. Leonard, eds. Psychological Theories of Drinking and Alcoholism.
New York: Guilford Press, 1987.
Abrams, D. B., J. Elder, T. Lasater et al. A comprehensive framework for conceptualizing
and planning organizational health promotion programs. In M. Cataldo and T. Coates,
eds. Behavioral Medicine in Industry. New York: John Wiley and Sons, 1986.
Alexander, C. N., Jr., and E. Q. Campbell. Peer influences on adolescent drinking. Q. J.
Stud. Alcohol 28:444-453, 1967.
\
Amen, I., and M. Fishbein. Understanding Attitudes and Predicting Behavior. Englewood
Cliffs, NJ: Prentice-Hall, 1980.
Ball, J. C., and C. D. Chambers. The epidemiology of opiate addiction in the United
States. Springfield, IL: Charles C. Thomas, 1970.
Baltes, P. B., H. W. Reese, and L. P. Lipsitt. Life-span developmental psychology. Ann.
Rev. Psychol. 31:65-110, 1980.
Bandura, ~ Principles of Behavior Modification. New York: Holt, Rinehart and
Winston, 1969.
Bandura, ~ Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977.
Bandura, ~ Social Foundations of Thought and Action. Englewood Cliffs, NJ:
Prentice-Hall, 1986.
Baribeau, J. C., M. Ethier, and C. M. Braun. Neurophysiological assessment of selective
attention in males at risk for alcoholism. Electroenceph. Clin. Neurophys. 40:651-656,
1987.
Barnes, G. M., M. P. Farrell, and ~ Cairns. Parental socialization factors and adolescent
drinking behaviors. J. Marriage Fam. 48:27-36, 1986.
Beardslee, W. R., L. Son, and G. E. Vaillant. Exposure to parental alcoholism during
childhood and outcome in adulthood: A prospective longitudinal study. Br. J.
Psychiatry 149:584-591, 1986.
Begleiter, H., B. Projesz, B. Bihari, et al. Event-related brain potentials in boys at risk for
alcoholism. Science 225:1493-1496, 1984.
Berger, D. E., and J. R. Snortum. A structural model of drinking and driving: Alcohol
consumption, social norms, and moral commitments. Criminology 24:139-153, 1986.
Best, J. A, S. J. Thomson, S. M. Santi et al. Preventing cigarette smoking among school
children. Pp. 161-201 in L. Breslow, J. E. Fielding, and L. B. Lave, eds. Annual Review
of Public Health, vol. 9. Palo Alto, CA: Annual Reviews, 1988.
Biddle, B. J., B. J. Bank, and M. M. Marlin. Social determinants of adolescent drinking.
J. Stud. Alcohol 41:215-241, 1980.
-67
OCR for page 68
Blane, H. T., and K E. Leonard. Psychological Theories of Alcohol Use and Abuse.
New York: Guilford Press, 1987.
Block, J., J. H. Block, and S. Keyes. Longitudinally foretelling drug usage in adolescence:
Early childhood personality and environmental precursors. Child Develop. 59:336-355,
1988.
Brooks, J. S., ~ S. Gordon, M. Whiteman et al. Dynamics of childhood and adolescent
personality traits and adolescent drug use. Dev. Psychol. 22:403-414, 1986.
Burnside, M. A, P. E. Baer, R. J. McLaughlin et al. Alcohol use by adolescents in
disrupted families. Alcoholism 10:274-278, 1986.
Cadoret, R. J., E. Troughton, and T. O'Gorman. Genetic and environmental factors in
alcohol abuse and antisocial personality. J. Stud. Alcohol 48:1-8, 1987.
Cantwell, D. P. Hyperactivity and antisocial behavior. J. Am. Acad. Child Psychiatry
17:252-262, 1978.
Chaney, E. F., M. R. O'Leary, and G. ~ Marlatt. Skill training with alcoholics. J.
Consult. Clin. Psychol. 48~3~:305-316, 1978.
Christiansen, B. A, M. S. Goldman, and S. ~ Brown. The differential development of
adolescent alcohol expectancies may predict adult alcoholism. Addict. Behav.
10:299-306, 1985.
Cloninger, C. R. Neurogenetic adaptive mechanisms in alcoholism. Science 236:410-416,
1987.
Cloninger, C. R., M. Bohman, and S. Siguardson. Inheritance of alcohol abuse:
Cross-fostering analysis of adopted men. Arch. Gen. Psych. 38:861-868, 1981.
