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FACTORS AFFECTING SUBSTANCE ABUSE IN ADOLESCENT FEMALES IN RURAL RESIDENTIAL COMMUNITIES by Susan L. Renes

Joan Durante, Ph.D., Faculty Mentor and Chair Alice Yick-Flanagan, Ph.D., Committee Member Christopher Lucies, Ph.D., Committee Member

Christopher Cassirer, ScD, MPH, Dean, School of Human Services

A Dissertation Presented in Partial Fulfillment Of the Requirements for the Degree Doctor of Philosophy

Capella University March 2008

UMI Number: 3296745

Copyright 2008 by Renes, Susan L. All rights reserved.

UMI Microform 3296745 Copyright 2008 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code.

ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, MI 48106-1346

© Susan L. Renes, 2008

Abstract During the last 20 years in the United States, gender identity, peer relationships, and parental relationships have all been associated with adolescent female substance use in urban contexts. The goal of this study was to explore these associations with adolescent females living in rural environments. The quantitative correlation study utilized data gathered from self-reports of females 12 to 15 years of age attending middle school in two rural Washington State communities. Levels of current or 30-day use of alcohol, marijuana, and cigarettes were consistent with national levels of use. The level of current inhalant use, however, was more than twice the national level. European American and Hispanic/Spanish/Latino ethnic groups showed a higher risk for current use of cigarettes, marijuana, and amphetamines and American Indian/Alaska Natives showed a higher risk for current alcohol use than Asian Americans, Native Hawaiians, and African Americans. The gender identity of aggressive masculinity was found as the best predictor of illegal substance use while peer attachment and parent attachment offered some protection from illegal substance use for the population. Combining the results of this study with the work of other researchers could improve substance abuse prevention practices and improve the understanding of how and why such behavior is found among this group.

Dedication To my friend Denise and my sister Nancy, who understand me; my sons, Joe and Mike, who inspire me; but most of all to my husband Ralph who has remained my biggest fan from the day we met. I cannot imagine my life without any of you.

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Acknowledgments No one completes a Ph.D. without the inspiration and support of many individuals. Those whose support and expertise I could not have lived without are my mentor Joan Durante, Ph.D. who constantly provided positive support; my committee members, Christopher Lucies, Ph.D. who helped extend my writing abilities and suggested I pursue a Ph.D.; and Alice Yick-Flanagan, Ph.D. who remains my favorite expert on research methods. In addition, Christopher Ringwalt, DrPH turned an unplanned lunch into continued employment for me, and a professional association for both of us. Heddy Kovach, Ph.D., MJ Paschall, Ph.D., and Sean Hanley, MPH, kept me sane during data collection and analysis. I also wish to thank Tony Strange, Ed.D. who brought me to the University of Alaska Fairbanks and kept me on track to the completion of this degree and Bev Eisele, former administrative assistant at Sequim Middle School, who remained interested in my progress and insisted on referring to me as Dr. Renes long before it was deserved. My heart felt thanks to all of you for who you are in my life and what you helped me accomplish.

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Table of Contents Acknowledgments

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List of Tables

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CHAPTER 1. INTRODUCTION TO THE PROBLEM

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Introduction to the Problem

1

Background of the Study

3

Statement of the Problem

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Purpose of the Study

10

Research Questions

11

Significance of the Study

13

Nature of the Study

17

Theoretical Framework

18

Definition of Terms

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Assumptions and Limitations

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Organization of the Remainder of the Study

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CHAPTER 2. LITERATURE REVIEW

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Theoretical Frameworks

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Gender Identity

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Peer Relationships

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Parental Relationships

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Conclusion

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CHAPTER 3. METHODOLOGY

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Researcher’s Philosophy

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Research Design

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Sampling Design

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Measures

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Data Collection Procedures

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Data Analysis Procedures

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Limits of Methodology

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Expected Findings

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Ethical Issues

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Conclusion

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CHAPTER 4. DATA COLLECTION AND ANALYSIS

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Demographic Profile of Study Participants

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Description of the Variables

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Research Questions and Hypothesis Testing

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Summary

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CHAPTER 5. RESULTS, CONCLUSIONS, AND RECOMMENDATIONS

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Discussion of Findings

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Implications for Substance Abuse Prevention

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Implications for Practice

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Recommendations for Future Research

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Limitations of the Research Study

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Conclusion

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REFERENCES

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List of Tables Table 1. Demographic Profile of the Study Participants

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Table 2. Pearson Product-Moment Correlations between Gender identity and Illegal Drug Use

