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Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 3 - Prevention of Co-Occurring Disorders - Prevention for Children and Adolescents


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Prevention for Children and Adolescents

The tendency to develop substance abuse and mental disorders often reveals itself at an early age. Thus, many prevention programs and most prevention research efforts focus on children and adolescents in preventing the development of co-occurring substance abuse disorders and mental disorders.

The Window of Opportunity

Data presented in Chapter 1 have shown that co-occurring disorders are evident in childhood and adolescence, and that such disorders tend to develop at an early age (Kessler et al., 1996; Ziedonis, 1995; Coombs and Ziedonis, 1995). Children with serious emotional disturbance are at heightened risk for substance abuse, and youth already struggling with less severe mental disorders are particularly vulnerable to increasing problems as a result of substance use.

Compared to the nationally representative sample of youth in 8th and 10th grades reporting substance use in the National Institute of Drug Abuse's 2000 Monitoring the Future Study (Johnson et al., 2001), youth with serious emotional disturbance entering services in systems of care (CMHS, 1999b) in 1997 and 1998 had higher prevalence rates for use of all substances except inhalants, amphetamines, and tranquilizers across both grades (Manteuffel et al., 2002). More than 40 percent of youth, ages 11 to 17, who had either a substance use diagnosis or moderate to severe functional impairment as a result of substance use, reported problems that included involvement with the police, missing school or work, changing friends to those who drink or use drugs, getting into arguments with family and friends, and getting in trouble in school (Manteuffel et al., 2002).

Further, certain mental disorders among children are more likely than others to lead to later substance abuse. In a meta-analysis of the research related to the development of co-occurring disorders, Dr. Jane Costello and colleagues (2000) found that adolescents with behavioral disorders (e.g., conduct disorders and attention deficit hyperactivity disorder) were most likely to develop a substance abuse disorder.

Adolescents with anxiety or depressive disorders were two to four times more likely than their peers without mental disorders to develop substance abuse disorders, but still less likely than those with behavioral disorders. Costello (2000) found the odds ratios were stronger for substance abuse/dependence disorders than for substance use problems, consistent with findings that mental disorders are associated with more serious substance abuse problems (Merikangas et al., 1998).

Finally, as noted in Chapter 1, epidemiological data suggest that for at least some youth, the presence of a mental disorder may arise before the onset of a substance abuse disorder. The National Co-morbidity Study (Kessler et al., 1996) revealed that among individuals with co-occurring disorders, generally the mental disorder occurs in early adolescence (median age 11), followed by the substance abuse disorder 5 to 10 years later (median age 21).

This finding does not explain the sequencing of all co-occurring substance abuse disorders and mental disorders, particularly since many different factors affect how and when mental and substance abuse disorders may arise. This does not negate research cited earlier which reveals the many different ways in which co-occurring disorders may develop (Mueser et al., 1998). There is a need for research identifying ways to prevent mental disorders in youth with diagnosed substance abuse disorders. However, the knowledge that youth with certain mental disorders, in particular, are vulnerable to the development of substance abuse problems does suggest a window of opportunity for preventing co-occurring disorders.

The window of opportunity to implement prevention strategies may occur even before children reach middle school age. According to SAMHSA's National Household Survey on Drug Abuse, the rate of substance abuse increased with age - from age 12 to 21. Treatment of younger children for depression, anxiety, and other problems may help prevent engagement in high-risk behaviors such as substance use (Manteuffel et al., 2002).

Strong evidence suggests that childhood conduct disorder most often precedes the development of antisocial personality disorder in adults. Both are strongly related to substance use disorders (Kessler et al, 1996; Reiger et al., 1990).

Risk and Protective Factors

Many disciplines are in agreement about the nature of risk factors that predispose youth to problem behaviors and the protective factors that mitigate against negative outcomes. Children who experience pre- and post-natal complications (e.g., fetal alcohol syndrome), whose families live in extreme poverty, in constant conflict, or who are exposed to multiple traumatic events, are at significant risk for developing substance abuse and mental disorders.

Early Risk Factors for Children

The earlier young people experiment with substances of abuse-such as alcohol, tobacco, and marijuana-and the more substances they try, the more likely they are to develop substance abuse problems as adults (NIAAA, 2000; CASA, 1998). The risk factors of fetal alcohol syndrome and methamphetamine exposure relate directly to parents' activities, but inhalants are often a youth's first drug of choice.

