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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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