C 2006) Journal of Clinical Psychology in Medical Settings, Vol. 13, No. 2, June 2006 ( DOI: 10.1007/s10880-006-9021-z
Adolescent Substance Use and Abuse Prevention and Treatment: Primary Care Strategies Involving Social Networks and the Geography of Risk and Protection Leslie R. Walker,1,4 Michael Mason,2 and Ivan Cheung3 Published online: 23 March 2006
The use and abuse of licit and illicit substances in adolescence is a national public health concern. This behavior impairs healthy development for many adolescents in the United States. Although not every adolescent who becomes a regular user of licit and illicit substances will develop a substance abuse disorder, all adolescents using these substances can experience a life-threatening outcome. Understanding the epidemiology and social profile of adolescent substance use, namely the risk and protective factors and the environmental and genetic factors, is essential to the development of strategies for prevention. There are many methods that can be employed to better assess environments in which adolescents live. The method discussed in this paper is descriptive and utilizes Geographic Information Systems (GIS) technology. The primary goal of this paper is to illustrate and describe an analysis of substance using and non-substance using adolescents, their social networks, the risky and protective settings where they socialize, and the relationship of these variables to health outcomes such as substance use, depression, and stress. Published data from the researchers’ recent investigation examine the effect of social network affiliations and geographical risk factors on drug involvement and illustrate how these factors may then be incorporated into prevention and intervention planning, especially in medical settings. KEY WORDS: adolescent substance abuse; geographic information systems; social networks; primary care.
EPIDEMIOLOGY OF ADOLESCENT SUBSTANCE USE
all adolescents using these substances can experience a life-threatening outcome. The top three causes of death (accidents, homicide, and suicide) in adolescence are all associated with substance use (Comerci & Schwebel, 2000). Long-term consequences of adolescent substance use involve not only poor health outcomes but also lasting educational, social, and economic problems associated with drug dependence (Godley, Kahn, Dennis, Godley, & Funk, 2005; Miller & Brady, 2004; Rey, Martin, & Krabman, 2004; Wadland & Ferenchick, 2004). For those adolescents that become dependent on substances, effective evidence-based treatments are in short supply (Stevens & Morral, 2002). Understanding the epidemiology of adolescent substance use, specifically the risk and protective factors, and the
The use and abuse of licit and illicit substances in adolescence is not uncommon and is considered a right of passage by some. However, this behavior impairs healthy development for many adolescents in the United States. Although not every adolescent who becomes a regular user of licit and illicit substances will develop a substance use disorder, 1
Georgetown University Medical Center, Washington, DC. Villanova University, Villanova, Philadelphia. 3 Association of American Geographers, Washington, DC. 4 Correspondence should be addressed to Leslie R. Walker, Department of Pediatrics, Georgetown University Hospital, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, DC 20007; e-mail:
[email protected]. 2
131 C 2006 Springer Science+Business Media, Inc. 1068-9583/06/0600-0131/0
132 environmental and genetic factors is essential to the development of effective strategies for prevention and treatment in medical and other settings. While it is difficult to precisely monitor the prevalence of drug abuse in adolescents in the United States, there are two national surveys that are conducted with a nationally representative sample of adolescents on a yearly basis. These surveys are (1) “Monitoring the Future” (MTF) performed by National Institute on Drug Abuse (NIDA), and (2) “The National Household Survey on Drug Use and Health” (NSDUH) previously called the National Household Survey on Drug Abuse (NHSDA). MTF is a longitudinal study of American adolescents, college students and adults through age 40. This survey is administered in private and public schools in the 8th, 10th, and 12th grades. The NSDUH is sponsored by Substance Abuse and Mental Health Services Administration (SAMSHA). It has been in use since 1971 and surveys over 70,000 adults and adolescents ages 12 and over. It is a cross-sectional, yearly interview format survey performed in homes. The strength of these surveys is in the ability to evaluate change over time and cycles of current and past trends. But while these surveys reach a nationally representative sample of youth, they should be considered an underestimate of adolescent substance use. Adolescents at risk will likely be less available for in-school surveys, or may not be attending school at all by the secondary school years. Also, those selected to participate in home surveys may be less available for phone interviews for a number of reasons, including transient homelessness and lack of reliable phone service. The NSDUH survey has consistently found that males are more likely than girls to use substances with more boys preferring marijuana and more girls preferring non-medical use of psychotherapeutics. Race and ethnic differences currently show the highest illicit substance use among 12–17-year-olds at 9.9% in American Indians/Alaska Natives. For Whites and African Americans, the rates are similar at 7.2 and 7.4%, respectively, and slightly less for Hispanics (6.4%) with the least use observed for Asians at 2.8%. The highest illicit substance use geographically is in rural, nonmetropolitan areas (14.4%) with large metropolitan areas next at 10.4% (NSDUH, 2004). One trend that has been consistently noted in these surveys is that illicit drug use increases with age. In 2003, almost 74% of adults, age 21 or older reported that they had started drinking alcohol before the current legal drinking age of 21 (NSDUH, 2004).
