Preventing Co-Occurring Disorders: Prospects and Opportunities

1. Preventing Co-Occurring Disorders: Prospects and Opportunities J. David Hawkins Ph.D. Social Development Research Group University of Washington Data are from the Seattle Social Development Project supported by grants from the National Institute on Drug Abuse and the National Institute of Mental Health.

2. Prevention of co-occurring disorders requires identification of malleable risk and protective factors that predict comorbidity.

3. The Research Base for Prevention of Co-Occurring Conditions Longitudinal studies have identified risk and protective factors that predict substance abuse, depression, violence and other problem behaviors.

4. Risk Factors Substance Abuse Delinquency Teen Pregnancy School Drop-Out Violence Depression & Anxiety Community Availability of Drugs   Availability of Firearms   Community Laws and Norms Favorable Toward Drug Use, Firearms, and Crime    Media Portrayals of Violence  Transitions and Mobility     Low Neighborhood Attachment and Community Disorganization    Extreme Economic Deprivation      Predicting Adolescent Problems Used by permission of Channing Bete Company

5. Risk Factors Substance Abuse Delinquency Teen Pregnancy School Drop-Out Violence Depression & Anxiety Family Family History of the Problem Behavior       Family Management Problems       Family Conflict       Favorable Parental Attitudes and Involvement in the Problem Behavior    Predicting Adolescent Problems Used by permission of Channing Bete Company

6. Risk Factors Substance Abuse Delinquency Teen Pregnancy School Drop-Out Violence Depression & Anxiety School Academic Failure Beginning in Late Elementary School       Lack of Commitment to School      Predicting Adolescent Problems Used by permission of Channing Bete Company

7. Risk Factors Substance Abuse Delinquency Teen Pregnancy School Drop-Out Violence Depression & Anxiety Individual/Peer Early and Persistent Antisocial Behavior       Rebelliousness    Friends Who Engage in the Problem Behavior      Favorable Attitudes Toward the Problem Behavior     Early Initiation of the Problem Behavior      Constitutional Factors     Predicting Adolescent Problems Used by permission of Channing Bete Company

8. Protective and Promotive Factors Individual Characteristics • High Intelligence • Resilient Temperament • Competencies and Skills In family, school, peer group and neighborhood: • Prosocial Opportunities • Reinforcement for Prosocial Involvement • Bonding • Healthy Beliefs and Clear Standards

9. Question Can predictors of comorbid alcohol use disorders and major depression in early adulthood be identified in early adolescence?

10. Seattle Social Development Project • A theory-driven longitudinal study of the etiology of prosocial and antisocial behaviors. • An intervention study nested in the longitudinal study. • Initiated in 1981 in 8 Seattle elementary schools. • Expanded in 1985, to include 18 Seattle elementary schools that over-represented students from high crime neighborhoods. • 808 (77%) of the 5th grade students in these schools and their parents consented to participate in the longitudinal study; they constitute the study sample.

11. Study Characteristics Demographics • 51% Male • 46% Caucasian, 26% African American, 21% Asian-American • 52% from low income families (free-lunch eligible) • 40% from single-parent families Comparison Group Design • Full treatment (grades 1-6) = 149 • Late treatment (grades 5-6) = 243 • Control = 206 • Parent training only = 208

12. Middle High Elementary Adult SSDP Panel Retention MEANAGE 10 11 12 13 14 15 16 (17) 18 21 24 27 N 808 703 558 654 778 783 770 -- 757 766 752 747 % 87% 69% 81% 96% 97% 95% -- 94% 95% 93% 93% Interview completion rates for the sample have remained above 93% since 1989, when subjects were 14 years old.

13. Prevalences in the Seattle Social Development Project at Age 21 Alcohol Use Disorders Only 19.1% (n=144) More common among men (26.9%) than women (11.2%) Major Depression Only 11.9% (n=90) More common among women (15.7%) than men (8.2%) Comorbid AUD and MDD 7.8% (n=59)

14. Social Development Model (SDM)

15. Questions • What SDM factors at age 14 predict either alcohol use disorders alone or depression alone at age 21? • What SDM factors at age 14 predict comorbid alcohol use disorders and depression at age 21?

