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Chapter 4: Understanding Risk Factors and Other Variables That Define the Target Population

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Introduction
Chapter 4 provides an overview of several factors associated with risk for substance use and abuse and their implications for the selection of activities for and implementation of a substance abuse prevention curriculum.

First, risk and protective factors—conditions that have been demonstrated to increase or decrease the likelihood that youth will engage in substance abuse—are described. These factors, identified from multiple research studies, reflect what is understood about who may or may not be at increased risk for substance abuse and, to the extent that these factors are changeable, provide a focus for prevention.

Next, groups of youth whom research has demonstrated as experiencing increased risk for and prevalence of substance abuse are described. Youth in these groups experience increased risk of abuse in part because of the unique conditions of the group with which they are identified but primarily because these conditions are associated with greater numbers of risk factors and/or fewer protective factors.

Finally, this chapter provides an overview of gender, age, and geographic location characteristics that potentially have an impact on risk for substance abuse and on how prevention leaders might assemble their curricula and implement prevention activities. All sections of the chapter provide prevention leaders with implications of research findings in the form of "Practical Points."


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"Any parent, fellow student, teacher, principal, administrator, coach, secretary, counselor, nurse, bus driver or other school staff member who averts his or her eyes from a student suspected of using or abusing tobacco, alcohol or drugs is neglecting that child. Whether borne of despair, complacency, frustration or disregard, this neglect is not benign. It is a malignant neglect compromising the lives and futures of our children and metastasizing steadily and surely to younger children" (CASA, 2001).

General Risk and Protective Factors

  • Risk factors for substance abuse are characteristics that occur statistically more often for those who develop substance abuse problems—as either adolescents or adults.

  • Individual risk and protective factors:

    • Risk factors:

      • Shyness
      • Impulsiveness
      • Aggressiveness
      • Poor academic achievement
      • High level of sensation-seeking/risk-taking behavior
      • Low perceived risk of substance abuse
      • High levels of stress
      • Parent who is a substance abuser
      • Emotional problems.

    • Protective factors:

      • Stable temperament/self-control
      • High degree of motivation
      • Social competence
      • Problem-solving skills
      • Involvement in religion
      • Participation in extracurricular activities.

    • Implications:

      • Helping youth develop and practice age-appropriate social and problem-solving skills

      • Providing alternative activities that appeal to risk-taking youth

      • Intervening promptly to address behavioral and academic problems.

  • Family risk and protective factors:

    • Risk factors:

      • Lack of attachment and nurturing by caregivers
      • Poor parental monitoring.

    • Protective factors:

      • Strong bond between children and families
      • Age-appropriate parental monitoring of social behavior
      • Supportive parenting
      • Clear limits and enforcement of discipline
      • Family rituals
      • Parental disapproval of substance use.

    • Implications:

      • Teaching parents better family communication, discipline, firm and consistent rule-making, and other parenting skills

      • Helping families create warm family environments with high levels of bonding.

  • Peer risk and protective factors:

    • Risk factors:

      • Association with peers with problem behaviors, including substance abuse.

    • Protective factors:

      • Association with peers who reflect conventional norms against substance abuse.

    • Implications:

      • Helping young people develop social competency skills

      • Persuading drug-using members of the target population not to share drugs with friends (NIDA, 2003)

      • Providing opportunities for and encouraging participation in extracurricular activities

      • Helping youth develop and practice drug refusal skills.

  • School risk and protective factors:

    • Risk factors:

      • Prodrug-use norms
      • Availability of drugs in or near the school
      • Poor school academic climate
      • Lack of, unclear, or poor enforcement of school policies related to substance abuse.

    • Protective factors:

      • Consistent enforcement of substance use policies
      • Strong bond between youth and the school
      • High expectations for academic success
      • Opportunities for meaningful involvement with the school.

    • Implications:

      • To the extent possible, encouraging and supporting academic achievement

      • Strengthening youths' bonds with school and community organizations by giving them a sense of belonging and associated achievement

      • Correcting the misperception that most youth are using drugs by providing information about the true nature and extent of substance abuse among school and/or community youth (as discussed in Chapter 2, this would be an example of normative education).

  • Community risk and protective factors:

    • Risk factors:

      • Lack of positive afterschool academic programming
      • Lack of positive afterschool recreational programming
      • Easy access to drugs
      • Misperceptions of the extent and acceptability of substance-abusing behaviors
      • Poverty.

