Journal of Child & Adolescent Substance Abuse Preadolescent ...

This article was downloaded by: [Virginia Commonwealth University Libraries] On: 13 August 2015, At: 12:20 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: 5 Howick Place, London, SW1P 1WG

Journal of Child & Adolescent Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wcas20

Preadolescent Psychiatric and Substance Use Disorders and the Ecology of Risk and Protection Michael J. Mason PhD

a

a

Georgetown University Medical Center Published online: 12 Oct 2008.

To cite this article: Michael J. Mason PhD (2004) Preadolescent Psychiatric and Substance Use Disorders and the Ecology of Risk and Protection, Journal of Child & Adolescent Substance Abuse, 13:4, 61-81, DOI: 10.1300/J029v13n04_05 To link to this article: http://dx.doi.org/10.1300/J029v13n04_05

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

Downloaded by [Virginia Commonwealth University Libraries] at 12:20 13 August 2015

Preadolescent Psychiatric and Substance Use Disorders and the Ecology of Risk and Protection Michael J. Mason

ABSTRACT. This paper examines the literature regarding preadolescent (ages 9-12) psychiatric disorders, mental health problems, substance abuse disorders and the ecology of risk and protection. The paper is divided into three primary sections. The first section addresses the challenges in defining and applying disorders for preadolescents. The next section reviews the prevalence of psychiatric disturbances and substance abuse among preadolescents. This section also examines the state of knowledge regarding the emotional problems that do not meet DSMIV criteria as disorders but that may be prodromal for future disorders. The final section reviews risks and preventive factors as well as an ecological theoretical framework that organizes the influences of psychiatric disturbances and substance use. The primary conclusion drawn from this review of the literature is that preadolescence is a critical developmental crossroads for the expression of mental health problems and the Michael J. Mason, PhD, is affiliated with Georgetown University Medical Center. Address correspondence to: Michael J. Mason, PhD, Georgetown University Medical Center, Department of Psychiatry, Kober-Cogan 607, 3800 Reservoir Road NW, Washington, DC 20007-2197 (E-mail: [email protected]). Support for this paper was provided by the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (Contract No. 277-006500). The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Journal of Child & Adolescent Substance Abuse, Vol. 13(4) 2004 http://www.haworthpress.com/web/JCASA  2004 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J029v13n04_05

61

62

JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE

initiation of substance abuse and that researchers and clinicians should pay particular attention to this vulnerable age range. [Article copies avail-


able for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Preadolescent, psychiatric disorders, substance use, ecology, risk factors

An impressive literature has been created on the mental health concerns of children and adolescents. These two age groupings have typically received the most attention from researchers and clinicians. Recently, however, preadolescence has become more prominent in the literature as a critical childhood stage for addressing and preventing mental health problems. Preadolescence is generally defined as a period of childhood between the ages of nine and twelve. A U.S. Department of Health and Human Services agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), has begun to acknowledge preadolescence as an age grouping that is in need of attention from the research and clinical communities (SAMSHA, 1995). Recent research has confirmed the developmental stability of childhood mental disorders across time, thereby highlighting the preadolescent age-range (9-12) as a risky period for the development of these problems (Eccles, Lord, Roeser, Barber, & Hernandez-Jozefowicz, 1997; Kessler & Zhao, 1999; Kosterman et al., 2000; Mesman & Koot, 2001). Research has demonstrated that the age at which one initiates substance use, including alcohol, is predictive of developing a substance abuse problem and of those who will need treatment for substance abuse problems (Ellickson, Hays, & Bell, 1992; Hawkins, Catalano, & Miller, 1992; Kandel & Yamaguchi, 1993; Gruber et al., 1996; Gfroerer, J., & Epstein, J., 1999; Merrill et al., 1999; Kosterman, et al, 2000; Ellickson, Tucker, & Klein, 2001). Further, not only does earlier use place individuals at greater risk for substance abuse disorders, it also increases the risk for the development of other psychiatric disorders (Boyle & Offord, 1991; Brook, Whiteman & Finch, 1992; Kandel et al., 1996; Clark, Kirisci, & Moss, 1998). These data underscore the need for attention to be paid to preadolescence as a critical developmental crossroads for the development of psychiatric disorders and mental health problems. Towards this end, the past 25 years of the psychological, psychiatric, and educational preadolescent literature was reviewed and summarized

Michael J. Mason

63


to create a state of the art analysis. Attempts to accurately characterize this age grouping are very challenging, as many studies do not distinguish discreet age groupings. Therefore, this review will begin with a basic question of how children’s psychiatric and substance abuse disorders are understood and utilized by researchers and clinicians. DEFINING DISORDER Child psychiatric epidemiology is often hindered by the fact that no unequivocal criteria to define mental disturbance in children exist. A number of factors specific to children’s mental disorders complicate the decision on how and where to set the border between normality and pathology or deviance. Some of these factors include the dimensional nature of children’s mental disturbance and the developmental influences and complexities. Children’s unique expression of complicated behavioral and emotional disturbances have not been understood and therefore adult diagnostic criteria has typically been used (Mrazek & Haggerty, 1994; Weckerly, 2002). Difficulties in the assessment of adolescents, for example, may be related to their lack of identity and cognitive development (Winters, 1990). By extrapolation, it would seem that preadolescents would be at least as difficult to assess as adolescents, due to preadolescents’ unique developmental issues, such as the emerging changes brought on by pubertal maturation. The establishment of clear diagnostic criteria, as evidenced by the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1994), has been a major advance for child psychiatric epidemiology, though not without some controversy. Consensual diagnostic criteria have, in turn, facilitated the construction of relatively objective and replicable assessment protocols for determining the presence of disorders. Although the use of these structured assessments has improved the comparability of findings across studies, the methodological problem of information variance remains. Studies have documented, however, that each informant presents some valid information not provided by others (Zahner et al., 1992). Leaders in the field of childhood psychopathology often struggle with the basic question of whether or not a child who meets diagnostic criteria but is functioning well, should be regarded as having a mental disorder (Shaffer, Fisher, & Lucas, 1999). This question generates concern about over-diagnosing of children in various clinical settings. Attention to the inclusion of impairment measures has improved issues


