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Prevention and Treatment of Alcohol Problems: Research Opportunities (1990)

Chapter: 3 Individual-Environment Interactions: Focus on the Individual

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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"3 Individual-Environment Interactions: Focus on the Individual." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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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

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

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

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

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

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

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

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

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

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

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

· Learning to drink alcohol is an integral part of psychosocial development and socialization within a culture. Youthful drinking behaviors, beliefs, attitudes, and expectancies concerning alcohol are formed mainly through the social influences of culture, family, and peers. Much learning takes place before the child or adolescent consumes any alcohol. This learning influence is exerted indirectly through attitudes and expectancies and directly by the models of alcohol consumption provided by peers and family, by media portrayals of drinking, and by other mechanisms through which culturally acceptable or unacceptable habits are inculcated. · Individual differences that predispose a person toward alcohol-related problems may interact with the influence of socializing agents and situational determinants. Such factors may be general (e.g., sensitivity or excessive reactivity to stressful stimuli, mood disorders) or alcoholspecific (e.g., differential vulnerability to alcohol effects, genetic determinants). Predisposing psychosocial factors may include deficits in coping skills or such behavioral excesses as problems with managing emotions (e.g., anger). The absence of normal-drinking role models or the presence of abusive-drinking role models may also result in deficits in an individual's self-regulation of drinking. These factors may increase the risk of alcohol abuse in vulnerable persons. · Direct experience with alcohol becomes important when experimentation with alcohol begins (increasingly early in adolescence). At this point, continued alcohol use may be determined by the direct reinforcing and aversive effects of alcohol and such other proximal determinants as peer pressure and alcohol's stress-reducing properties or the belief that it enhances social interaction. Many of these effects will be mediated by modeling and by socially learned expectations, which may be the predominant determinants of the effects of alcohol (as opposed to pharmacological disinhibition processes). · To the extent that any predisposing individual differences or social learning history factors interact with current situational demands, a person's perception of self-efficacy and coping may be undermined, and alcohol abuse rather than normal use may occur. The probability of continued drinking and eventual abuse is high if the individual is unable to develop alternative and more adaptive ways of coping with immediate (proximal) situational demands. In essence, the major immediate determinants of problematic drinking are high levels of external demand or strain that develop because (a) environmental stresses are exceeding an individual's coping capacity, (b) there is low self-efficacy for alternative coping behaviors, and (c) there are high outcome expectations that alcohol will produce the desired results, while (d) there is minimization or denial of the long-term negative consequences. Individual variations exist in the severity of the immediate proximal demands, the social learning history and genetic vulnerability of the person, the availability of alcohol, the repertoire of current cognitive and behavioral coping skills, and the probability of perceived positive or negative consequences following behavior. Depending on these variables, the individual will abstain, control drinking, have episodic abuse, display problem behaviors, or develop alcohol dependence. · If alcohol use is sustained, an individual will develop a tolerance to its direct reinforcing properties (e.g., stress dampening) that will promote the ingestion of greater quantities to achieve similar effects. Thus, acquired tolerance and other pharmacological factors relating to dependence and withdrawal symptoms will come to control a person's behavior more powerfully than proximal environmental-cognitive interactions. Alcohol consumption can now be independently, negatively reinforced to avoid withdrawal symptoms, and increasing dependence can ensue. Classical conditioning factors, including conditioned cues and the sight and smell of alcohol, can themselves become environmental demands that result in a form of cognitive craving experienced as a desire or urge to drink (see Niaura et al., 1988~. · Any episode of alcohol abuse or problem behavior results in reciprocal individual and social consequences that can affect person-environment interactions in the future. Examples -58