Walker, Mason, and Cheung This is concerning because adults reporting first use of alcohol before age 15 were more than five times as likely to report past year alcohol dependence or abuse than persons who first used alcohol at age 21 or older (16 versus 3%) (NSDUH, 2004). The most recent MTF survey released in December, 2004 shows that the overall trend for adolescent drug use has had a gradual decline for most drugs except inhalants. This decline started in 1996 among those in the 8th grade, changing from 23.6% in 1996 to 15.2% in 2004 in the 12 months previous to the survey. In 2004, the proportion of adolescents reporting any use of illicit substances was 15%, 31%, and 39% in grades 8, 10, and 12, respectively. By the 12th grade, the proportion of youth who had ever tried an illicit drug was 51%. Of the illicit drugs used by youth, marijuana is the most common by far, crossing all socioeconomic and ethnic classes and groups. Primary marijuana use is the most common reason youth are placed in drug rehabilitation programs across the country, accounting for 64% of the admissions (DASIS Report, 2004). This drug over the last few years has had a small (1.2%) but consistent decline in use (Johnston, O’Malley, Bachman, & Schulenberg, 2005). This is possibly correlated to the MTF finding that youth currently perceive marijuana to be more risky than youth did in prior years. For other drugs such as ecstasy, amphetamines, methamphetamines, phencyclidine (PCP), hydrocodone (Vicodin), ketamine, and steroids, there were modest declines in 2004. As with marijuana, attitudes toward ecstasy have changed over the last 2 years and youth perceive more risk with its use than they did on 2000 and 2002. This may account for the decline in use in 2004. Painkillers and narcotic analgesics such as Vicodin and OxyContin, were not measured until 2002 but it was surprising to find that at least 9.3% of high school seniors had used Vicodin for illicit purposes, and 5.0% of seniors reported using OxyContin in 2004. More data will have to be gathered on these drugs to measure what the patterns of use and change are over time. Alcohol encompasses a number of different beverages such as beer, wine, wine coolers, and hard liquor. This substance is the most widely used by American youth. There has been a decline is alcohol use since 2001 in all grades, but in 2004 among 12th graders there was increased use. Because this increase is recent, it is unclear if this will become a trend. Currently of great concern is the episodic/binge drinking attitudes held by adolescents and college youth. In the most recent (2004) MTF
Adolescent Substance Use and Abuse Prevention and Treatment survey, only 44% of youth viewed binge drinking as risky, as it was defined as five or more drinks in a row once or twice a weekend (Johnston, O’Malley, Bachman, & Schulenberg, 2005). That amount is more than enough for an adolescent male or female to be dangerously intoxicated. In evaluating the survey data over the last three decades, cyclic trends are evident. The 1960’s until the late 1970s showed a marked increase in marijuana use in Americas adolescents. Marijuana use did not decrease until 1980 and it continued to decline until 1993 when it began to increase again. The proportion of youth using any illicit drugs has changed over the years with increases in the 1980s and decreased in the 1990s but the class of drugs used has changed even more, with some classes increasing dramatically while others decreasing dramatically. There are many theories why these changes occur. One theory is called the replacement/ displacement hypothesis where it is believed that younger youth observe older youth and develop different attitudes toward specific drugs than older youth who used these drugs had. For example, younger adolescents see older adolescents having problems with certain drugs like lysergic acid diethylamide (LSD), they then perceive that drug as risky and move on to other drugs they have no information about and do not consider as dangerous. While this may explain the less commonly used illicit substances, it does not explain the more common kinds of drug use with alcohol and marijuana. These two drugs tend to fluctuate parallel to each other, not inversely (NSDUH, 2004). Potency of drugs is cited as a reason for the trends in drug use, marijuana is the most obvious example with the potency increased by 560% since 1975. But even with this steady increase in potency over the last 30 years, there have not been steady increases in usage, rather, there have been both increases and decreases (Comerci & Schwebel, 2000.) With the 1970s youth growing-up and becoming parents of adolescents in the last decade, there has been a theory that parent attitudes have contributed to the increase in teen use in the 1990s. Parents who used illicit substances at the height of the United States drug usage in the 1960s and 1970s may be reluctant to assume a zero-tolerance stance against drugs with their youth in an effort not to be hypocritical. This generational difference would only explain some of the changes in marijuana usage over the last generation. National campaigns and changing public attitudes toward illicit drug use is credited for the de-
133 crease in drug use. Again, it appears to only be part of the answer as some drugs such as marijuana and ecstasy are declining, while others such as inhalants in younger adolescents are rising (Johnston, O’Malley, Bachman, & Schulenberg, 2004).