Cohen, M., I. ~ Liebson, L. ~ Faillace et al. Moderate drinking by chronic alcoholics.
I. Nerv. Ment. Dis. 153:434-444,1971.
Collins, R. L., and G. ~ Marlatt. Social modeling as a determinant of drinking behavior:
Implications for prevention and treatment. Addict. Behav. 6:233-239,1981.
Dawkins, M. P. Social correlates of alcohol and other drug-use among youthful blacks in
an urban setting. J. Alcohol Drug Educ. 32:15-28, 1986.
DiClemente, C. C., and J. O. Prochaska. Self-change and therapy change of smoking
behavior: A comparison of processes of change of cessation and maintenance. Addict.
Behav. 7:133-142, 1982.
El-Guebaly, N., and D. R. Offord. The offspring of alcoholics: A critical review. Am. J.
Psychiatry 134:357-365, 1977.
Fillmore, K, and L. Midanik. Chronicity of drinking problems among men: A longitudinal
study. J. Stud. Alcohol 45:228-236, 1984.
-68
OCR for page 69
Fillmore, K M., E. Hartka, B. M. Johnstone et al. Spontaneous remission from alcohol
problems: A critical review. Background paper prepared for the Institute of Medicine
Committee on Alcohol Treatment. 19~.
Flay, B. R. What we know about the social influences approach to smoking prevention:
Review and recommendations. Pp. 67-112 in C. S. Bell and R. Battles, eds. Prevention
Research: Deterring Drug Abuse Among Children and Adolescents. NIDA Research
Monograph No. 63. USDHHS Publ. No. (ADM)85-1334. Rockville, MD: NIDA, 1984.
Folsom, ~ R., J. R. Hughes, J. F. Buehler et al. Do type A men drink more frequently
than type B men? Findings in the multiple risk factor intervention trial (MRFIT).
J. Behav. Med. 8:227-235, 1985.
Gaines, L. S., and G. J. Connors. Drinking and personality: Present knowledge and future
trends. Pp. 331-346 in Alcohol Consumption Related Problems. NIAAA Research
Monograph No. 1. USDHHS Publ. No. (ADM)82-1190. Washington, DC: NIAAA,
1982.
Gibbons, S., M. L. Wylie, L. Echterling et al. Situational factors related to rural adolescent
alcohol use. Int. J. Addict. 21:1183-1195, 1986.
Gliksman, L., and B. R. Rush. Alcohol availability, alcohol consumption, and
alcohol-related damage. II. The role of sociodemographic factors. J. Stud. Alcohol
47:11-18, 1986.
Goldman, M., S. Brown, and B. Christiansen. Expectancy theory--Thinking about drinking.
In H. T. Blane and K E. Leonard, eds. Psychological Theories of Drinking and
Alcoholism. New York: Guilford Press, 1987.
Goodstadt, M. S. Alcohol education research and practice: A logical analysis of the two
realities. J. Drug Educ. 16~4~:349-365, 1986.
Goodwin, D. W., F. Schulsinger, L. Hermansen et al. Alcohol problems in adoptees raised
apart from alcoholic biological parents. Arch. Gen. Psychiatry 28:238-243, 1973.
Goodwin, D. W., F. Schulsinger, N. Molter, et al. Drinking patterns in adopted and
nonadopted sons of alcoholics. Arch. Gen. Psychiatry 31:164-169, 1974.
Goodwin, D. W., F. Schulsinger, L. Hermansen et al. Alcoholism and the hyperactive
child syndrome. J. Nerv. Ment. Dis. 160:349-353, 1975.
Hagnell, O., P. Isberg, J. Lanke et al. Predictors of alcoholism in the Lundby Study. III.
Social risk factors for alcoholism. Eur. Arch. Psychiatry Neurol. Sci. 235:197-199, 1986.
Hay, W. M., and P. E. Nathan, eds. Clinical Case Studies in the Behavioral Treatment of
Alcoholism. New York: Plenum, 1982.
Heather, N., and I. Robertson. Controlled Drinking. London: Methuen, 1983.
Heibrun, ~ B., J. C. Cassidy, M. Diehl et al. Psychological vulnerability to alcoholism:
Studies in internal scanning deficit. Br. J. Med. Psychol. 59:237-244, 1986.
-69
OCR for page 70
Institute of Medicine. Causes and Consequences of Alcohol Problems: An Agenda for
. Research. Washington, DC: National Academy Press, 1987.
Jessor, R. Adolescent development and behavioral health. In J. Matarazzo, S. Weiss, J.