16. Multinomial Logistic Regression Analyses Three Odds Ratios: 1) Alcohol use disorder only versus neither 2) Depression only versus neither 3) Comorbid disorders versus neither Separate regression equations for each predictor at age 14 Controlling for gender, alcohol problems, and anxious/depressive symptoms at age 13.

20. Summary • Predictors of comorbid alcohol use disorders and major depressive disorder are identifiable by age 14. • Comorbid alcohol use disorders and major depression are predicted by more factors than either disorder alone.

21. Predicting Violence and Depression at Age 21 Childhood conduct problems at age 10 are malleable risk factors for both violence and depression at age 21.

22. Adjusted Odds Ratios (95% Confidence Interval) for Conduct Problems Predicting Age 21 Outcomes(Controlling for Gender, Ethnicity, and Low Income Status) N = 765. **p < .01; ***p < .001. Adapted from Mason et al. (2004), Seattle Social Development Project data.

23. Summary We have substantial knowledge of malleable predictors of comorbid alcohol disorders, depressive disorders and violence.

24. Questions • Can addressing these predictors prevent these diverse problems? • Can addressing these predictors prevent comorbid disorders in early adulthood?

25. Seattle Social Development Project InterventionTargeted Risk Factors • School Domain • Low commitment to school • Academic failure • Family Domain • Poor family management • Family conflict • Individual Domain • Early antisocial behavior • Favorable attitudes to problem behavior • Friends who engage in problem behavior • Early initiation of problem behavior

26. Social Development Model (SDM)

27. Intervention Goals • Promote bonding to school and family by: • Enhancing opportunities for involvement in school and family • Enhancing rewards for involvement in school and family • Strengthening children’s social competencies

28. SSDP Intervention • Teachers: 5 days of training annually, grades 1 to 6, in proactive classroom management, interactive teaching and cooperative learning. • Children: training in grades 1 and 6 on interpersonal problem-solving and refusal skills. • Parents: offered voluntary training (43%) in grades 1 to 6 on child behavior management skills, academic support skills and skills to reduce risks for drug use.

29. Significant effects of SSDP intervention on childhood predictors have been found: • Age 7: Less aggressiveness, antisocial behavior & self-destructiveness. • Age 10: Better family management & bonding; better school bonding. • Age 12: better social skills; more classroom participation; better school bonding, grades & achievement test scores.

30. Seattle Social Development ProjectResults at Age 18 Scale score

31. Seattle Social Development ProjectResults by Age 18 *p< .05

32. Seattle Social Development ProjectResults at Age 18Heavy Alcohol Use *p< .05

33. Seattle Social Development ProjectEffects by Age 21 *p< .05

34. Seattle Social Development ProjectEffects at Age 21 *p< .05

35. Seattle Social Development ProjectEffects at Age 21 Prevalence * + ** +p<.10; *p<.05; **p<.01 compared with controls.

36. Summary Universal intervention with an urban multiethnic population during elementary grades targeted at shared predictors significantly reduced comorbid alcohol use disorders and major depressive disorder 9 years after intervention ended.

37. Conclusion Prevention of co-occurring disorders is possible by addressing shared malleable predictors of these disorders during childhood.

38. Implications for Access and Utilization • Schools are key delivery sites for universal and selective preventive interventions focused on shared risk and protective factors for comorbid disorders.

39. Involving Schools as Prevention Partners • Shared predictors of academic, behavior, and mental health outcomes must be recognized. • The potential to achieve better academic outcomes by addressing these shared predictors must be understood by school personnel.

40. Access and Utilization Primary care providers should screen for shared malleable predictors of comorbid disorders, like childhood conduct problems, to guide referrals for selective preventive interventions.

41. Access and Utilization Systems for community wide assessment, planning and action to address predictors of comorbid disorders in youth populations are needed.

42. Preventing Co-Occurring Disorders: Prospects and Opportunities J. David Hawkins Ph.D. Social Development Research Group School of Social Work University of Washington www.sdrg.org jdh@u.washington.edu