of reciprocal consequences include marital discord, loss of employment, and other changes in social supports. These changes, in turn, may create additional stress that further exacerbates drinking problems. · Recovery after episodes of abusive drinking will require interventions that are different from those used to prevent or reduce the likelihood of problems developing initially (e.g., relapse prevention coning skills trainings - r ---= -- - ~~~ ~~ ~~~~~~~=, Implications of Social Learning Theory for Research on Prevention The central assumptions of a social learning perspective on the prevention of alcohol-related problems suggest various opportunities for prevention research. With respect to prevention, these assumptions place greater emphasis on the here-and-now (proximal) person-env~ronment interactions than on those occurring in the more distant past. Furthermore, the individual is an active agent in the learning process, not a passive recipient. The specific emphasis of prevention activities may differ, depending on the stages of the life span and other factors, but in the social learning view, desirable self regulation of alcohol use and even modulation of behavior when intoxicated are thought to be primarily the result of interaction between current (proximal) individual and situational factors. Specific cognitive information-processing mechanisms (beliefs, expectations, coping skills, self-efficacy) play a central role in regulating alcohol-related behavior (Bandura, 1977, 1986; Marlatt and Gordon, 1985; Wilson, 1987, 1988; O'Leary and Wilson, 1988~. For the most part, health education and health belief models based on knowledge and attitude change can be incorporated into research on cognitive mechanisms, but they are poorly related to behavior and are therefore regarded as necessary but insufficient for change (Goodstadt, 1986~. Selected examples of key concepts requiring more research include self-efficacy, vicarious learning or modeling, and the importance of beliefs and expectations of reward. A social learning perspective assigns central importance to the construct of self-efficacy to explain how behavior patterns are acquired and how they are maintained in the face of external pressures and temptations (Bandura, 1977, 1986~. Self-efficacy refers to an individual's perception of his or her capability to execute a particular course of action and his or her confidence in the mastery of the skills required to cope with a situation (Abrams and Niaura, 1987; Wilson, 1987, 1988~. Efficacy judgments are thought to influence a person's choice of action, effort expended, perseverance in the face of resistance, and quality and strength of performance in a specific situation. There are four mechanisms (listed here in order of power or importance) that can alter efficacy expectations: (1) actual performance accomplishments and corrective feedback that result in a change in behavior (e.g., skills training in a specific situation); (2) modeling or vicarious learning--observing others and their success or failure, as well as the similarity between the role model and oneself (e.g., identification with a sports star); (3) social persuasion (e.g., psychotherapy, verbal admonitions, or attempts at knowledge or attitude change); and (4) direct physiological changes during task performance (e.g., tension reduction or experiences of pleasure). More research is needed to determine the various ways these basic principles can be applied to alcohol prevention research and its applications. 59

Observational learning, both modeling and imitation, is considered to be of central importance in understanding such factors as peer pressure to drink, media influences, and the development of perceived social norms and expectations of what is appropriate and inappropriate behavior when intoxicated. MacAndrew and Edgerton (1969) relied heavily on learning through modeling in their anthropological account of drunken behavior. They noted that the wide variation in drinking rituals across cultural groups and ethnic groups could not be explained by biological or pharmacological factors alone (e.g., disinhibition models). Collins and Marlatt (1981) have summarized the modeling literature and concluded that Modeling has a powerful effect wherein the individual's consumption of alcohol will vary to match that of the model. rid r ~7 ~ An understanding of the strong influence of modeling on behavior is essential to develop Prevention Programs. especially among youth and adolescents. Unfortunately, many traditional educational enorts in this area have been ineffective or actually counterproductive because of problems in either their content or their form (Nathan, 1983~. For example, values clarification approaches or educational messages that are designed to modify knowledge or attitudes about alcohol can actually be counterproductive if they heighten an individual's curiosity about drinking without providing specific role models and guidelines on how to self-regulate behavior (e.g., Schlegel, cited in Best et al., 1988~. Nathan (1983) and Wilson (1988) draw attention to a social learning analysis of media portrayals of drinking that is relevant for prevention research (see Chapter 4~. Another important element in social learning theory is that of learned expectancies and expectancy sets. Marlatt (1976, 1984) has postulated that people learn to expect short-term positive consequences from drinking and to minimize the longer term negative consequences. Also, as part of its stress-dampening effect, alcohol forestalls negative emotional reactions in many individuals because it blocks the memory of adverse consequences (Skier and Levenson, 1982~. As Marlatt (1984) states, "Freed from the pressures of past painful memories and the anxious anticipation of future negative consequences, the heavy drinker experiences a narrowing of attention to the here and now and increased responsivity to immediate external cues to the exclusion of other past or future events." Thus, expectancies about drinking enable individuals to transform negative feelings into positive feelings or to reduce such negative emotional states as depression, anger, or anxiety. An individual's beliefs and outcome expectations are often better predictors of behavior than the actual consequences of action (Marlatt and Rohsenow, 1980~. A person's expectancy of reward, therefore, is a critical mediating variable that governs alcohol use and abuse, as well as problem behaviors when intoxicated (e.g., violence). It is by now well accepted that many "out-of-control behaviors displayed by individuals when intoxicated are the result of beliefs, expectations, and attributions that are derived from perceived cultural norms. Expectancy theory has significant implications for prevention both in adolescents (Goldman, Brown, and Christiansen, 1987) and in adults. Social learning theory has been used in numerous studies to show that response-contingent positive consequences (reinforcement) increase drinking and negative consequences (punishment) decrease drinking. Based on the principles of operant conditioning, studies in controlled Laboratory settings (Cohen et al., 1971; Nathan and O'Brien, 1971) have shown that alcoholics will restrict their drinking to less than 5 ounces a day if this behavior is positively reinforced. It is thought that the combined effects of social influence that result from modeling and differential reinforcement patterns within the social network of the individual can account for most of the differing rates of alcoholism among different -60