64


with overdiagnosis seen in earlier studies (Bird et al., 1988). In a recent attempt to address over-diagnosing, developmental researchers have highlighted the need to contextualize developmental psychopathology by approaching children’s mental health as a continuously unfolding, dynamic, and changing context (Ciccehetti & Aber, 1998). Other concerns about the accuracy of prevalence rates for children’s psychiatric disorders have been addressed through methodological considerations related to the accuracy of the data collected. For example, when investigating the epidemiology of childhood mental disorders from reports of children themselves, there are comparable methodological concerns about reliability and validity of recall as a function of recall period, developmental status, and the items queried (Costello, Erkanli, Federman, & Angold, 1999). It appears then, that the method of assessment, along with variations in the age range covered, the population studied, and the period assessed, substantially influence all prevalence estimates. MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS AMONG PREADOLESCENTS Mental Health Disorders The recently issued Mental Health: A Report of the Surgeon General reports that there are approximately 6 to 9 million children and adolescents in the United States with serious emotional disturbances, accounting for 9 to 13 percent of all children (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1996; Lavign et al., 1996). Specifically focusing on children, the report states that one in five children suffers from a mental disorder that causes at least minimum impairment–this includes 13 percent who suffer from anxiety disorders, 10.3 percent with conduct disorders, 6.2 percent with mood disorders, and 2.0 percent with substance abuse disorder (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1998). Other recent studies have estimated that the prevalence rate of psychiatric disorders for children in the United States is between 14 and 27 percent (Achenbach & Howell, 1993; Costello and Tweed, 1994; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993). Kazdin (1993), in a review of epidemiological studies, also paints a grim picture, reporting that 17 to 22 percent of children under 18 suffer developmental, emotional, and behavioral problems, accounting for 11 to 14 million children.


Michael J. Mason

65

The prevalence of disruptive behavior disorders (DBD) in boys has been reported as 10 percent in children aged 4 toll years (Offord, Boyle, Fleming, and Blum, 1989). DBD includes attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Epidemiological research on community samples of adolescents has found obsessive-compulsive disorder (OCD) prevalence rates ranging from 1.9 to 3.5 percent (Scahill, Riddle, McSwiggin-Hardin, Ort, King, Goodman, Cicchetti, and Leckman, 1997). Research has also estimated suicidal tendencies (ideation, threats, and attempts) at 12 percent of the general population of preadolescent children (Pfeffer, Zuckerman, Plrutchik, and Mizruchi, 1984). In a recent study, Costello, Erkanli, Federman, and Angold (1999) conducted a re-analysis of five community studies with the goal of using existing data to provide an empirically based estimate of the prevalence of serious emotional disturbance (SED) in children and adolescents. A common definition of the essential components of SED was: a psychiatric diagnosis and significant functional impairment. Two definitions of impairment were used: domain-specific (impairment in one or more of three areas of functioning) and global impairment (functioning in the lowest 10 percent on the overall measure). Results indicated a median estimate of SED with global impairment at 5.4 percent (range 4.3-7.4 percent). Estimates of domain-specific SED ranged from 5.5 to 16.9 percent (median of 7.7 percent). Rates were slightly higher in boys as compared with girls, and poverty doubled the risk of SED. There were no clear ethnic differences in prevalence of SED. Regrettably, only one child in four had received recent mental health care. The Surgeon General’s (1999) report on mental health emphasizes this problem of mental health services utilization: the conclusion that a high proportion of young people with diagnosable mental disorder do not receive any mental health services at all (Burns et al., 1995; Leaf et a1., 1996) reinforces an earlier report by the U.S. Office of Technology Assessment (1986), which indicated that approximately 70 percent of children and adolescents in need of treatment do not receive mental health services. Only one in five children with a serious emotional disturbance used mental health specialty services, although twice as many such children received some form of mental health intervention (Burns et al., 1995). Thus, about 75 to 80 percent fail to receive specialty services, and the majority of these children fail to receive any services at all, as reported by their families.


66


It would appear that in order to adequately serve those children in need of mental health care, clinicians need to provide services where children are principly located. For example, of the children receiving mental health services, most receive services through school or medical settings, underscoring the significance of addressing children’s needs within their natural environments (Werthamer-Larson, 1994). Addressing children in their natural environments seems to be well suited for the researcher as well as for the clinician. For instance, the classroom has a unique context that represents transitional challenges and developmental stresses that have been shown to be significant for the studies of the nature and etiology of disorders and prevention and intervention research (Kellam, Xiange, Merica, Brown, & Ialongo, 1998). Substance Abuse The Monitoring the Future survey has examined drug use among eighth, tenth, and twelfth grade students in American secondary schools since 1975. The survey found that the lifetime prevalence of illicit drug use among students reached a peak in 1979. Rates then declined through the 1980s, hitting a low in 1991 and 1992. A new period of rising lifetime prevalence rates followed, during which the proportion of students reporting any use of illicit drugs increased by 61 percent (from 18 to 29 percent) among eighth graders, 45 percent (from 31 to 45 percent) among tenth graders, and 23 percent (from 44 to 54 percent) among twelfth graders. Over the past three years, these rates have tended to decline slightly and then stabilize for most drugs (Johnston, O’Mally, and Bachman, 2001). Despite this new decline, U.S. secondary school students show a level of involvement with illicit drugs greater than that found in other industrialized nations (Johnston, O’Mally, and Bachman, 2001). The costs of this increased usage are great as children exposed to alcohol or other drugs (AOD) manifest more psychosomatic illnesses, emotional, anxiety, and conduct disorders, along with school problems, including hyperactivity (Werner, Joffe, & Grahm, 1999). While the Monitoring the Future survey measures current drug use among adolescents, it also provides some data on preadolescent use through retrospective questions. Based on retrospective reports from eighth grade students, lifetime prevalence of marijuana use by sixth grade and lower students increased gradually from 0.6 percent in 196869 to a peak of 4.3 percent in 1977-78. Use declined thereafter to a rate of 1.1 percent in 1992. The prevalence then began to increase again, at least in grades six and seven, leveling off in 1995 in grade six and 1996