RISK FACTORS There has been a considerable effort over the past two and a half decades to understand the etiology of adolescent substance abuse. Some of this research has led to insights. However, many of these insights have been viewed in isolation and there has been a need to examine them in a much more integrated way and in relationship to one another. While it is complex to understand and study a more comprehensive conceptual model, it is necessary to look at trajectories and social and environmental factors of adolescent drug use and abuse over time (Botvin et al., 2000; Center for Substance Abuse Treatment, 2001; Johnston, O’Malley, & Bachman, 2001). Using an ecological perspective, (see Brofenbrenner, 1979 and Szapoznik & Coatsworth, 1999 for discussion) initiating drug use by youth can be divided into different categories of risk and protection including three areas: (1) individual/personal, (2) social networks including family, and (3) community and environmental. Each of these areas is reviewed below.
Individual/Personal Risk These risk factors range from biogenetic influences, appearing older than peers, low sociability and temperament problems, sensation-seeking and deficits in self-regulation, to comorbid mental health disorders such as depression (Comerci & Schwebel, 2000). Physical and sexual abuse also places some adolescents at risk for substance abuse.
Social Networks Including Family One of the more powerful risk factors in this category is parental or sibling history of substance use. Also included are poor and inconsistent parenting and child-rearing practices, family conflicts and lack of family connectedness. Lack of monitoring and family violence all can contribute to adolescent substance abuse. In the community, laws favorable to drug use and social norms favorable to drug
134 use along with availability of drugs will add to the likelihood that substance use will begin and continue (Newcomb, 1997). Rejection and isolation from peers, and having peers who use substances can all predispose adolescents to the initiation of substance use (Simkin, 2002).
Community and Environment Neighborhood disorganization and lack of recreational activities in a neighborhood can be a risk factor to drug use (Simkin, 2002). There is much less evidence about environmental risk factors that impact on substance use and abuse by adolescents. Current research is ongoing to help detail this information. Currently, the opportunities for risky experimentation and the lack of opportunities for constructive expressions of emerging capacities and identities as early adolescents mature into young adults may lead to higher incidences of poorer mental health outcomes for urban youth (Nettles & Pleck, 1994). For high-risk youth who live in environments that provide more opportunities for risky behavior than constructive behavior, they are at increased risk for substance use as well (Greydanus & Patel, 2003). Recent research has begun to examine differential effects of discrete urban locations in attempt to understand where urban youth spend their time, whom they associate with, and the health outcomes such as substance use, depression, and stress (Mason, Cheung, & Walker, 2004).