    • Protective factors:

      • Strong bond between youth and community institutions
      • Communitywide antidrug-use messages and norms
      • High levels of perceived social disapproval of substance abuse.

    • Implications:

      • Enhancing antidrug norms and prosocial behavior with civic, religious, law enforcement, and governmental organizations through changes in policy or regulations, mass-media efforts, and communitywide awareness programs

      • Advocating for limits on alcohol outlets near schools, enforcement of age restrictions in the purchase of tobacco and alcohol, and limits on tobacco and alcohol advertising

      • Enhancing youths' media literacy so that they can deconstruct and become more critical of youth-directed messages and images supportive of substance abuse.

Selected High-Risk Groups

  • Children of alcoholics and other substance abusers:

    • There is strong scientific evidence suggesting that alcoholism and use of other drugs tend to run in families. Children of alcoholics (COAs) are four times more likely than non-COAs to become alcoholics, and evidence suggests that genetic factors play a major role in the development of alcoholism.

    • Some protective factors that may buffer the many problems associated with growing up in an alcoholic family include: maintaining healthy family rituals or traditions, such as vacations, mealtimes, or holidays; confronting the active alcoholic parent with his or her problem; having a consistent significant other in the life of the youth; and having moderate to high levels of religious observance.

    • Practical Points: Children of Alcoholics and Other Substance Abusers

  • Youth with learning and/or behavioral disorders:

    • The association between behavioral disorders and substance abuse is one of the strongest, most consistent correlations among research findings.

    • Estimates suggest that up to 20 percent of school-aged youth have a learning disability, and anywhere from 1 to over 20 percent have behavioral disorders.

    • Learning disabilities are often accompanied by behavioral disorders, most commonly attention deficit/hyperactivity disorder (ADHD) and Conduct Disorder.

    • Both learning disabilities and behavioral disorders have high potential to impair a child's social, academic, and family functioning-all risk factors for substance abuse.

    • Research findings suggest an increased risk for substance abuse among adolescents diagnosed with ADHD.

    • Current research indicates that children with ADHD who are treated with properly controlled medication are no more likely to become involved in substance abuse than those who are not treated.

    • Practical Points: Youth With Learning and/or Behavioral Disorders

  • Abused and/or neglected youth:

    • Childhood emotional, physical, or sexual abuse; emotional or physical neglect; and/or other household dysfunction have been identified as risk factors for substance abuse.

    • Greater levels of abuse and neglect are associated with a greater likelihood of substance abuse.

    • Studies indicate that child abuse and neglect are a root cause of one-half to two-thirds of serious problems with substance use.

    • Childhood sexual abuse has a particularly strong relationship with later substance abuse.

    • A study of adolescents in substance abuse treatment revealed that approximately one-third of the sample had a history of sexual abuse, with girls reporting abuse much more frequently than boys.

    • Practical Points: Abused and/or Neglected Youth

  • Economically disadvantaged youth:

    • Children living in poverty often lack adequate health care, proper nutrition, and quality schools-all considered to be protective buffers. These disadvantaged youth suffer disproportionately high levels of prenatal damage, poor health during infancy and childhood, malnutrition, and emotional and physical abuse and neglect.

    • Economic disadvantage can lead to individual risk factors that can combine with environmental risk factors, each exacerbating the other's harmful effects.

    • Marijuana and alcohol use among 12th-grade students have little association with socioeconomic level, with the exception that the lowest economic group has the lowest prevalence of use.

    • Binge drinking is inversely related to SES, particularly in middle-school grades; middle-school youth with lower SES tend to have higher levels of binge drinking.

    • Among 8th- and 12th-grade students, the higher the SES, the less likely the adolescent is to smoke.

    • Practical Points: Economically Disadvantaged Youth

  • Homeless and runaway youth:

    • Of youth who are homeless, 38 percent have alcohol abuse problems and 26 percent have problems with illicit drug abuse.

    • Families with children account for 40 percent of the homeless population.

    • Most homeless children are elementary-school age, but it is more difficult to identify secondary students who are homeless because they may be less likely to access related services and more likely to either not attend school or successfully hide their homelessness.

    • Almost half of runaway and homeless youth report having experienced physical abuse, and 17 percent report having been forced into a sexual relationship with a family member.