Michael J. Mason

67

in grade seven (Johnston, O’Malley, and Bachman, 1999). Youth prevalence rates have remained generally stable for the past three years (NIDA, 1999). Substance use differs qualitatively from abuse with the later having much lower prevalence rates than the former. Cohen et al. (1993) found a rate of current marijuana abuse disorder among 10 to 13 year olds of 0.2 percent. While the rates of actual substance abuse disorders among preadolescents appears to be very low, some studies have demonstrated that later substance abuse can be predicted on the basis of preadolescent behavior (Brook, Cohen, Whiteman, and Gordon, 1991; Kandel, 1982; Tarter and Mezzich, 1991). These studies suggest that focusing on risk factors could be of value in the targeting of universal prevention efforts. The work of Gruber, DiClemente, Anderson and Lodico,(1996), Hawkins, Catalano, and Miller, (1992); Kandel and Yamaguchi, (1993), Yu and Williford, (1992), and Ellickson, Hays, and Bell, (1992) regarding possible gateway drugs also suggests that identifying preadolescent drug users may in itself constitute identification of a high risk group for later abuse. To further demonstrate the importance of addressing preadolescent substance initiation, recent research has empirically identified this age group to represent the highest risk for the initiation of substance use. Kosterman, Hawkins, Guo, Catalano, and Abott, (2000), found that the risk for alcohol and marijuana initiation to be the highest between 10.5 and 11 years of age. The risk for alcohol use initiation spans virtually all of adolescence, while the risk for marijuana initiation increases with age through the age of 18 years. Co-Morbidity Among Preadolescents The complexity of dealing with children and adolescents who present substance abuse and psychiatric symptomatology has come to the forefront of the clinical and research communities. In a national representative study of adults and adolescents (as young as age 15) Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, and Kendler (1994) in the National Co-morbidity Study (NCS) found that adolescents had the highest prevalence of co-occurring addictive and mental disorder (COAMD) within the last 12 months (2.1 odds ratio [OR]); the highest of any substance use disorder (3.7 OR); and the highest prevalence of three or more disorders (2.1 OR) compared to the other age groupings. Approximately half of all adolescents receiving mental health services report having a dual disorder or COAMD.


68


The most common co-morbid psychiatric diagnosis for adolescents is conduct disorder (CD). In a rare study that examined preadolescent co-morbidity, Myers, Brown, and Mott, (1995) found that greater diversity of CD behaviors in preadolescents before the initiation of drug involvement corresponds with greater alcohol use but not drug involvement, as shown during a two-year post-treatment follow-up study. Preadolescent CD behaviors were also linked to negative self-statements indicating self-criticism and self-blame as coping responses when faced with a relapse risk situation. Finally, preadolescent interpersonal problems and exposure to alcohol use were found to be the strongest predictors of alcohol use for adolescents with CD. The Substance Abuse and Mental Health Services Administration, (SAMHSA) has further demonstrated the linkage and interactivity between emotional and behavioral problems and substance involvement. Adolescents who demonstrated behavioral and emotional problems were seven times more likely to be dependent on substances than those who presented with fewer symptoms (SAMHSA, 1999). Clearly then, co-morbidity is a major challenge for mental health researchers and practitioners who work with preadolescents. Table 1 provides a summation of the substance use, psychiatric symptoms, and disorders reviewed. Those problems that do not meet DSMIV criteria, substance use and psychiatric symptoms, are also presented along with diagnosed disorders. By way of comparison, children and adolescents are listed separately and then together to provide a fuller picture of the available studies targeting these three categories. Children in these studies ranged from 5 to 12 years of age and adolescents ranged from 13 to 18 years old. RISKS AND CONTRIBUTING FACTORS Of significant relevance to the development of preadolescent mental health and substance abuse disorders are the findings on the factors that appear to contribute to the development of disorder. Various studies suggest that serious disorders that emerge in adolescence or even adulthood can often be predicted on the basis of risk factors detectable in preadolescence and younger (Brook, Cohen, Whitman, and Gordon, 1992; Tarter and Mezzich, 1992; Kellam, Xiange, Merica, Brown, & Ialongo, 1998). Numerous literature reviews of risk factors for mental health disorders are already available (e.g., Clayton, 1992; Kraemer et al., 1997). The existing literature shows considerable areas of agree-

Michael J. Mason

69

TABLE 1. Substance Use, Psychiatric Symptoms, and Disorders Psychiatric Symptoms or Disorders

Sample

Prevalence

Author

Clinical Sample

14%-24%

SAMHSA, 1995

Psychiatric disorders

General population

14%-27%

Achenbach et al., 1993; Costello and Tweed, 1994; Lewinsohn et al., 1993; Mesman & Koot, 2001

Suicidal tendencies

General population

12%

Pfeffer, Zuckerman, Plutchik, and Mizruchi,1984

Disruptive behavior disorders in boys

General population

10%

Offord, Boyle, Fleming, and Blum, 1989

Substance use

General population

29%-54%

Johnston, O'Mally, Bachman, 1998

Marijuana abuse disorder

General population

1.4%-2.9%

Cohen et al.,1993

Substance abuse or dependence

General population

1%-1.8%

Community samples

1.9%-3.5%


Children Substance use

Adolescents

Obsessive-compulsive disorder

Lewinsohn et al., 1993 Scahill, Riddle, McSwiggin-Hardin, Ort, King, Goodman, Cicchetti, & Leckmann, 1997

Children and Adolescents Past 30-day substance use in African American and Latina females, ages 10-16

Convenience sample

Psychiatric disorders, ages 18 and under

General population

12%

Developmental, emotional, and behavioral problems, ages 18 and under

General population

17%-22%

Serious Emotional Disturbance

General population

Marijuana abuse disorder, ages 10-13

General population

0.20%

Substance use disorder, ages 9-16

General population

3.5%-6%

Costello et al., 1999

Substance use, ages 9-16

General population

56.80%


Substance use disorder by age 16

General population

6%


8.4%-15.9% Amaor, Schwartz, Raj, & Winter, 1999 Institute of Medicine, 1989 Kazdin, 1993