PROTECTIVE FACTORS Equally important to risk factors are resilience or protective factors that may help to ward off use and abuse. Protective factors include the adolescent having a stable environment–meaning that the home and community in which the adolescent lives in is high in motivation and setting and achieving goals aimed at current and future achievement. Other social attributes include positive self-identify and selfesteem, assertiveness, social competence and academic success, and good general health (Greydanus & Patel, 2003). A strong parent-child bond with effective communication and consistent supervision and discipline by parents or guardians coupled with strong anti-drug and alcohol messages can decrease the risk of adolescent substance abuse. Also, having peers with positive personal attributes is pro-
Walker, Mason, and Cheung tective as well. In the community, an adolescent who bonds to community places and activities like consistent church participation, school involvement, and sports involvement are protective. In the environment, healthful social networks within urban neighborhoods can provide opportunities for positive modeling, mentoring, and sponsorship for youth (Simkin, 2002). In sum, these protective and risk factors can all be at work for the same teen at any given point in time. Having multiple aspects of etiology makes developing early intervention and prevention programs somewhat challenging, especially in medical settings. While there are many different social contexts in which adolescents exist, this paper focuses on the role of the primary care setting in addressing adolescent substance abuse in conjunction with the application of social network analysis and Geographic Information Systems. It is important to understand what work can be accomplished in the primary care setting and by whom (psychologists, physicians, nurses, health educators) to diagnose and manage substance use since youth ages 15–24 years are more likely to see a pediatric primary care provider at least two times a year (Woodwell & Cherry, 2004).
PRIMARY CARE PREVENTION STRATEGIES Accepted prevention and intervention strategies (and a short descriptors of each) for the primary care setting as noted by Comerci and Schwebel (2000) are: • Drug education: Best utilized in prevention of substance use in the hope of reducing the number of youth that experiment with drugs; • Behavioral wellness: Primarily examines the role of the primary care provider in preparing children to meet their psychological and social emotional needs without drugs and alcohol. Accomplishing these tasks with the cooperation of parents may help to reinforce positive behaviors as the child matures; • Promoting family communication: Promoting an open dialogue between parents and their children around health reduced risk choices; • Provider-patient discussion and assessment: Adolescents at-risk for substance use are recommended for drug use screening and assessment at their annual physicals. This assessment can be verbal, but it is
Adolescent Substance Use and Abuse Prevention and Treatment recommended that a confidential questionnaire between the adolescent and the physician be completed (Elster & Kuznets, 1994). This report should be reviewed with the adolescent by the provider during a time in which the parents are not in the room to increase the likelihood that the teen may disclose substance use behaviors (Greydanus & Patel, 2003; Macdonald & Patel, 2002). There are many different tools that are available for this type of evaluation in clinical settings (e.g., RAFFT, CAGE, AUDIT, and CRAFFT). They consist of a short series of questions that can quickly indicate to the provider if further referral and evaluation is needed for substance abuse (Kaul, Coupey, Knight, Sherritt, & Shrier, 2000; Knight, Sherritt, Shrier, Harris, & Chang, 2002).
PRIMARY CARE ENVIRONMENTAL EVALUATION Although environmental concerns can be both protective and risk-conferring, they are not necessarily a specific component of the usual primary care evaluation and/or recommendations in evaluating substance use and abuse. In urban settings where transportation can extend the geographic distance an adolescent considers their community, it is increasingly important to be clear on what environmental risk and protective factors may or may not be available to aid in meaningful education and counseling provided to the adolescent. Nevertheless, access to this type of information would be useful in the primary care setting, especially if psychologists and other behavioral providers were available to assist in its interpretation (Brooks-Gunn, Duncan, Leventhal, & Aber, 1997). This could offer information on the adolescent’s environment, and how likely it is that the risky environmental settings may make access to a more protective setting more or less difficult. For example, if a provider knows that a nearby boys and girls club would provide a safe recreational setting for a patient after school, but also knows that in order to travel to the boys or girls club then the adolescent would have to pass through a neighborhood or street where drug sales and arrests are common, then the provider can work with the teen and family to explore an alternative route or setting for after school activities. While this may bring some complexity to prevention efforts in medical settings, it
135 will likely yield more insights into useful prevention measures. When considering the substance use of adolescents from an ecological perspective, it becomes important to have an accurate assessment of the environment. These assessments can aid in devising realistic interventions and protective measures for the adolescent. Again, psychologists working in medical settings may be in a unique position to integrate these and similar approaches into patient care as they involve an appreciation for both research and clinical issues at the individual and population levels.