ethnic groups. Vaillant (1983) reports findings which suggest that drinking patterns may be modified by differentially rewarding moderate drinking; they may also change when cultures display immediate, consistent, and predictable disapproval of drunkenness or inappropriate behavior when intoxicated. More research of this type is needed to determine to what extent the principles of operant conditioning can he nnn1ie~ to .cn~r;fi~. t~rae.tc friar the prevention of alcohol abuse. ~_ _, ! _ _ _ r ~w ^~^ In summary, then, social learning theory proposes that excessive drinking and alcohol-related problem behavior are to a large extent learned behaviors (P. M. Miller, 1976~. It is also generally accepted that the acquisition of appropriate behaviors or the weakening of learned behaviors is most readily accomplished early in life. Although recognizing the importance of an individual's social learning history, the social learning approach focuses on the immediate proximal environment as the primary source of behavioral control in the here-and-now. The social learning viewpoint also encourages a coping skills training approach to prevention that emphasizes learning new habits to increase an individual's ability to exercise appropriate self-control while drinking. Other approaches include self-management techniques, such as self-monitoring of blood alcohol levels, cognitive restructuring techniques, and understanding motivational factors and the stages-of-change model (Prochaska and DiClemente, 1982~. These approaches are reviewed briefly below. The Coping Skills Training Approach Traditional progressive disease models of alcoholism assume that drinking problems generally intensity inexorably over time as the disease progresses. In contrast, social learning researchers suggest that many individuals can learn to stabilize or even reduce their drinking by acquiring alternative coping skills, changing life-style habits, and learning safe drinking practices. This hypothesis follows from the critical assumption that drinking problems can be aligned along a continuum of severity ranging from moderate drinking to alcohol dependence. Moderation or the controlled use of alcohol may be more acceptable as a goal for primary and secondary prevention programs than as an alternative to abstinence for the treatment of alcohol dependence (Heather and Robertson, 1983; Marlatt, 1984; Marlatt and Gordon, 1985~. Behavioral coping skills training methods can be used to achieve goals of either abstinence or moderate drinking. The skills that are often taught include drink refusal training and how to cope with peer pressures to drink. Such skills are usually taught in group settings in which role playing, direct practice, rehearsal, and corrective feedback can be provided either by the group or by a professional group leader (see Peer resistance training in school-based programs: Flay, 1984; Killen, 1985; Best et al., 1988~. Other coping skills (e.g., relaxation training, exercise, anger or assertiveness training) are also taught as alternatives to drinking under the assumption that some individuals drink to manage their moods and interpersonal relations. The goal here is to provide these individuals with "functionally equivalents substitutes for drinking, which will provide them with a broader repertoire of responses in stressful situations. Behavioral relapse prevention strategies using many of these techniques have been developed as a way to help former alcoholics maintain sobriety (Marlatt and Gordon, 1985~. Although skills programs were originally designed and evaluated for use in adult alcoholism treatment programs (Chancy, O'Leary, and Marlatt, 1978; Monti et al., 1986), such procedures are also being used in primary and secondary prevention programs with children, -61

young adults, and college students (Mills, Pfaffenberger, and McCarty, 1981; McCarty et al., 1983; Schiffman and Wills, 1985; W. R. Miller and Heather, 1986). More research is needed to identify the skills training techniques and methods of dissemination that may be appropriate for different individuals in different settings and to develop ways of adapting these strategies for broad-scale primary prevention interventions. Self-Management Techniques Self-management techniques lend themselves to preventive interventions. Clients can be taught the basic principles of habit change, using minimal self-help or media-assisted protocols. The techniques involved in this approach include dealing with problem identification and heightening awareness that a problem exists, setting the stage for change by increasing motivation, teaching the appropriate selection of specific methods of change, and providing technologies to maintain and generalize the change. The targets of change may vary, depending on the priorities and targets of prevention (e.g., excessive drinking, acute drinking-related problem behavior). They will also vary with such individual factors as age, life-span stage, gender, and stage of motivation. Self-monitoring is a relatively simple procedure that heightens an individual's awareness of the behavior in question and helps to quantify the frequency, severity, and unique patterns of drinking or the associated problematic target behavior. The information gained from self-monitoring can be compared with normative data so that individuals can judge how far their behavior deviates from the norm (e.g., number of times late to work because of a hangover). Self-monitoring increases a person's self-awareness, and sometimes may result in behavior change without any additional intervention. Research on increasing self-awareness can be useful in both primary and secondary prevention programs. Self-monitoring with feedback can be used to teach individuals how to estimate their blood alcohol levels. A number of public drinking settings now provide instruments that allow people to obtain data to monitor more accurately the severity of their intoxication (Nathan, 1978~. The results of studies on blood alcohol level discrimination and feedback training suggest that many normal social drinkers and even some heavy drinkers can be trained to estimate their blood alcohol level accurately. People can then be taught to titrate their blood alcohol level with such methods as spacing drinks over time, interchanging nonalcoholic drinks with alcoholic beverages, and consuming beverages with a lower alcohol content (Hay and Nathan, 1982; Miller and Munoz, 1982~. Cognitive Restructuring Cognitive restructuring interventions are based on social learning theory models that consider expectancy and self-efficacy to be critical elements in behavior change. In this type of prevention approach, the focus is on the psychological aspects of problem drinking, for example, the thought processes associated with excessive drinking or with drinking-related problem behavior. InteIventions using this approach are designed to modify expectancies, beliefs, attributions, and perceived norms about what is culturally appropriate and inappropriate. As noted earlier, persons who take excessive risks or become violent or sexually overactive when intoxicated may be doing so as a result of learned expectations rather than pharmacological effects (Marlatt and Rohsenow, 1980~. -62