4.3%-16.9% Costello et al., 1998 Cohen et al., 1993

70



ment across studies. Some of the variability that does exist in this literature may be the result of looking at simple relationships without considering the complex interactions that underlie the etiology of the disorder. Other sources of variability may result from inadequate measurement of complex constructs. Classes of Vulnerability General classes of vulnerability factors and approaches to studying the vulnerability factors emerge from the risk factor literature. Clayton (1992) provides a topical structure for some of the types of risk factors that could be included in the treatment and prevention of psychiatric and substance abuse disorders. Genetic-Biological. Twin studies and adoptees of mentally ill parents have demonstrated that many mental disorders are in part genetically transmitted (Mechanic, 1999). The role of genetic and biological factors has been strongly supported by twin studies of alcoholism and schizophrenia. Mounting evidence of clustering of other disorders within families has suggested that such disorders as substance abuse or bipolar disorders may have genetic causes (Plomin, 1990; Wallace, 1994; Gershon & Nernberger, 1995; Merikangas, Dierker, & Szatmari, 1998; Schwartz, 1999). Psychological. The exclusive focus on psychological vulnerability factors reflects American psychology’s historical focus on individualism; to assume that most, if not all, etiological factors stem from intrapsychic characteristics. The strong genetic, familial, and environmental evidence has significantly weakened this perspective. Nevertheless, the psychological domain of vulnerability is still an important piece to the total picture of risk and protection. Weinberg and Glantz (1999) report that certain types of child psychopathology, especially conduct disorder and bipolar disorder, serve as very strong risk factors for adolescent substance use disorders. Specifically in preadolescents, a temperament constellation that includes high activity level, negative withdrawal responses to new stimuli, arrhythmicity, rigidity, and distractibility is linked with drug abuse (Blackson, 1994). Disinhibition and novelty seeking behaviors have been correlated with increased substance use in adolescents (Windle & Windle, 1993; Masse & Treblay, 1997). Finally, linking the psychological and the familial, parental psychological resources, such as sense of mastery over life events and self-esteem, have been shown to have both direct and indirect positive effects on chil-


Michael J. Mason

71

dren’s mental health (Clausen, 1991; Menaghan & Parcel, 1991; Moore & Snyder, 1991; Menaghan, 1999). Family. Considerable evidence has documented that children from disrupted families are at greater risk for mental disorders than are children from stable families (Jacobson & Addis, 1993; Willens & Biederman, 1993). This relationship appears to hold whether the research is focusing on parents’ marital discord, divorce, or separation (Emery, 1982; Sandler, Tein, & West, (1994), parental rejection and parentchild conflict (Patterson, 1982), parental substance abuse (Adger, 1998; Clark, Kirisci, & Moss, 1998), or perceived negative quality of overall family relationships (Williams et al., 1990). Children of substance abusers also display poor behavioral inhibition and perform poorly on tests of executive cognitive functioning (Giancola, Martin, Tarter, Pelham, and Moss, 1995). Recently, family researchers have shown that consistent prosocial family processes (family management, monitoring, rules, & attachment) have an enduring effect of the delaying of substance initiation and deterring association with antisocial peers (Oxford, Harachi, Catalano, & Abbott, 2001). School. The school setting context is invaluable for identifying children’s mental health problems because of the natural dynamics that occur between children and their peers, their authority figures, and their responsiveness to the general structure of the school day (Bronfenbrenner, 1989). Specifically, children who fail to meet academic tasks by grade four and/or who develop social incompetence, impulsivity, and aggressive behavior are at heightened risk for developing substance abuse and mental health disorders (Mrazek and Haggerty, 1994). The most commonly mentioned school-related vulnerability factors pertain to poor academic performance (Bry, McKeon and Pandina, 1982; Newcomb, Maddahian, and Bentler, 1986) and lack of commitment to school and school activities (Hawkins, Lishner, and Catalano, 1985). Social impairment, which is often first noticed in school settings, functions as a risk factor even after controlling for several other risk factors (e.g., conduct disorder, aggressive behavior, family functioning, and SES) (Green et al., 1997; Green et al., 1999). Environmental. The environments in which children live interact with psychological, familial, and genetic influences to shape the emergence of a broad spectrum of psychopathology (Bornstein, 1995; Harris, 1995; Hiday, 1995). For example, studies have documented a powerful, indirect link between poverty and mental disturbance, leading experts to conclude that poverty is one of the major risk factors for mental disorders (Albee, 1986; Rutter and Rutter, 1993). Olsen, Allen, and Azzi-


72


Lessing (1996) report that the Child Welfare League of America’s national survey yielded rates of alcohol and other drug use as high as 60 percent for families involved in the state child welfare system. Other studies continue to demonstrate an association between the occurrence of large numbers of major life change events and the onset of substance abuse or other mental disorders (Duncan, 1977; Goodyear, 1990). Therefore, environmental stress is critically important to understanding substance abuse. Specifically, individuals who are exposed to stress are more likely to abuse alcohol and other drugs. Among those individuals who are struggling to remain drug-free, exposure to personal stress situations leads to drug craving as well as physiological stress response (Sinha, Fuse, Aubin, O’Malley, 2000). Cumulative Effects of Risk Factors The total number of risk factors in the child’s background appears to be the strongest predictor for development of psychiatric disorder (Bry, McKeon, and Pandina, 1982; Glantz and Pickens, 1992; Maddahian, Newcomb, and Bentler, 1988). Williams, Anderson, McGee, and Silva (1989), for example, found in their study that 10-year-old boys with one or no risk factors had about a 2 percent chance of developing a psychiatric disorder, while those with four or more risk factors had a 20 percent chance. This suggests that a simple summation of the number of risk factors a child reported would be a valuable screening approach for mental health and substance abuse disorders. It is important to keep in mind, however, that risk factors are probabilistic; they imply potentiality, for not all who manifest a risk factor will develop negative outcomes (Cicchetti and Rogosh, 1999). A complicated picture emerges as the risk factor literature is examined. A challenge for researchers as well as for clinicians is to attempt to understand preadolescents’ multiple settings of risk and protection and the complex interactions between their multi-layered ecologies and mental health outcomes. AN ECODEVELOPMENTAL MODEL A recent theoretical development that provides a comprehensive framework for organizing the influences on problem behaviors such as substance use, is the Ecodevelopmental Model (Szapocznik and Coatsworth, 1999). This model builds and extends on the paradigm of risk