PRIMARY CARE SOCIAL NETWORK EVALUATION Unfortunately, there is little research documenting urban adolescents social networks and detailed effects of neighborhood and communities and health compromising effects (Mason, Cheung, & Walker, 2004). But evidence suggests that this type of information would be helpful in addressing substance use in adolescents, making it a promising approach (Lambert, Brown, Phillips, & Ialongo, 2004). In managing adolescent substance use in the primary care setting, it is important for the provider to ascertain how likely the adolescent will be able to access positive supports. A provider who is working with an adolescent may ask the adolescent to decrease recreational exposure to those who are using substances but not realize that there are few people available in the social network whom he or she can spend time with who are not risky in that or other ways. It is also important to note if the adolescent has to travel further to have recreational time with protective individuals in their life than they do to spend time with risky individuals.
GEOGRAPHIC INFORMATION SYSTEMS The epidemiology and risk and protective factors discussed above leave gaps in the research on how to address and assess the social network and environmental impact in the primary care setting. In order to better assess environments in which adolescents live, there are many methods that can be employed. One method that has been used in previous research and will be discussed in this article is Geographic Information Systems (GIS). GIS is an information method that captures, manages, analyzes, and visualizes spatial data. GIS answers
136 the questions, “what is where” and “why it is there”. Armed with this information, GIS can be employed to detect and recognize spatial patterns and to investigate processes that shape them. Spatial data can best be captured by digitalizing–process that turns analog maps into digital ones. Large relational geospatial databases can then be developed by integrating geographic information with others, such as social, economic, cultural, and environmental information. So long as the latter information is referred to with specific geographic features, such as counties, census tracts, or addresses, GIS allows an integration with common spreadsheet and database management software programs. This technology allows one to examine (at the neighborhood level) patterns of social networks with spatial variation that can be detected, defined and mapped to guide prevention efforts in the community (Mason, Cheung, & Walker, 2004). Critical variables related to social support, the use of natural helping systems, and pathways to services delivery systems are known to be spatially differentiated at the neighborhood level and can be mapped for analysis (Andrews, 1985). In the context of clinical research, GIS provides a means to integrate spatial information gathered while interviewing an adolescent with neighborhood level information to form a social ecological profile. For example, the locations of alcohol outlets, libraries, boys and girls clubs, and crime incidences, can be geocoded using street addresses as well as the Typologically Integrated, Geographically Encoded Reference (TIGER)/Line files provided by the United States Census Bureau. Data can then be analyzed to determine the effect of social network affiliation and how geographical risk characteristics are related to different outcomes of substance use (Mason, Cheung, & Walker, 2004). This method of viewing social networks and GIS as a part of health intervention is beginning to be successfully employed in other health areas. These range from environmental health to evaluate a child’s traffic exposure by neighborhood and socioeconomics (Green, Smorodinsky, Kim, McLaughlin, & Ostro, 2004), to immigration and geographic access to prenatal clinics (McLafferty & Grady, 2005), and to optimal placement of syringe-exchange programs to combat HIV/AIDS and injection drug use (Welton, Adelberger, Patterson, & Gilbert, 2004). Psychologists and other primary care providers could also use the information to better inform themselves about the communities they serve and the options available
Walker, Mason, and Cheung to the patients who are in need of increased protective neighborhood settings. By introducing the concepts of social networks and GIS in substance use and abuse prevention and intervention, this paper seeks to explore a promising new approach. This approach is firmly grounded in research and has the potential to impact health at both the individual and population levels. Research and development into these approaches is still ongoing. At present, it is not yet readily available for practitioners to access. As GIS mapping becomes more integrated into how researchers and practitioners conceptualize adolescents at risk of substance abuse, it has the potential to become a valuable practical tool. GIS was used in our previously published report on this topic to extract environmental information in terms of protection and risk of the subject’s residential area (Mason, Cheung, & Walker, 2004). For example, the locations of alcohol outlets, libraries, Boys and Girls Clubs, and crime incidences were geocoded. GIS then allowed spatially-derived relationship analyses between these locations and risk and protection in the environment, and the area where the teen was active. Study data was analyzed to determine the effect of social network affiliation and how geographical risk factors led to different outcomes of substance use. A brief review of this work is given below to illustrate these points. This work was carried out in a medical setting, in the context of clinical research, and in collaboration among a psychologist, adolescent medicine physician, and GIS specialist.