Herd et al., eds. Behavioral Health: A Handbook of Health Enhancement and Disease
Prevention. New York: John Wiley and Sons, 1984.
Jessor, R., and S. L. Jessor. Adolescent development and the onset of drinking: A
longitudinal study. J. Stud. Alcohol 36:27-51, 1975.
Jessor, R., and S. L. Jessor. Problem Behavior and Psychosocial Development: A
Longitudinal Study of Youth. New York: Academic Press, 1977.
Jones, M. C. Personality correlates and antecedents of drinking patterns in adult males.
J. Consult. Clin. Psychol. 32:2-12, 1968.
Jones, M. C. Personality antecedents and correlates of drinking patterns in women. J.
Consult. Clin. Psychol. 36:61-69, 1971.
Kandel, D. B. Drugs and drinking behavior among youth. Ann. Rev. Sociology, 6:235-285,
1980.
Kandel, D. B., R. C. Kessler, and R. Z. Margulies. Antecedents of adolescent initiation
into stages of drug abuse: A developmental analysis. In D. Kandel, ed. Longitudinal
Research on Drug Use: Empirical Findings and Methodological Issues. New York:
John Wiley and Sons, 1978.
Kellam, S. G. Developmental epidemiological framework for family research on depression
and aggression. In G. R. Patterson, ed. Depression and Aggression: Two Facets of
Family Interactions. Englewood Cliffs, NJ: Lawrence Erlbaum Associates, in press.
Kellam, S. G., and L. Werthamer-Larsson. Developmental epidemiology: A basis for
prevention. Pp. 154-180 in M. Kessler and S. E. Goldston, eds. A Decade of Progress
in Primary Prevention. Hanover, NH: University Press of New England, 1986.
Kellam, S. G., C. H. Brown, and J. P. Fleming. The prevention of teenage substance use:
Longitudinal research and strategy. Pp. 171-200 in T. J. Coates, ~ C. Petersen, and C.
Perry, eds. Promoting Adolescent Health: A Dialogue on Research and Practice. New
York: Academic Press, 1982.
Kellam, S. G., M. E. Ensminger, and M. B. Simon. Mental health in first grade and
teenage drug, alcohol, and cigarette use. Drug and Alcohol Depend. 5:273-304, 1980.
Kellam, S. G., J. D. Branch, K. C. Agrawal et al. Mental Health and Going to School:
The Woodlawn Program of Assessment, Early Intervention, and Evaluation. Chicago:
University of Chicago Press, 1975.
~1
Kellam, S. G., C. H. Brown, B. R. Rubin et al. Paths leading to teenage psychiatric
svmotoms and substance use: Developmental epidemiologic studies in Woodlawn. Pp.
17-51 in S. B. Gure, F. J. Earls, and J. E. Barrett, eds. Childhood Psychopathology and
Development. New York: Raven Press, 1983.
-70
OCR for page 71
Killen, J. D. Prevention of adolescent tobacco smoking: The social pressure resistance
training approach. J. Child Psychiatry 26:7-15, 1985.
Knop, J., T. W. Teasdale, F. Schulsinger et al. A prospective study of young men at high
risk for alcoholism: School behavior and achievement. J. Stud. Alcohol 46:273-278,
1985.
Labouvie, E. W., and C. R. McGee. Relation of personality to alcohol and drug abuse in
adolescence. J. Consult. Clin. Psychol. 54:289-293, 1986.
Linsly, A. S., J. P. Colby, Jr., and M. ~ Straus. Drinking norms and alcohol-related
problems in the United States. J. Stud. Alcohol 47:384-393, 1986.
MacAndrew, C., and R. Edgerton. Drunken Comportment. Chicago: Aldine Publishing
Co., 1969.
MacDonald, D. I., and S. B. Blume. Children of alcoholics. Am. J. Dis. Child.
140:750-754, 1986.
Marlatt, G. ~ Alcohol, stress and cognitive control. Pp. 271-296 in J. G. Sarason and
C. D. Spielberger, eds. Stress and Anxiety, vol. 1. Washington, DC: Hemisphere
Publishing, 1976.
Marlatt, G. ~ Alcohol, the magic elixir: Stress, expectancy, and the transformation of
emotional states. Paper presented to the Seventh Annual Coatesville Jefferson
Conference, V.N Medical Center, Coatesville, PA, 1984.
Marlatt, G. A, and J. R. Gordon. Relapse Prevention: Maintenance Strategies in the
Treatment of Addictive Behaviors. New York: Guilford Press, 1985.