Michael J. Mason

73

and protective factors that guides preventive research and is the cornerstone of developmental psychopathology (Cicchetti and Cohen, 1995; Hawkins, Catalano, and Miller, 1992; Institute of Medicine, 1994). The study of risk and protective factors has historically approached problem behavior in a linear fashion, creating statistical models to identify and predict risk and protective factors for substance use. For example, as many as 72 risk and protective factors have been identified thus far for the development of a substance abuse disorder (Leshner, 1996). The assumption is that once these factors are identified and classified, the developmental trajectories of children could be predicted and ultimately manipulated for healthier outcomes. The risk and protective factor model has been organized by domains for children: individual, family, peer, school, and neighborhood. One of the primary limitations of the risk and protective factor model is that it only examines the children’s interactions within each domain, and neglects the more complex interactive effects among domains (Szapocznik and Pantin, 1996). Additionally, to focus on risk or protective factors in isolation or out of context, at the expense of more complicated processes–patterning of relations among seemingly disconnected variables in a child’s social ecology–is likely to overstate the power of a single factor (Szapocznik and Coatsworth, 1999). The ecodevelopmental model is strongly influenced by Bronfenbrenner’s (1979) work on social ecology of human development as well as Kurtines and Szipocznik (1996) and Minuchin’s (1974) social interaction approaches to problem behavior and structural family theory, respectively. This model is predicated on the need for researchers and clinicians to examine beyond the primary social ecological domain of interest and across to the other social systems that may be involved in risk and protective processes (Szapocznik and Coatsworth, 1999). Specifically, an ecological approach to children’s mental health is one in which the practitioner is sensitive to the changing properties of the immediate settings in which the child lives, and understands that this process is affected by the relations between these settings (or systems) and the larger contexts in which the settings are embedded (Bronfenbrenner, 1989). The essence of the Ecodevelopmental Model then, is a complex set of features and processes that emerge over time within the child and in the child’s ecologies that affect mental health outcomes such as substance abuse disorders. An Example of an Ecological Assessment An ecological assessment attempts to account for incongruency and congruency within a child’s social ecology. This approach toward assessment examines the degree of discordance in the child’s ecological


74


systems, or the goodness of fit among the child and the child’s multiple ecologies (Tharinger and Lambert et al., 1999). These incongruencies, or lack of fit among the child’s ecosystems, manifest themselves as disturbances, problems, or in extreme cases, psychiatric disorders. An ecological assessment attempts to identify points of discordance as well as points of concordance among the child’s social ecology. Evaluating a child’s specific functioning from an ecological perspective requires the practitioner to assess (a) the degree of normality of current functioning in multiple domains such as intelligence, language, health, academic, social, behavioral, and emotional, and determine the concordance or disconcordance among them; (b) the current environmental factors that are positively and negatively affecting the child’s functioning; (c) current resourcefulness and expectations, especially including family members and significant school personnel; and (d) the fit among the child, family, and school (Tharinger and Lambert, et al, 1999). Finally, an ecological approach towards children’s mental health assumes that political, social, and cultural forces influence children beyond their immediate awareness. As Bronfenbrenner’s (1979) model illustrates, these influences are typically experienced through encounters with a particular domain as well as from interactions between domains. For example, a family’s relationship with their child’s school may be affected by political forces such as budget changes, and therefore could instigate the family’s involvement with the school through volunteering. This increased engagement with the school by family members increases the child’s bonding to the school and to the family and thus creates a protective factor for this child. This example of ‘macro’ level factors (state budgets) being mediated through ‘micro’ level factors (family processes) and ultimately influencing risk and protective factors for the child (increased school and family bonding [Bronfenbrenner’s (1979) mesosytem]) demonstrates the comprehensiveness as well as the specificity of the ecological model. CONCLUSION This review demonstrated that, (a) preadolescence represents a critical developmental crossroads which needs attention from researchers and clinicians, (b) the need for mental health services appears to be increasing and those children in most need of services are not receiving them, and (c) an ecological model for addressing preadolescent issues holds much promise for a multivariate understanding of preadoles-


Michael J. Mason

75

cence. The complexities of childhood development are compounded when vulnerability to mental health disorders and substance abuse is considered. Because these complex problems have multiple causes stemming from biological, social, psychological, and ecological dynamics, conducting comprehensive assessments and interventions is very challenging. Nonetheless, it follows that the ecological settings in which children live must take precedence in the study of problem behavior, not merely as an independent variable, but rather as the median in which we seek to understand children’s worlds, including both problematic and resilient behaviors. The challenge for researchers and clinicians is to begin with their work with the understanding that preadolescent psychiatric disorders are embedded into children’s everyday activities that are part of a unique culturally organized sequence with its own internal logic and goals (Cole, 1992). Through recognizing the primacy of children’s everyday activities, their multiple connections, and co-participants of their worlds, a fuller understanding of the significant pathways of the ecology of risk and prevention is afforded to the sensitive researcher and clinician (Andrews, 1985). Fortunately, it appears that ecologically sensitive research activities to intervene and prevent children’s mental disorders, and comprehensive epidemiological efforts to collect data on the distribution of risk factors and problem behaviors, may mutually reinforce one another in a process leading to better definitions, understanding, and interventions. REFERENCES Achenbach, T & Edelbrock, C. (1981). Behavioral problems and competencies reported by parents of normal and disturbed children aged 4 through 16. Monographs of the Society for Research in Child Development, 46(6, Serial No. 188). Achenbach, T. & Howell C. (1993). Are American children’s problems getting worse? A 13-year comparison. Journal of the American Academy of Child & Adolescent Psychiatry, 32(6):1145-54. Adger, H. (1998). Children in alcoholic families: Family dynamics and treatment issues. In Principles of Addiction Medicine, Second Edition. Chevy Chase, MD: American Society of Addictive Medicine, 1111-1114. Albee, G. W. (1986). Toward a just society: Lessons from observations on the primary prevention of psychopathology. American Psychologist, 41, 891-898. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Washington, DC: American Psychiatric Association.