STUDY FINDINGS To illustrate the social network and GIS methodology approach to adolescent substance use prevention and intervention, findings from a convenience sample of adolescents ascertained from an urban primary care clinic at Georgetown University Hospital were described (Mason, Cheung, & Walker, 2004). This study examined 37 adolescents age 14–18 years who were 51% female and of mixed ethnic/racial origin (49% African American, 37% White American, 12% other). The participants in this research were from primarily impoverished neighborhoods with crime rates 7.5 times higher than the national average. These adolescents were asked to complete self-report questionnaires on substance use and social networks. They completed the
Adolescent Substance Use and Abuse Prevention and Treatment Adolescent Drug Involvement Scale (ADIS) (Moberg & Hahn, 1991), the Children’s Depression Inventory (CDI) (Kovacs, 1992), the Adolescent Family Inventory of Life Events and Changes (A-File) (McCubbin, Patterson, Bauman, & Harris, 1981), and the Social Network Assessment (ASNA), (Hirsch, 1979; Hall, 1995; Rothenberg, 2001). The assessment concluded with an ecological interview using “Free Listing” methodology (Weller & Romney, 1998). It was found that 65% of the sample disclosed the non-medical use of substances and, on average, their use fell into the category of regular use but not yet dependency as measured by the ADIS. Adolescents who reported substance use were also more likely to report that more of their social network members also used substances. These adolescents also had more depressive symptoms, were more stressed, and participated in more negative activities with their social network members. A risk analysis of their social networks demonstrated that adolescent substance users had more complex and dense networks than non-substance users, and that those who had substance using friends were 16 times more likely to be substances users themselves and 3.5 times more likely to have elevated stress symptoms as compared to those adolescents with no daily substance user in their network. A geographic profile was then created for one adolescent enrolled in the study. The profile was graphically depicted and indicated the risk and protection measured by the ecological interview with a georeference to the locations adolescents listed as safe or risky, as well as information from area crime reports, liquor stores, and libraries to further characterize the environment. One finding interestingly showed that, on average, the distance between the homes and the safe places for substance users was 3 times the distance between the homes and risky places. This graphic illustration attempts to begin to understand the personal, social network, and environmental risk of the urban youth studied. It illustrates the nature of a 3-dimensional risk profile that can be developed with this information (see Mason et al., 2004 p. 1767). With the aide of a figure, it then becomes clearer what immediate protective and risk factors an adolescent or environment has accessible. Thus, the systematic process augmented by GIS to evaluate social networks, community locations of specific activities and their proximity to safe or risky places, could be an investigative tool to help inform
137 prevention programming for intervention protocols at a local community level. With the progression of technology, the individual level may be informed as well. PREVENTION IMPLICATIONS Using an ecodevelopmental model and GIS to enhance what is known about adolescent substance use risk and protection involves transdisciplinary (defined as consensus building, regular and open communication, and expanding roles across discipline boundaries) collaboration and is able to address more comprehensively the complexity of urban youth. Having youth become an integral part of understanding their own environment and social network capabilities can be instrumental in helping them not only begin to comprehend the need for change but also gives the adolescent a road map for that change. Also, bringing together the community, primary care, geographical analyses, and prevention science not only expands the knowledge base for adolescent health behavior but also introduces prevention implications. Using this information tool can highlight specific contextual forces that impact urban youth, such as culturally-specific information and environmental influences. Coupled with the meanings the adolescents associate with them, this information can be applied to prevention approaches. Instead of offering generic recommendations to find a recreation center to increase after school physical activity as a healthier source of reward rather than alcohol or other drugs, providers could have access to specific services that are active, available and accessible in the patients’ daily neighborhood. While psychologists, physicians, and other health