Risk and Protective Factors for Alcohol and Other Drug Problems in

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  • Psychological Bulletin1992, Vol. 112. No. 1.64-105

    Cop\right 1992 h> t h e American Psychological Association, I I

    Risk and Protective Factors for Alcohol and Other Drug Problemsin Adolescence and Early Adulthood: Implications

    for Substance Abuse Prevention

    J. David Hawkins, Richard E Catalano, and Janet Y MillerSocial Development Research Group, School of Social Work

    University of Washington

    The authors suggest that the most promising route to effective strategies for the prevention ofadolescent alcohol and other drug problems is through a risk-focused approach. This approachrequires the identification of risk factors for drug abuse, identification of methods by which riskfactors have been effectively addressed, and application of these methods to appropriate high-riskand general population samples in controlled studies. The authors review risk and protective factorsfor drug abuse, assess a number of approaches for drug abuse prevention potential with high-riskgroups, and make recommendations for research and practice.

    In spite of general decreases in the prevalence of the nonmed-ical use of most legal and illegal drugs in recent years, the abuseof alcohol and other drugs during adolescence and earlyadulthood remains a serious public health problem (Adams,Blanken, Ferguson, & Kopstein, 1990). The consequences ofdrug abuse are acute on both a personal and a societal level. Forthe developing young adult, drug and alcohol abuse under-mines motivation, interferes with cognitive processes, contrib-utes to debilitating mood disorders, and increases risk of acci-dental injury or death. For the society at large, adolescent sub-stance abuse extracts a high cost in health care, educationalfailure, mental health services, drug and alcohol treatment, andjuvenile crime.

    Added to the immediate personal and social costs of adoles-cent drug abuse are the longer range implications for young-sters who continue to abuse alcohol and drugs into adult life.Drug abuse is involved in one third to one half of lung cancerand coronary heart disease cases in adults (R. Blum, 1987).Alcohol and other drugs are major factors in acquired immuno-deficiency syndrome (AIDS), violent crimes, child abuse andneglect, and unemployment. The problems associated with al-cohol and other drug abuse carry costs in lost productivity, lost

    Preparation of this article was supported in part by Grant DA03721from the National Institute on Drug Abuse and by Grant 87-JS-CX-K084 from the Office of Juvenile Justice and Delinquency Prevention.Points of view or opinions expressed are those of the authors.

    Our thanks to George S. Bridges, Elise Lake, Randy Gainey, TimMurphy, John Campos, and Cheryl Yates for their assistance in thepreparation of this article and to Patricia Huling for her managementof the document's creation. Thanks also to Barry Brown, DavidFarrington, Michael Goodstadt, Rolf Loeber, Roger Weissberg, He-lene White, and two anonymous reviewers for their comments ondrafts.

    Correspondence concerning this article should be addressed to J.David Hawkins, Social Development Research Group, School of So-cial Work, University of Washington, 146 N. Canal Street, Suite 211,Seattle, Washington 98103.

    life, destruction of families, and a weakening of the bonds thathold the society together.

    Given the serious consequences of drug and alcohol abuse,considerable effort has been directed toward identifying effec-tive treatment. Until recently, applied research in the substanceabuse field has consisted primarily of experimental trials ofvarious forms of treatment for alcohol and other drug abuse.The goal has been to identify ways to increase the effectivenessof treatment and to prevent relapse following treatment. Strate-gies ranging from self-help to aversive counterconditioninghave been advocated and assessed.

    Many of these studies have demonstrated how abstinencecan be achieved, but long-term maintenance of abstinence hasbeen more difficult. The reinforcing properties of alcohol andother drugs are themselves often reinforced by norms and be-haviors of family members and others in the communities inwhich recovering people live. These combined reinforcementsoften overcome short-term treatment gains. According to thesurgeon general: "For many drug-dependent persons, achievingat least brief periods of drug abstinence is a readily achievablegoal. Maintaining abstinence, or avoiding relapse, however,poses a much greater overall challenge" (Surgeon general, 1988,P. 311).

    Added to disappointment with the staying power of drugtreatment is a growing recognition of the high cost of treatmentand of the inability of existing treatment programs to keep upwith increasing demand. In recent years, these considerationshave stimulated interest in primary prevention of alcohol andother drug abuse.