76


Andrews, H. (1985). The ecology of risk and the geography of intervention: From research to practice for the health and well-being of urban children. Annals of the Association of American Geographers, 75, 370-382. Bird, H.R., Canino, G., Rubio-Stipec, M., Gould, M. S., Ribra, J., Sesman, M., Woodbury, M., Huertas-Goldman, S., Pagan, A., Sanchez-Lacay, A. et al. (1988). Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. The use of combined measures. Archives of General Psychiatry. 45, 1120-1126. Blackson, T. (1994). Temperament: A salient correlate of risk factors for alcohol and drug abuse. Drug & Alcohol Dependence, 36, 3, 205-214. Bornstein, M. (1995). Form and function: Implications for studies of culture and human development. Culture Psychology, 1, 123-137. Boyle, M. & Offord, D. (1991). Psychiatric disorder and substance use in adolescence. Canadian Journal of Psychiatry, 36, 699-705. Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press. Bronfenbrenner, U. (1989). Ecological system theories. Annals of Child Development, 187-249. Brook, J., Whiteman, M. & Finch, S. (1992). Childhood aggression, adolescent delinquency, and drug use: A longitudinal study. Journal of Genetic Psychology, 153, 369-383. Brook, J. S., Cohen, P., Whiteman, M., and Gordon, A. 5. (1992). Psychosocial risk factors in the transition from moderate to heavy use or abuse of dugs. In M.D. Glantz and R.W. Pickens (Eds.), Vulnerability to Drug Abuse (pp. 359-388). Washington, DC: American Psychological Association. Bry, B. H., McKeon, R., & Pandina, R. J. (1982). Extent of drug use as a function of number of risk factors. Journal of Abnormal Psychology, 91, 273-279. Burns, B. J., Costello, E. J., Angold, A., Tweed, D., Stangl, D., Farmer, E. M., and Erkanli, A. (1995). Children’s mental health service use across service sectors. Health Affairs, 14 147-159. Ciccehetti, D. & Aber, L. (1998). Contextualism and developmental psychopathology. Development and Psychopathology, 10, 137-141. Cicchetti, D. and Cohen, D. (Eds.), (1995). Developmental Psychopathology: Vol. 1. Theory & Methods. New York: Plenum. Cicchetti, D. and Rogosch, F. (1999). Psychopathology and risk for adolescent substance use disorders: A developmental psychopathology perspective. Journal of Clinical Child Psychology, 28, 3, 355-365. Clark, D., Kirisci, L. & Moss, H. (1998). Early adolescent gateway drug use in sons of fathers with substance use disorders. Additive Behaviors, 23, 561-566. Clausen, J. (1991). Adolescent competence and the shaping of the life course. American Journal Sociology, 96, 805-842. Clayton, R. R. (1992). Transitions in drug use: Risk and protective factors. In M. D. Glantz and R. W. Pickens (Eds.), Vulnerability to Drug Abuse (pp. 15-51). Washington, DC: American Psychological Association. Cole, M. (1992). Culture in development. In M.H. Born stein and M.E. Lamb (Eds.), Developmental Psychology: An Advanced Textbook (pp. 731-78). Hillside, NJ: Lawrence Erlbaum.


Michael J. Mason

77

Costello, E. J. and Tweed, D. (1994). Prevalence of Severe Emotional Disturbances in Children and Adolescents. Rockville, MD: Report to the Center for Mental Health Services, National Institute of Mental Health. Costello, E. J., Erkanli, A., Federman, E., and Angold, A. (1999). Development of psychiatric comorbidity with substance abuse in adolescents: Effects of timing and sex. Journal of Clinical Child Psychology, 28, 3, 298-311. Dawes M. A., Antelman, S. M., Vanyukov, M. M., Giancola, P., Tarter, R. E., Susman, E.J., Mezzich, A., Clark, D.B. (2000). Developmental sources of variation in liability to adolescent substance use disorders. Drug & Alcohol Dependence, 61, 3-14. Eccles, J. Lord, S., Roeser, R., Barber,B., & Hernandez-Jozefowicz, D., (1997). The association of school transitions in early adolescence with developmental trajectories through high school. In J. Schulenberg, J. Maggs, & K. Hurrelmann (Eds.). Health Risks and Developmental Transitions During Adolescence (pp. 283-320). Cambridge, England: Cambridge U. Press. Ellickson, P., Hays, R. & Bell, R. (1992). Stepping through the drug use sequence: Longitudinal scalogram anlaysis of initiation and regular use. Journal of Abnormal Psychology, 101, 3, 441-451. Ellickson, P., Tucker, J. & Klein, D. (2001). High-risk behaviors associated with early smoking: Results from a 5-year follow-up. Journal of Adolescent Health, 28, 6, 465-473. Friedman, R., Katz-Leavy, J., Manderscheid, R., and Sonilheimer, D. (1996). Prevalence of serious emotional disturbance in children and adolescents. In K. W. Manderscheid and M. A. Sonnenschein (Eds.), Mental Health, United States, (pp. 77-91). Washington, DC: U.S. Government Printing Office. Friedman, R., Katz-Leavy, J., Manderscheid, R., and Sondheimer, D. (1998). Prevalence of serious emotional disturbance in children and adolescents. An update. In R. W. Manderscheid and M. A. Sonnenschein (Eds.), Mental Health, United States (pp. 110-112). Washington, DC: U.S. Government Printing Office. Gershon, E. & Nurneberger, J. (1995). Bipolar illness. In J. Oldham & M. Riba (Eds.), Review of Psychiatry, 14 (pp. 339-423). Washington, DC: American Psychiatric Press. Gfroerer, J. & Epstein, J. (1999). Marijuana initiates and their impact on future drug abuse treatment need. Drug and Alcohol Dependence, 54, 229-237. Giancola, P., Martin, C., Tarter, R., Pelham, and Moss, H. (1995). Executive cognitive functioning and aggressive behavior in preadolescent boys at high risk for substance abuse/dependence. Journal of Studies on Alcohol, July, 352-359. Glantz, M. D., and Pickens, R. W. (1992). Vulnerability to drug abuse: Introduction and overview. In M.D. Glantz and R.W. Pickens (Eds.), Vulnerability to Drug Abuse (pp. 1-14). Washington, DC: American Psychological Association. Goodyear, I. N. (1990). Family relationships, life events and child psychopathology. Journal of Child Psychology and Psychiatry, 31, 16 1-192. Greene, R.W., Biederman, J., Faraone, S.V., Wilens, T.E.. Mick, E., and Blier, H.K. (1999). Further validation of social impairment as a predictor of substance use disorders: Findings from a sample of siblings of boys with and without ADILD. Journal of Clinical Child Psychology, 28, 3, 349-354. Gruber, E., DiClemente, R., Anderson, M., & Lodico, M. (1996). Early drinking onset and its association with alcohol use and problem behavior in late adolescence. Preventive Medicine, 25, 293-300.