Fetal Alcohol Syndrome. Even before they are born, children may be exposed to toxic substances, including tobacco and alcohol that impede normal growth and development. Fetal alcohol syndrome (FAS) is made up of birth defects that are caused by mothers who drink alcohol when they are pregnant. These birth defects can affect how a person's face looks, how a person grows and how a person's brain and nervous system develop (Streissguth et al., 1996).

Of all the substances of abuse, including heroin, cocaine, and marijuana, alcohol can produce the most serious neurobehavioral effects in the fetus, resulting in life-long permanent disorders of memory function (impulse control and judgment) (Institute of Medicine, 1999). In a large study of secondary disabilities in people of various ages with either FAS or fetal alcohol exposure, 94 percent were found to have a history of mental disorders (Streissguth et al., 1996). Other studies that assess social abilities and psychological functioning have indicated impairments in alcohol-exposed children. One such study indicated that alcohol-exposed children had greater problems in such areas as anxiety, social skills and academic achievement (Streissguth et al., 1996).

Methamphetamine. When parents manufacture methamphetamine in the home, their children may be the first victims. The chemicals used to make methamphetamine are highly toxic and tend to affect children more adversely than they do adults, potentially leading to developmental problems, and short-term or permanent brain damage. In some California counties, one-third of children found living in homes with methamphetamine labs tested positive for methamphetamine (West, 2001). Moreover, the likelihood of violence in homes running methamphetamine labs is high - posing an additional risk factor for children. Children's exposure to violence and maltreatment is significantly associated with increased depression, anxiety, posttraumatic stress disorders, anger, greater alcohol use, and lower school attainment (CMHS, 1999a; Singer et al., 1995; Martinez and Richters, 1993; Garbarino et al., 1992).

Inhalants. Inhalants may be the first substance a child abuses, primarily because they are in legal products like spray paint, correction fluid, rubber cement, and nail polish remover that were developed for other purposes. As such, they are readily available and difficult to detect. Use of inhalants can lead to sudden death or long-term damage to the brain, nerve cells, heart and lungs. A 1998 survey found that 2.2 percent of fourth graders and 2.7 percent of sixth graders admitted to sniffing glue and other inhalants on a monthly basis (DEA, 2002). SAMHSA's own data (2001) indicate that 19 percent of adolescents admitted to treatment for using inhalants in 1999 were younger than 12 when they started "huffing."

Common Risk and Protective Factors for Problem Behaviors

In line with its developmental framework, the IOM report describes biopsychosocial risk and protective factors for infants, young children, elementary-age children, and adolescents. By identifying risk factors and applying evidence-based interventions throughout childhood and adolescence, there is opportunity for prevention of co-occurring disorders. Research has disclosed that gender may be a risk factor for behavioral problems only at specific developmental stages. Boys, in general, are more vulnerable to the development of mental disorders in the first decade of life; girls become more vulnerable in the second decade. Poverty and family disharmony have a greater effect on young boys' physical and emotional status than on girls at the same age (Werner and Smith, 1982, 1992, in Davis, 1999). As they enter adolescence, girls become less sure of themselves as they attempt to meet stereotypic gender expectations (Gilligan et al., 1982).

Prevention Programs for Children and Adolescents

Prevention programs need to focus on risk and protective factors that are both identifiable and modifiable, recognize schools as central loci for intervention, and provide long-term support (SAMHSA, 2002c; CSAP, 2000; Davis, 2002; Greenberg, 1999; Olds, 1999; CMHS School Violence Prevention Program, 1999; U.S. NIDA, 1997a; GAO, 1995; Mrazek and Haggerty, 1994). Children and adolescents at risk for co-occurring substance abuse disorders and mental disorders have multiple and complex needs, and they interact with a variety of school, community and social service agencies. Effective prevention programs must address the multiple domains in the life of a child and the family and promote a consistent message among key agents (e.g., parents, peers and teachers) (CSAP, 2001; NIDA, 1997a). Ideally, prevention programs should be coordinated with systems of treatment to facilitate the best possible outcomes for children and adolescents and their families (Greenberg, 1999). Prevention programs should be sustained over multiple years, e.g., from kindergarten through 12th grade (GAO, 1995), with repeat interventions to reinforce the original prevention goals (NIDA, 1997a). After school programs included in SAMHSA's National Registry for Effective Prevention Programs (NREPP) also demonstrate effective prevention strategies.