    • Homeless adolescents often experience severe anxiety, depression, low self-esteem, poor nutrition, poor health, and a greater likelihood of experiencing post-traumatic stress disorder.

    • Risk for substance use and abuse increases with the amount of time runaways are on their own.

    • Practical Points: Homeless and Runaway Youth

  • School dropouts or those at risk of dropping out:

    • View Figure 1: School Dropout Rates by Ethnicity

    • While there is some association between substance abuse and dropping out of school, findings are mixed.

    • Rates of alcohol use and heavy drinking are generally lower among school dropouts; however, African-American dropouts are more likely to report binge drinking than their counterparts who remain in school.

    • Use of illicit drugs is slightly greater among African-American and non-Hispanic white dropouts compared with their peers who stay in school, but it is comparable to nondropouts in other ethnic groups.

    • African-American and non-Hispanic white school dropouts are more likely than nondropouts to be current cigarette smokers. Other ethnic groups report comparable smoking rates between dropout and in-school youth.

    • There is a fivefold increase in risk for dropping out of school among high school students who report frequent use of alcohol or other substances.

    • Practical Points: School Dropouts

  • Suicidal youth and youth with serious emotional disturbances:

    • Almost 20 percent of high school students have seriously considered suicide; 8.3 percent have attempted suicide.

    • Among the strongest risk factors for attempted suicide among youth is a substance abuse disorder.

    • Approximately 90 percent of suicides are associated with a mental health or substance abuse disorder or both.

    • Suicidal tendencies and substance abuse share many risk factors, suggesting that successful alcohol and other substance abuse prevention programs may also be helpful in reducing suicidal tendencies.

    • Compared with youth who have low levels of serious emotional disturbances, those with high levels of serious emotional disturbances are twice as likely to have used alcohol in the past month and five times as likely to report alcohol dependence.

    • Practical Points: Suicidal Youth and Youth With Serious Emotional Disturbances

  • Youth with physical disabilities:

    • By the 12th grade, when compared with their nondisabled peers, disabled students have higher rates of alcohol, cocaine, and cigarette use.

    • Disabled students have much higher dropout rates.

    • Common risk factors for substance abuse shared by youth with physical disabilities include use of prescribed medications, chronic medical problems, isolation, behavioral problems, lack of recreational alternatives, and disenfranchisement.

    • Youth with mental retardation and developmental disabilities need to have prevention materials adapted to their learning needs, addressing communication barriers, increased family stress, and friends and family who may enable substance abuse.

    • Dangerous interactions could result from substance abuse combined with use of prescribed medications.

    • Risk factors associated with blindness, deafness, and orthopedic disabilities tend to be disability-specific.

    • Blind or visually impaired individuals may have increased risk due to social isolation or underemployment.

    • Deaf or hard-of-hearing individuals have less access to incidental forms of information and need prevention activities adapted to their cultural, linguistic, and communication needs. In addition, with the intimacy of the deaf community, there may be heightened motivation to avoid the social stigma associated with substance abuse.

    • Almost half of spinal cord or traumatic brain injuries are associated with subsequent substance abuse, and postinjury risk remains for many individuals.

    • Special attention is warranted for individuals taking medications, particularly antiseizure medications, that could combine dangerously with nonprescribed drugs.

    • Practical Points: Youth With Physical Disabilities

  • Sexual minority youth:

    • Gay, lesbian, and bisexual (GLB) youth represent between 20 and 40 percent of homeless youth.

    • GLB youth are more likely to run away from home and drop out of school.

    • Relative to their heterosexual peers, sexual minority youth experience:

      • Increased risk of multiple substance use
      • Greater likelihood of early initiation (prior to age 13) of cocaine, marijuana, tobacco, and alcohol use
      • Greater frequency of crack cocaine use
      • Greater frequency of smokeless tobacco and marijuana use.

    • Practical Points: Sexual Minority Youth

  • Users of alcohol, tobacco, or marijuana:

    • Individuals who use these drugs do not necessarily progress to other substance abuse; however, other substance abuse rarely occurs in the absence of previous use of these substances.

    • Alcohol and tobacco users are presented with significantly greater opportunities to try marijuana and are more likely to take advantage of such opportunities than their peers who do not drink alcohol or smoke.

    • Youth who use marijuana are 15 times more likely to have opportunities to use cocaine than those who do not use marijuana.