78


Harris, J. (1995). Where is the child’s environment? A group socialization theory of development. Psychology Review, 102, 3, 458-489. Hawkins, J. Catalano, R. & Miller, J. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64-105. Hawkins, J. D., Lishner, D. M., and Catalano, R. F. (1985). Childhood predictors and the prevention of adolescent substance abuse. In: C. L. Jones and R. J Battjes (Eds.), Etiology of Drug Abuse: Implications for Prevention (NIDA Research Monograph 56). Washington, DC: Government Printing Office. Hiday, V. (1995). The social context of mental illness and violence. Journal of Health and Social Behavior, 36, 122-137. Institute of Medicine. (1989). Research on Children and Molescents with Mental, Behavioral and Developmental Disorders. Washington, DC: National Academy Press. Institute of Medicine. (1994). Reducing Risks for Mental Disorders. Washington, DC: National Academy Press. Jacobson, E. & Addis, M. (1993). Research on couples and couple therapy: What do we know? Where are we going? Journal of Consulting & Clinical Psychology, 61, 85-93. Johnston, L., OMally, P., and Bachman, J. (1991). Drug Use Among American High School Seniors, College Students, and Young Adults, 1975-1990. National Institute on Drug Abuse (DHHS Publication No. ADM91-1813). Rockville, MD. Johnston, L., OMally, P., and Bachman, J. (1999). Drug Use among American High School Seniors, College Students, and Young Adults, 1975-1998. National Institute on Drug Abuse (NIH Publication No. 98-4660). Rockville, MD. Johnston, L., OMally, P., and Bachman, J. (2001). Drug Use among American High School Seniors, College Students, and Young Adults, 1975-2000. National Institute on Drug Abuse (NIH Publication No. 01-4923). Rockville, MD. Kandel, D. B. (1982). Epidemiological and psychosocial perspective on adolescent drug use. Journal of the American Academy of Child Psychiatry, 20, 328-347. Kandel, D, & Yamaguchi, K. (1993). From beer to crack: developmental patterns of drug involvement. American Journal of Public Health, 83, 851-855. Kandel, D. et al (1996). Psychiatric disorders associated with substance use among children and adolescents: Findings from the methods for the Epidemiology of children and adolescent mental disorders (MECA) study. Journal of Abnormal Child Psychology, 25, 2, 121-132. Kellam, S., Xiange, L., Merica, R., Brown, C., & Ialongo, N. (1998). The effect of the level of aggression in the first grade classroom on the course and malleability of aggressive behavior into middle school. Development and Psychopathology, 10, 165-185. Kessler, R. & Zhao, S. (1999). The prevalence of mental illness. In A. Horwitz & T. Scheid (Eds.), A Handbook for the Study of Mental Health (pp. 58-78). Cambridge: Cambridge U. Press. Kessler, R., McGonagle, K., Zhao, 5, Nelson, C., Hughes, M., Eshleman, S., Wittchen, H., and Kendler, K. (1994). Lifetime and 12-Month Prevalence of DSM-UI-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51, 8-19. Kosterman, R., Hawkins, D., Guo, L., Catalano, R., Abott, R. (2000). The dynamics of alcohol and marijuana initiation: Patterns and predictors of first use in adolescence. American Journal of Public Health, 90, 360-366.


Michael J. Mason

79

Kurtines, W. & Szapocznik, J. (1996). Structural family therapy in contexts of cultural diversity. In E. Hibbs & R. Jensen (Eds.), Psychosocial treatment research with children (pp. 671-697). Washington, DC: American Psychological Association. Lavigne, J. V., Gibbons, R. D., Christoffel, K., K., Arend, R., Rosenbaum, D., Binns, H., Dawson, N., Sobel, H., & Isaacs, C. (1996). Prevalence rates and correlates of psychiatric disorders among preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 204-214. Leaf, P. J., Alegria, M., Cohen, P., Goodman, S. H., Horwitz, S. M., Hoven, C. W., Narrow, W. E., Vaden-Kiernan, M., & Regier, D. A. (1996). Mental health service use in the community and schools: Results from the four-community MECA study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 889-897. Leshner, A. (1996, August). Behavioral Science and Drug Abuse: A Half Century of Productive Partnership. Presentation at the annual convention of the American Psychological Association, Toronto, Canada. Lewinsohn, P., Hops, H., Roberts, R., Seeley, J., and Andrews, J. (1993). Adolescent psychopathology: Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 102, 133-144. Masse, L. & Tremblay, R. (1997). Behavior of boys in kindergarten and the onset of substance use during adolescence. Archives of General Psychiatry, 54, 62-68. Menaghan, E. & Parcel, T. (1991). Determining children’s home environments: The impact of maternal characteristics and current occupational and family conditions. Journal of Marriage and Family, 53, 417-431. Menaghan, E. (1999). Social stressors in childhood and adolescence. In A. Horwitz & T. Scheid (Eds.), A Handbook for the Study of Mental Health (pp. 315-327). Cambridge: Cambridge U. Press. Merikangas, K. R., Dierker, L. C., & Szatmari, P. (1998). Psychopathology among offspring of parents with substance abuse and/or anxiety disorders: a high risk study. Journal of Child Psychology and Psychiatry, 39,711-720. Merrill, J. et al. (1999). Cigarettes, alcohol, marijuana, other risk behaviors, and American youth. Drug Dependence, 56, 205-212. Messman, J. & Koot, H. (2001). Early preschool predictors of preadolescent internalizing and externalizing DSM-IV diagnoses. Journal of the Academy of Child and Adolescent Psychiatry, 40, 9, 1029-1036. Minuchin, 5. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Moore, K. & Snyder, N. (1991). Cognitive attainment among firstborn children of adolescent mothers. American Sociological Review, 56, 612-624. Mrazek, P., and Haggerty, R. (Eds.). (1994). Reducing Risks for Mental Disorders: Frontiers for Prevention Intervention Research. Institute of Medicine. Washington, DC: National Academy Press. Myers, M., Brown, S. and Mott, M. (1995). Preadolescent conduct disorder behaviors predict relapse and progression of addiction for adolescent alcohol and drug abusers. Alcoholism: Clinical and Experimental Research, 19, 6, 1528-1536. National Institute on Drug Abuse (Dec. 17, 1999). NIDA News Release: Drug use among teenagers leveling off. Available online at: http://www.nida.nih.gov/MedAdv/