    This article focuses on the prevention of alcohol and otherdrug abuse among adolescents. A number of views have beenadvanced about what constitutes substance abuse when con-sidering adolescents (Hawkins, Lishner, & Catalano, 1985). Inthis article, adolescent drug abuse is denned as the frequent useof alcohol or other drugs during the teenage years or the use ofalcohol or other drugs in a manner that is associated with prob-lems and dysfunctions. This conception of the problem is not

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  • RISK AND PROTECTIVE FACTORS FOR DRUG PROBLEMS 65

    meant to condone the infrequent use of alcohol or other drugsby teenagers, which is a violation of the law. The present defini-tion simply reflects a recognition that a relatively large propor-tion of teenagers try alcohol or other drugs without becominginvolved in the frequent use of these substances or developingdrug-related problems (Newcomb & Bentler, 1988; Shedler &Block, 1990).

    Cloninger and his colleagues (Cloninger, Bohman, Sigvards-son, & von Knorring, 1985; Cloninger, Sigvardsson, & Boh-man, 1988) have identified two types of alcoholism. One type isassociated with frequent impulsive-aggressive behavior and fol-lows an early onset of alcohol use and alcohol problems in ado-lescence. This type of drug abuse is considered in this article. Itis distinct from alcoholism that develops after age 25, which isnot a focus of the current article.

    Precursors of drug and alcohol problems have been de-scribed as risk factors for drug abuse. Risk factors occur beforedrug abuse and are associated statistically with an increasedprobability of drug abuse. A risk-focused approach seeks toprevent drug abuse by eliminating, reducing, or mitigating itsprecursors. This article suggests that a promising line for pre-vention research lies in testing interventions targeting multipleearly risk factors for drug abuse.

    A risk-focused approach in drug abuse prevention researchand policy is warranted given the apparent success of this ap-proach in reducing risk factors for problems as divergent asheart and lung disease (Bush et al., 1989; Vartiainen, Pallonen,McAlister, & Puska, 1990) and school failure (Berrueta-Cle-ment, Schweinhart, Barnett, Epstein, & Weikhart, 1984). Theapparent failure of early prevention interventions, such as druginformation programs that did not address known risk factorsfor drug abuse (Stuart, 1974; Weaver & Tennant, 1973), alsoargues for this approach.

    Many of the risk factors for adolescent drug abuse also pre-dict other adolescent problem behaviors (Hawkins, Jenson, Ca-talano, & Lishner, 1988). There is evidence that adolescent drugabuse is correlated with delinquency teenage pregnancy, andschool misbehavior and drop out (Elliott, Huizinga, & Menard,1989; Jessor & Jessor, 1977; Zabin, Hardy, Smith, & Hirsch,1986). Comprehensive risk-focused efforts probably can pre-vent other adolescent problem behaviors besides drug abuse.

    If prevention of drug abuse (as denned above) is the goal, thenrisk factors salient for drug abuse rather than for the occasionaluse of alcohol or other drugs should be targeted. A relativelysmall proportion of adolescent drinkers or users are frequent orproblem users (Johnston, O'Malley, & Bachman, 1988; Shedler& Block, 1990). The following review focuses on factors thathave been shown to precede drug abuse.

    Risk Factors for Adolescent Drug Abuse

    Most studies to date have focused on small subsets of identi-fiable risk factors for drug abuse. There is little evidence avail-able regarding the relative importance and interactions ofvarious risk factors in the etiology of drug abuse, althoughcurrent studies are seeking to measure a broader range of iden-tified risk factors. At this time, it is difficult to ascertain, forinstance, which risk factors or combination of risk factors aremost virulent, which are modifiable, and which are specific to

    drug abuse rather than generic contributors to adolescent prob-lem behaviors. Current knowledge about the risk factors fordrug abuse does not provide a formula for prevention, but itdoes point to potential targets for preventive intervention. Im-plications for intervention are considered in this article after areview of known risk factors for drug abuse in adolescence andearly adulthood.

    These risk factors can be roughly divided into two categories.First are broad societal and cultural (i.e., contextual) factors,which provide the legal and normative expectations for behav-ior. The second group includes factors that lie within individ-uals and their interpersonal environments. The principal inter-personal environments in children's lives are families, schoolclassrooms, and peer groups. The risk factors have been de-scribed elsewhere (Hawkins, Lishner, Catalano, & Howard,1986; Kandel, Simcha-Fagan, & Davies, 1986; Newcomb, Mad-dahian, & Bentler, 1986; Simcha-Fagan, Gersten, & Langner,1986) and are summarized here and in the left half