Marlatt, G. A, and D. J. Rohsenow. Cognitive process in alcohol use: Expectancy and the
balanced placebo design. In N. K Mello, ed. Advances in Substance Abuse, vol. 1.
Greenwich, CIq: JAI Press, 1980.
Marlatt, G. A, J. S. Baer, D. M. Donovan et al. Addictive behaviors: Etiology and
treatment. Ann. Rev. Psychol. 39:223-252, 1988.
McCarty, D., M. Poore, K C. Mills et al. Direct-mail techniques and the prevention of
alcohol-related problems among college students. J. Stud. Alcohol 44~1~:162-170, 1983.
McCord, J. Alcoholism: Toward understanding genetic and social factors. Psychiatry
51:131-141, 1988a.
McCord, J. Identifying developmental paradigms leading to alcoholism. J. Stud. Alcohol
49:357-362, 1988b.
McCord, W., and J. McCord. Origins of Alcoholism. Stanford, CA: Stanford University
Press, 1960.
McCord, W., and J. McCord. A longitudinal study of the personality of alcoholics. Pp.
413-430 in D. F. J. Pittman and C. R. Snyder, eds. Society, Culture and Drinking
Patterns. New York: John Wiley and Sons, 1962.
-71
OCR for page 72
Miller, P. M. Behavioral Treatment of Alcoholism. Oxford: Pergamon Press, 1976.
Miller, W. R. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking,
and Obesity. New York: Pergamon Press, 1980.
Miller, W. R., and N. Heather. Treating Addictive Behaviors: Processes of Change. New
York: Plenum, 1986.
Miller, W. R., and R. F. Munoz. How to Control Your Drinking. Albuquerque:
University of New Mexico Press, 1982.
Mills, K C., B. Pfaffenberger, and D. McCarty. Guidelines for alcohol abuse prevention
on the college campus. J. Higher Educ. 52~4~:399-414, 1981.
Monnelly, E. P., E. M. Hartl, and R. Elderkin. Constitutional factors predictive of
alcoholism in a follow-up of delinquent boys. J. Stud. Alcohol 44:530-537, 1983.
Monti, P., D. B. Abrams, J. Binkoff et al. The relevance of social skills training for alcohol
and drug abuse problems. In C. Hollin and P. Trower, eds. Handbook of Social Skills
Training. New York: Pergamon Press, 1986.
Nathan, P. E. Studies in blood alcohol discrimination. Pp. 161-175 in P. E. Nathan, G.
Marlatt, and T. Loberg, eds. Alcoholism: New Directions in Behavioral Research and
Treatment. New York: Plenum, 1978.
Nathan, P. E. Failures in prevention. Arn. Psychologist 38:459-467,1983.
Nathan, P. E., and R. S. Niaura. Prevention of alcohol problems. Pp. 333-354 in W. M.
Cox, ed. Treatment and Prevention of Alcohol Problems: A Resource Manual.
Orlando, FL: Academic Press, 1987.
Nathan, P. E., and J. S. O'Brien. An experimental analysis of the behavior of alcoholics
and nonalcoholics during prolonged experimental drinking behavior therapy. Behav.
Ther. 2:455-476, 1971.
Needle, R., H. McCubbin, M. Wilson et al. Interpersonal influences in adolescent drug
use: The role of older siblings, parents, and peers. Int. J. Addict. 21:739-766, 1986.
Niaura, R. S., D. J. Rohsenow, J. ~ Binkoff et al. Relevance of cue reactivity to
understanding alcohol and smoking relapse. J. Abnorm. Psychol. 97~2~:133-152, 1988.
O'Leary, K D., and G. T. Wilson. Behavior Therapy: Application and Outcome, 2nd ed.
Englewood Cliffs, NJ: Prentice-Hall, 1988.
Partanen, J., K Bruun, and T. Markkanen. Inheritance of Drinking Behavior. Helsinki:
Finnish Foundation for Alcohol Studies, 1966.
Perry, C. L. Community-wide health promotion and drug abuse prevention. J. School
Health 56~9~:359-363, 1986.
-72
OCR for page 73
Pomerleau, O. F., and C. S. Pomerleau. Neuroregulators and the reinforcement of
smoking: Towards a biobehavioral explanation. Neuroscience Biobehav. Rev. 8:503-513,
1984.
Prochaska, J. O., and C. C. DiClimente. Transtheoretical therapy: Toward a more
integrative model of change. Psychother. 19:276-288, 1982.