80


99INR-1217.htmi National Institute on Alcohol Abuse and Alcoholism (1993). Eighth Special Report to the U.S. Congress on Alcohol and Health. NIH Pub. No. 94-3699. Bethesda, MD, National Institutes of Health. Office of Technology Assessment. (1986). Children’s Mental Health: Problems and Services: A Background Paper (OTA-BP-H-33). Washington, DC: U.S. Government Printing Office. Offord, D., Boyle, M., Szatmari, P., Rae-Grant, N., Links, P., Cadman, D., Byles, J., Crawford, J., Blum, H., Byrne, C., Thomas, H., and Wooodward, C. (1987). Ontario Child Health Study: II. Six month prevalence of disorder and rates of service utilization. Archives of General Psychiatry, 44, 832-836. Offord, D., Boyle, M., Fleming, J.,Blum, H., (1989). Rae Grant. Ontario Child Health Study: summary of selected results. Canadian Journal of Psychiatry, 34, 483-91. Olsen, L. J., Allen, D., and Azzi-Lessing, L. (1996). Assessing risk in families affected by substance abuse. Child Abuse and Neglect, 20, 9, 833-842. Oxford, M., Harachi, T., Catalano, R. & Abbott, R. (2001). Preadolescent predictors of substance initiation: a test of both direct and mediated effect of family social control factors on deviant peer associations and substance initiation. Journal of Drug and Alcohol Abuse, 27, 4, 599-616. Patterson, G. R. (1982). Coercive Family Process. Eugene, OR: Castalia. Preadolescent mental health and substance abuse disorders. Pfeffer, C., Zuckerman, S., Plutchik, R., and Mizruchi, M. (1984). Suicidal behavior in normal school children: A comparison with child psychiatric inpatients. Journal of the American Academy of Child Psychiatry, 23, 4 16-423. Plomin, R. (1990). Nature and Nurture: An introduction to human behavioral genetics. Pacific Grove, CA: Brooks/Cole. Rutter, M. and Rutter, M. (1993). Developing Minds: Challenge and Continuity across the Life Span. NY: Basic Books. SAMHSA, Office of Applied Studies. TEDS Publications. (1995). Advance Report # 12, National Admissions to Substance Abuse Treatment Services: The Treatment Episode Data Set, 1992–1995. Sandler, I., Tein, J. & West, S. (1994). Coping, stress, and the mental health of children of divorce: A longitudinal study. Child Development, 65, 1744-1763. Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., On, S. I., King, R. A., Goodman, W. K., Cicchetti, D., and Leckman, J. F. (1997). Children’s Yale-Brown obsessive compulsive scale: Reliability and validity. Journal of the American Academy of Child Adolescence and Psychiatry, 36, 6, 844-852. Schwartz, S. (1999). Biological approaches to psychiatric disorders. In A. Horwitz & T. Scheid (Eds.), A Handbook for the Study of Mental Health (pp. 79-103). Cambridge: Cambridge U. Press. Shaffer, D., Fisher, P., & Lucas, C. (1999). Respondent-based interviews. In D. Shaffer, C. Lucas, & J. Richters (Eds.), Diagnostic Assessment in Child and Adolescent Psychopathology (pp. 3-33). New York: Guilford. Sinha R., Fuse, T., Aubin, L. R., O’Malley, S. S. (2000). Psychological stress, drug-related cues and cocaine craving. Psychopharmacology, 152,140-148. Stroul, B., and Friedman, R. (1986). A System of Care for Severely Emotionally Disturbed Children and Youth. Washington, DC: Georgetown University: CASSP Technical Assistance Center.


Michael J. Mason

81

Szapocznik, J. and Pantin, H. (1996). Structural Ecosystems Preventive Intervention. Unpublished report. Rockville, MD: Center for Substance Abuse Prevention. Szapocznik, J., and Coatsworth, J. D. (1999). An ecodevelopmental framework for organizing the influences on drug abuse: A developmental model of risk and protection. In Glanz, M. D. and Hartel, C. R. (Eds.), Drug Abuse: Origins and Interventions (pp. 331-366). Washington, DC: American Psychological Association. Tarter, R. E., and Mezzich, A. (1992). Ontogeny of substance abuse: Perspectives and findings. In M. D. Glantz and R. W. Pickens (Eds.), Vulnerability to Drug Abuse (pp. 149-177). Washington, DC: American Psychological Association. Tharinger, D. Lambert, N., Bricklin, P., Feshbach, N., Johnson, N., Oakland, T., Paster, V., and Sancez, W. (1996). Educational reform: Challenges for psychology and psychologists. Professional Psychology: Research and Practice, 27, 24-33. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Health, National Institute of Mental Health, (1999). Wallace, J. (1994). Modem disease models of alcoholism and other chemical dependencies: The new biopsychosocial models. Drugs and Society: A Journal of Contempory Issues, 8, 69-87. Weckerly, J. (2002). Pediatric bipolar mood disorder. Journal of Developmental & Behavioral Pediatrics, 23, 42-56. Weinberg, N. Z., and Glantz, M. D. (1999). Child psychopathology risk factors for drug abuse: Overview. Journal of Clinical Child Psychology, 28, 3, 290-297. Werner, M. J., Joffe, A., and Graham, A.V. (1999). Screening, early identification, and office-based intervention with children and youth living in substance-abusing families. Pediatrics, 103, 5, 1099-1112. Werthamer-Larsson, L. (1994). Methodological issues in school-based services research. Journal of Clinical Child Psychology, 23, 12 1-132. Willens, T. Biederman, J. (1993). Psychopathology in preadolescent children at high risk for substance abuse: A review of the literature. Harvard Review of Psychiatry, 1, 207-218. Williams, S., Anderson, J., McGee, R., and Silva, P. A. (1990). Risk factors for behavioral and emotional disorder in preadolescent children. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 413-419. Williams, S., Anderson, J., McGee, R., and Silva, P. A. (1989). Risk factors for behavioral and emotional disorder in preadolescent children. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 3, 413-419. Windle, M. & Windle, R. (1993). The continuity of behavioral expression among disinhibited and inhibited childhood subtypes. Clinical Psychology Review, 13, 741-761. Winters, K. (1990). The need for improved assessment of adolescent substance involvement. Journal of Drug Issues, 20, 487-502. Zahner, G. E. P., Leckman, J., Benedict, T. et al. (1992). The Clinical Process of Assembling Psychodiagnostic Information from Parents, Children, and Teachers: Recommendations for Multiple Informant Algorithms for the Diagnostic Interview Schedule for Children. Report to the Epidemiology and Psychopathology Research Branch, Division of Clinical Research, National Institute of Mental Health, Washington, DC.