professionals working in medical settings have the burden of dispensing healthy prevention recommendations on a number of topics in a short period of time, the frustration at identifying a problem and not having access to valuable suggestions the family could use would be eliminated by some of the methods detailed herein. Additionally, providers may not have a firm working knowledge of the communities the teens under their care live in. Even more important in the treatment of substance abuse in adolescents, a provider with access to the knowledge that the substance abuse treatment center in the patient’s neighborhood is also within a high violent crime area that the parents will not go to for required evening family meetings, may lead them to suggest another center even if it is further
138 away but is more acceptable to the family. Again, this technology is not currently available in most settings, but in looking toward the future it is both hopeful and inspiring. Given that this technology is beginning to be used in other areas of health, progress in substance use and abuse prevention and intervention may be approaching. CONCLUSION The goal of this paper was to describe adolescent substance use and current primary care prevention and intervention methods that are being used to curb the problem, and to demonstrate how substance using and non-substance using adolescents’ risky and protective social network and the risky and protective environmental settings can suggest primary care applications. The results of the empirical study described by our research team suggests that exploring social networks and environmental risky and safe places with an ecodevelopmental model can add depth in developing prevention strategies for adolescent substance use. Currently, primary care providers may identify high-risk substance use behaviors in adolescents without understanding the contexts in which these adolescent live. With information supplied by geographic mapping of risky and protective locations and individual social contacts, whether on a individual or community level, psychologists in medical settings and other providers may be in a better position to make sound recommendations for addressing identified substance use concerns. Likewise, they may also be moved to become informed advocates in the community to implement interventions for prevention and change. The challenge for this method is to make the information meaningful for large numbers in a community or larger setting. This agenda may be best accomplished through transdisciplinary research, including collaboration among psychologists, physicians, nurses, prevention scientists, GIS experts, and others. This technology is exciting and interactive and ideally suited to for primary care-focused approaches to positively impact adolescent substance use and abuse. ACKNOWLEDGMENT The Manuscript preparation was supported by a grant from the National Institute of Mental Health (MH57909).
Walker, Mason, and Cheung REFERENCES Andrews, H. (1985). The ecology of risk and the geography of intervention: From research to practice for the health and wellbeing of urban children. Annals of the Association of American Geographers, 75, 370–382. Botvin, G., Griffin, K., Diaz, T., Sheier, L., Williams, C., & Epstein, J. (2000). Preventing illicit drug use in adolescents: Long Term follow-up data from a randomized control trial of a school population. Addictive Behaviors, 5, 769–774. Brofenbrenner, U. (1979). The ecology of human development : Experiments by nature and design. Cambridge, MA: Harvard University Press. Brooks-Gunn, G., Duncan, J., Leventhal, T., & Aber J. (1997). Lessons learned and future directions in research on the neighborhood in which children live. Neighborhood Poverty: Context and consequences for children. New York, NY: Russell Sage Foundation. Center for Substances Abuse Treatment. (2001). Persistent effects of treatment studies: Longer term adolescent study. Washington, DC: US Department of Health and Human Services. Comerci, G. D., & Schwebel, R. (2000). Substance abuse: An Overview. Adolescent Medicine: State of the Art Reviews, 11(1), 79–101. Elster, A., & Kuznets, N. (1994). Guidelines for Adolescent Preventive Services. Baltimore: MD Williams and Wilkins. Godley, M. D., Kahn, J. H., Dennis, M. L., Godley, S. H., & Funk, R. R. (2005). The stability and impact of environmental factors on substance use and problems after adolescent outpatient treatment for cannabis abuse or dependence. Psychology of Addictive Behavior, 19(1), 62–70. Green, R. S., Smorodinsky, S., Kim, J. J., McLaughlin, R., & Ostro, B. (2004). Proximity of California public schools to busy roads. Environmental Health Perspectives, 112(1), 61– 66. Greydanus, D. E., & Patel, D. R. (2003). Substance abuse in adolescents: a complex conundrum for the clinician. Pediatric Clinics of North America, 50(5), 1179–1223. Hall, J. (1995). Training for Pregnant and Parenting Adolescents. Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. Rockville, MD: NIDA Research Monograph. Hirsch, B. J. (1979). Psychological dimensions of social networks: A multimethod analysis. American Journal of Community Psychology, 7, 263–277. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2004, December 21). Overall teen drug use continues gradual decline; but use of inhalants rises. University of Michigan News and Information Services: Ann Arbor, MI. [On-line]. Retrieved June 2, 2005 from www.monitoringthefuture.org. Johnston, L. D., O’Malley, P. M, Bachman, J. G., & Schulenberg, J. E. (2005). Monitoring the future national results on adolescent drug use: Overview of key findings, 2004. (NIH Publication No. 05–5726, p. 66). Bethesda, MD: National Institute on Drug Abuse. Johnston, L., O’Malley, P. M., & Bachman, G. (2001). National survey results on drug use from monitoring the future study. Rockville, MD: National Institute on Drug Abuse. Kaul, P., Coupey, S. M., Knight, J. R., Sherritt, L., & Shrier, L. A. (2002). Clinical evaluation of substance abuse. Pediatrics In Review, 23, 85–93. Knight, J. R., Sherritt, L., Shrier, L. A, Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatric Adolescent Medicine, 156, 607–614. Kovacs, M. (1992). Children’s Depression Inventory. North Tonawanda, NY: Multi Health Systems. Lambert, S. F., Brown, T. L., Phillips, C. M., & Ialongo, N. S. (2004). The relationship between perceptions of neighborhood
Adolescent Substance Use and Abuse Prevention and Treatment characteristics and substance use among urban African American adolescents. American Journal of Community Psychology, 34(3–4), 205–218. MacDonald, E. K., & Patel, D. R. (2002). Adolescent substance abuse treatment: A primer for pediatricians. International Pediatrics, 17, 5–12. Mason, M, Cheung, I., & Walker, L. (2004). Substance Use, Social Networks, and the Geography of Urban Adolescents. Substance Use and Misuse, 39(10–12), 1751–1778. McCubbin, H., Patterson, J., Bauman, E., & Harris, L. (1981). The Adolescent Family—Inventory Life Events and Changes. Family Assessment Inventories for Research and Practice. Madison, WI: University of Wisconsin Press. McLafferty, S., & Grady, S. (2005). Immigration and geographic access to prenatal clinics in Brooklyn, NY: A geographic information systems analysis. American Journal of Public Health, 95(4), 638–640. Miller, N. S., & Brady, K. (2004). Addictive Disorders. Psychiatric Clinics of North America, 27(4), xi–xviii. Moberg, P., & Hahn, L. (1991). The adolescent drug involvement scale. Journal of Adolescent Chemical Dependency, 2, 75–88. Nettles, S., & Pleck, J. (1994). Risk, Resilience, and development: The multiple ecologies of black adolescents in the United States. Stress, risk, and resilience in children and adolescents: Processes, mechanisms, and interventions. New York, NY: Cambridge University Press. Newcomb, M. D. (1997). Psychosocial predictors and consequences of drug use: a development perspective within a prospective study. Journal Addiction Disease, 16, 57–59. Rey, J. M., Martin, A., & Krabman, P. (2004). Is the party over? Cannabis and juvenile psychiatric disorder: The past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 43(10), 1194–1205.
139 Rothenberg, R. (2001). Adolescents and STD/HIV transmission: A social network questionnaire. Unpublished manuscript. Simkin, D. R. (2002). Adolescent Substance use Disorders and Comorbidity. Pediatric Clinics of North America, 49, 463–477. Stevens, S. J., & Morral, A. R. (2002). Adolescent Substance Abuse Treatment in the United States: Exemplary Models from a National Evaluation Study. Binghamton, New York: Haworth Press. Szapoznik, J., & Coatsworth, D. (1999). An ecodevelopmental framework for organizing the influences on drug abuse: A developmental model of risk and protection. Drug abuse: Origins and interventions. Washington, DC: American Psychological Association. The DASIS Report: Adolescent Treatment Admissions (2004). SAMSHA, Washington, DC: US Department of Human Services. The National Survey on Drug Use and Health Report: Driving under the influence (DUI) among young persons. Retrieved December 31, 2004. from www.drugabusestatistics.samhsa.gov. The National Survey on Drug Use and Health Report, Alcohol dependence or abuse and age at first use. Retrieved October 22, 2004 from www.drugabusestatistics.samhsa.gov. Wadland, W. C., & Ferenchick, G. S. (2004). Medical comorbidity in addictive disorders. Psychiatric Clinics of North America, 27(4), 675–687. Weller, S., & Romney, K. (1998). Systematic data collection. Thousand Oaks, CA: Sage Foundation. Welton, A., Adelberger, K., Patterson, K., & Gilbert, D. (2004). Optimal placement of syringe-exchange programs. Journal of Urban Health, 81(2), 268–277. Woodwell, D. A., & Cherry, D. K. (2004). National Ambulatory Medical Care Survey: 2002 Summary. Advanced Data, 346, 1– 44.