One of the more promising avenues for prevention comes from the study of alcohol outcome expectancies. This area has received widespread attention over the past two decades and has resulted in the development of such psychometrically sound assessment instruments as the alcohol expectancy questionnaire (Goldman, Brown, and Christiansen, 1987~. For example, young drinkers who show a particularly high-risk expectancy profile (expecting alcohol to act as a mood modifier, producing euphoric states and the alleviation of negative moods, as well as to enhance physical and sexual prowess) are individuals who may be at high risk for developing problematic drinking patterns. Outcome expectancies can develop very early in life and can serve as powerful compelling factors that determine future behavior when intoxicated. Research is needed in this field to examine the potential for modifying expectancies and for determining whether such changes are associated with reductions in actual drinking or in drinking-related problem behavior. Cognitive-behavioral prevention programs can be targeted to high-risk individuals or groups. The specific content of the program may depend on the target population and the target behaviors within that population. Motivation and Readiness to Change Behavior Motivational factors are of prime importance for the cognitive- behavioral mechanisms that mediate behavior change. Individuals who are not aware that problems exist are not going to be receptive to any kind of preventive intervention, whether it be focused on education or skills training. Indeed, motivation is a largely unexplored proven- lion area. A useful conceptual model that was first developed in the areas of mental health and smoking cessation (DiClemente and Prochaska, 1982; Prochaska and DiClemente, 1986) postulates stages of readiness to change. Individuals and even groups or whole organizations can vary along a continuum of readiness to change (Abrams et al., 1986~: they may be disinterested in change, in a contemplation phase (considering change but not yet ready), ready for action, or moving into the maintenance and termination of change efforts. Different skills may be appropriate at different stages of readiness. For instance, a person contemplating change may not benefit much from action-oriented skills training because he or she has not yet made a commitment to action. Such individuals display decision-making processes which suggest that, for them, the positive aspects of change have not yet overtaken the negatives; they are not convinced they have a problem that warrants effort to change. Inappropriate pressure toward action could result in a rebellious backlash or increased denial/avoidance of the need for change. The prevention approaches targeted to persons in the contemplation phase would include consciousness raising and supportive efforts to alter the decisional balance. For example, the perceived negative consequences of alcohol abuse may begin to outweigh the perceived benefits of use. Once individuals move from contemplation into readiness for action, the specific prevention strategies change from consciousness raising, support, and education to coping skills training. Research needs to be undertaken to evaluate the stages-of-change model and to document whether the matching of preventive interventions to specific stages will be of value in the prevention of alcohol- related problems. Research using this model can help identify strategies for accelerating change within individuals, organizations, communities, and society at large. Some individuals within society will be on the forefront of change processes (early adopters); these individuals can serve as role models and agents for the social diffusion of change to others. Once a large enough subgroup within a society begins to change its behavioral practices so that a "critical masse is achieved, other individuals who have not yet changed (late adopters) may begin to feel that they are not abiding by current cultural -63

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

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

· 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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A thorough examination of nearly everything known about the prevention and treatment of alcohol problems, this volume is directed particularly at people interested in conducting research and at agencies supporting research into the phenomenon of drinking. The book essentially is two volumes in one. The first covers progress and potential in the prevention of alcohol problems, ranging from the predispositions of the individual to the temptations posed by the environment. The second contains a history and appraisal of treatment methods and their costs, including the health consequences of alcohol abuse. A concluding section describes the funding and research policy emphases believed to be necessary for various aspects of research into prevention and treatment.

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