    • Approximately 50 percent of marijuana users try cocaine within 2 years of their first opportunity to do so.

    • Marijuana users are also significantly more likely than nonusers to have and take advantage of opportunities to try LSD, mescaline, and PCP.

    • Approximately 9 percent of all marijuana users will become dependent on the drug, with most of those becoming dependent in their first 5 years of use.

    • Approximately 21 percent of cocaine users will become dependent on the drug, with the largest proportion becoming so in their first year of use.

    • Initiation of marijuana use before age 17 is associated with a twofold increase in the likelihood of other illicit drug abuse.

    • While the majority of young marijuana users do not progress to abuse of or dependence on another drug, they have a two to five times greater likelihood of abuse of or dependence on alcohol, marijuana, stimulants, opioids, and/or sedatives.

    • Practical Points: Users of Alcohol, Tobacco, and/or Marijuana



Gender Considerations

  • Pathways to substance abuse:

    • Girls and young women use substances for different reasons and may have different pathways to substance abuse than boys and young men.

    • Girls may be more vulnerable to abuse and addiction and are physiologically more vulnerable to the effects of drugs.

    • Females are more likely to experience several risk factors for substance abuse, including weight concerns, eating disorders, and history of physical or sexual abuse.

    • Female adolescents are more vulnerable to addiction to a particular substance than are males.

    • Girls and young women report greater ease in obtaining illegal substances.

    • Girls and young women report using drugs as to enhance mood, boost confidence, relieve tension, cope with problems, lessen inhibitions, enhance sex, or lose weight.

    • Boys and young men are more likely to use substances to enhance their social status or for sensation seeking.

    • Male youth tend to perceive substance abuse as less risky than do females.

  • Prevalence of substance abuse by gender:



Age and Developmental Considerations

  • Youth develop at different rates; therefore, it is important that prevention programs include interactive activities that address the needs present at different developmental stages. Most developmental changes are not age-specific but, rather, occur over a wide range of ages and may be different for boys and girls.

  • Preschool-aged youth:

    • The preschool age group is not too young for substance use prevention programs, as long as these are designed for the youngsters' level of understanding.

    • Prevention materials targeted at preschoolers exist in a variety of creative formats (e.g., puppets, dolls, coloring and storybooks, posters, games, song cassettes, and stickers).

  • Elementary-aged youth:

    • The kindergarten-to-6th-grade school years are a critical time for reaching youth because children that age are old enough to understand some adult problems yet still young enough to be readily influenced by adults who care for them.

    • Pressure to use alcohol, tobacco, and marijuana usually begins during the latter part of these years.

    • Practical Points: Grades K to 3

    • Practical Points: Grades 4 to 6

  • Middle school/junior high-aged youth

    • Although many 12- to 14-year-olds are maturing physiologically, most remain emotionally, cognitively, and morally immature.

    • Youth of this age often feel that the adults in their lives are unable to identify with their concerns.

    • The simple ideas and truths that adults may have presented at an earlier time no longer work for adolescents; adolescents want explanations.

    • Practical Points: Grades 7 and 8

  • High school-aged youth:

    • View Figure 3: Past-Year and Past-Month Use of Drugs by High School Seniors, 2002

    • Youth ages 14 through 18 represent a diverse population that ranges from immature adolescents to nearly mature adults.

    • For younger adolescents in this age cluster, older youth can be the link to substance abuse; young adolescents may engage in dangerous and self-destructive activities in their eagerness to belong.

    • Adults become especially important resources for helping youth in this age group resist drugs; adults can influence youth by being models of positive, healthy, and responsible attitudes and behaviors.

    • It is critical for parents to keep channels of communication open and, while being authoritative, to avoid being overly judgmental.

    • Friendships become increasingly important, especially with persons of the opposite sex; friends become an important source of information for making significant decisions.

    • Practical Points: Grades 9 to 12



Geographic Considerations




Previous Chapter: Chapter 3 Next Chapter: Chapter 5
  Handbook Preface
Chapter 1: The Nature and Extent of Substance Abuse in the U.S.
Chapter 2: Foundations of Substance Abuse Prevention Curricula
Chapter 3: Needs Assessment and Curriculum Development
Chapter 4
Chapter 5
Chapter 6
Chapter 7: Curriculum Implementation
Practical Points


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