Researchers have learned that family-focused prevention efforts have a greater impact than strategies that focus on children only or parents only (NIDA, 1997a). Further, findings of the Yale Family Study of Co-morbidity of Substance Use Disorders and Psychopathology demonstrate that a family history of substance abuse is one of the most potent risk factors for the development of substance abuse among exposed offspring (Merikangas and Avenevoli, 2000). Both individual and environmental factors contribute to this risk. The study revealed that the other major risk factor for the development of substance abuse disorders is pre-existing psychopathology.

Prevention programs must be developmentally and culturally appropriate and gender specific (CSAP, 2001; NIDA, 1997c). Because youth risk and protection influences differ, prevention programs must include relevant gender-based strategies (SAMHSA, 2002c).

Individuals selected to deliver prevention programs must be trained in the intervention (CSAP, 2001). Researchers found that effective interventions use individuals known to the students (peers, parents, teachers, guidance counselors, coaches, etc.) to deliver prevention messages (CSAP, 2001).

Programs that Work

Two programs in the SAMHSA prevention portfolio - the subject of extensive process and outcome evaluation - suggest how the foregoing principles can work and do work to reduce risk factors and enhance protective factors for children and youth. They are the National High-Risk Youth Demonstration Program and the Starting Early Starting Smart (SESS) program. The latter program was implemented in partnership with the Casey Family Programs, a private foundation which provides support for children from foster care to adoption. Both of these programs focus on early identification of problem behaviors and apply interventions to develop resiliency and prevent the onset of substance abuse and/or mental disorders. Each is profiled below.

High-Risk Youth Demonstration Program

From 1987 to 1995, SAMHSA's National High-Risk Youth Demonstration Program funded more than 400 projects that have created a wealth of knowledge about substance abuse prevention (SAMHSA, 2002c). Designed for youth at high risk of substance abuse, the program sought to reduce the effects of such individual, family and community risk factors as a history of suicide attempts or other problems of mental disorders, involvement in violence or other delinquent behavior, leaving school before graduation, a home in which alcohol or drugs are abused, or in which there is physical, sexual or psychological abuse, and an economic disadvantaged environment.

Major findings

. The national 48-site evaluation of the High-Risk Youth Programs revealed that substance abuse prevention produces statistically significant reductions in substance use:

Substance abuse prevention programs reduce rates of substance use. Substance use for participants was 12 percent less at exit than among comparison youth and 6 percent below comparison youth 18 months later. Positive effects of program participation continue for at least 18 months after the program ends.

Youth already using cigarettes, alcohol or marijuana significantly reduced substance use after joining a program. Substance use by participants who reported prior drug use was 10 percent less at exit than comparison youth. Use levels were 22 percent below comparison youth 18 months later.

The evaluation revealed that substance use outcomes were more positive for boys than for girls at program end, but tended to fade by 18 months later. For girls, effects on substance use emerged later and lasted longer (SAMHSA, 2002c). It also revealed important information about the components of particularly successful prevention programs

Starting Early Starting Smart

Starting Early Starting Smart, a four-year grant program and study, began in 1997 as a public-private partnership between SAMHSA and the Casey Family Programs. The grant program's goal was to identify new and effective ways to provide substance abuse prevention and treatment and mental health services to at-risk young children (birth to age 7) and their families by reaching them in settings such as primary health care and early childcare (e.g., Head Start, daycare, preschool). Five of 12 nationwide project sites were housed in primary care physician centers, and the remaining seven sites were housed in early childhood programs.

Major findings

. Preliminary findings from a study of 2,908 children across the 12 sites reveal significant improvements in both child and family functioning:

Participating families reduced verbal aggression in the home 17 percent more than comparison families, where reported verbal aggression increased on average. SESS families reported statistically significant improvements relative to comparison families in use of appropriate discipline, positive reinforcements, and the variety of experiences.

Preschool-aged children in SESS improved significantly in social-emotional and cognitive development relative to comparison youth. These developmental areas are crucial to school readiness. Of particular interest, parents reported that SESS children reduced externalizing problem behaviors 21 percent more than comparison children.


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