Prochaska, J. O., and C. C. DiClimente. Processes and stages of self-change: Coping and
competence in smoking behavior change. Pp. 319-343 in S. Shif~nan and T. ~ Wills,
eds. Coping and Substance Use. New York: Academic Press, 1985.
Prochaska, J. O., and C. C. DiClimente. Toward a comprehensive model of change. Pp.
3-27 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of
Change. New York: Plenum, 1986.
Robins, L. N. Deviant Children Grown Up. Baltimore, MD: Williams and Wilkins, 1966.
Robins, L. N., W. N. Bates, and P. O'Neal. Adult drinking patterns of former problem
children. Pp. 395-412 in D. Pittman and C. R. Snyder9 eds. Society, Culture, and
Drinking Patterns. New York: John Wiley and Sons, 1962.
Rogers, E. M., and F. F. Shoemaker. Communication of Innovations: A Cross-Cultural
Approach. New York: Free Press, 1971.
Selnow, G. W., and W. D. Crano. Formal vs. informal group affiliations: Implications
for alcohol and drug use among adolescents. J. Stud. Alcohol 47:48-52, 1986.
Sher, K J., and R. W. Levenson. Risk for alcoholism and individual differences in the
stress-response-dampening effect of alcohol. J. Abnorm. Psychol. 91:350-367, 1982.
Shiffman, S., and T. ~ Wills, eds. Coping and Substance Use. New York: Academic
Press, 1985.
Smart, R. G. Dnnking problems among employed, unemployed, and shift workers. J.
Occup. Med. 21:731-736,1979.
Stephens, R., and E. Cottrell. A follow-up of 200 narcotic addicts committed for treatment
under the Narcotic Addiction Act (NARA). Brit. J. Addict. 67:45-53, 1972.
Straus, R., and S. D. Bacon. Drinking in College. New Haven, CI: Yale University Press,
1953.
Tarter, R. E., ~ I. Alterman, and K I. Edwards. Vulnerability to alcoholism in men: A
behavior-genetic perspective. J. Stud. Alcohol 46:329-356, 1985.
Temple, M. T., and K M. Fillmore. The variability of drinking patterns and problems
among young men, ages 16-31: A longitudinal study. Int. J. Addictions 20:1595-1620,
1985.
Vaillant, G. E. A twelve-year follow-up of New York narcotic addicts: Some social and
psychiatric characteristics. Arch. Gen. Psychiatry 15:599-609, 1966.
-73
OCR for page 74
Vaillant, G. E. The Natural History of Alcoholism: Causes, Patterns, and Paths to
Recovery. Cambridge, MA: Harvard University Press, 1983.
Vaillant, G. E. Cultural factors in the etiology of alcoholism: A prospective study. Ann.
N.Y. Acad. Sci. 472:142-148, 1986.
Wilson, G. T. Cognitive process in addiction. Br. J. Addict. 82:343-353, 1987.
Wilson, G. T. Alcohol use and abuse: A social learning analysis. In D. Chaudron and
Wilkinson, eds. Theories of Alcoholism. Toronto: Addiction Research Foundation,
1988.
Wolin, S. J., and L. ~ Bennett. Disrupted family rituals: A factor in the intergenerational
transmission of alcoholism. J. Stud. Alcohol 41:199-214, 1980.
Wolin, S. J., L. ~ Bennett, and D. L. Noonan. Family rituals and the recurrence of
alcoholism over generations. Am. J. Psychiatry 136:589-593, 1979.
Zucker, R. A, and F. H. Barron. Parental behaviors associated with problem drinking
and antisocial behavior among adolescent males. In M. E. Chafetz, ed. Research on
Alcoholism: Clinical Problems and Special Populations. Proceedings of the First
Annual Alcoholism Conference of the National Institute on Alcohol Abuse and
Alcoholism. USDHEW Publ. No. (NIH)74-675. Washington, DC: NIAAA, 1973.
Zucker, R. A, and E. S. L. Gomberg. Etiology of alcoholism reconsidered: The case for
a biopsychosocial process. Am. Psychol. 41:783-793, 1986.
Zucker, R. A, and R. B. Noll. Precursors and developmental influences on drinking and
alcoholism: Etiology from a longitudinal perspective. Pp. 289-327 in Alcohol
Consumption Related Problems. NIAAA Research Monograph No. 1. USDHHS
Publ. No. (ADM) 82-1190. Washington, DC: NIAAA, 1982.
-74
Representative terms from entire chapter:
skills training