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Table 3. Pearson Product-Moment Correlations between Peer and Parental Relationships and Illegal Drug use

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Table 4. Standardized Coefficients for the Regression of Illegal Drug Use and Aggressive Masculinity

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CHAPTER 1 INTRODUCTION TO THE PROBLEM Prior to year 1985, rates of illegal drug use among adolescent females and males differed significantly, leading some researchers to argue that adolescent females were in less danger than males of abusing illegal drugs (Substance Abuse and Mental Health Services Administration [SAMHSA], 1997). Rates of alcohol, tobacco, marijuana, and inhalants by adolescents of both genders started to merge in the 1980’s. In 1975, according to national survey results from a study supported by the National Institute on Drug Abuse and conducted by Johnston, O’Malley, Bachman, & Schulenberg (2005), 49% of 12th grade males reported drinking five drinks in a row on one or more occasions compared to a rate of 26% for twelfth grade females. In 2004, the rates were 34.3% for males and 24.2% for females. In 1965, according to national survey results from a study supported by the Substance Abuse and Mental Health Services Administration and conducted by the Research Triangle Institute (SAMHSA, 2002), lifetime cigarette use for males 12 to 17 years was 38%; for females, the rate was 22%. In 1982, the lifetime cigarette use for both males and females 12 to 17 years of age was 34%. Between 2003 and 2004, twelfth grade females had increased 30-day cigarette use by two percentage points, while twelfth-grade males had reduced 30-day cigarette use by almost (.9) one percentage point (Johnston et al., 2005). In 1976, 50.6% of twelfth grade males had used marijuana in the last twelve months compared to 37.8% of twelfth grade females. In 2004, the rates were 37.4% for twelfth grade males and 30.8% for twelfth grade females.

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Currently, use rates for certain illegal drugs are greater for females than males. In 1977, 5.1% of twelfth grade males had used inhalants in the last twelve months compared to 2.4% of twelfth grade females (Johnston et al., 2005). In 2004, the rates were 8.8% for eighth-grade males and 10.5% among eighth-grade females. As with inhalants, eighthgrade female population rates for tranquilizers and amphetamines have surpassed the rate among their male counterparts (Johnson et al.). In 2004, 1.9% of eighth-grade males had used tranquilizers in the past twelve months compared to 3.2% among eighth-grade females, and 3.7% of eighth grade males had used amphetamines in the past twelve months compared to 6.1% among eighth-grade females. Currently, overall, illegal drug use is down among all adolescents, but the level of use for adolescent females has not dropped at the same rate as the level of use for adolescent males. According to SAMHSA (2005), there has been an increase in the rate of initial use for alcohol and prescription drug use among younger adolescent females. Nearly 1.5 million females ages 12 to 17 years had started drinking in 2004, compared to 1.28 million males, and 14% of females 12 to 17 misused prescription drugs, compared to the rate of 12.5% for males. This rise in illegal drug use among some adolescent females necessitates greater focus on the prevention needs of this population (Amaro, Blake, Schwartz, & Flinchbaugh, 2001; Blake, Amaro, Schwartz, & Flinchbaugh, 2001; Guthrie & Flinchbaugh, 2001a; Guthrie & Flinchbaugh, 2001b; Kulis, Marsiglia, & Hurdle, 2003; Lennings, Kenny, Howard, Arcuri, & Mackdacy, 2007; Pizer, 1999; Tarasevich, 2001).

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Background of the Study The change in substance use by adolescent females is baffling (Blake et al., 2001; Guthrie & Flinchbaugh, 2001a; Guthrie & Flinchbaugh, 2001b; Kulis et al., 2003; Pizer, 1999; Tarasevich, 2001). The increase in the rate of initial use for alcohol and other drugs among females 12 through 17 years of age (SAMHSA, 2005) is particularly disturbing; substance abuse dependency at later ages correlates with experimentation at younger ages (Dick, Rose, Viken, & Kaprio, 2000; Grant & Dawson, 1997; Ilomäki, Kaartinen, Viilo, Mäkikyrö, & Räsänen, 2005; Taylor, Lloyd, & Warheit, 2005). Gender differences in the causes of initial illegal drug use, causes of continued drug use, patterns of drug use, and effects of substance abuse prevention programs are all areas of concern in the substance abuse prevention field (Amaro et al., 2001; Dakof, 2000; Johnston et al., 2005). This study focused on adolescent females attending two middle schools in rural communities in northern Washington State. In an effort to describe the health behavior of the state’s youth, Washington State administers the Healthy Youth Survey bi-annually to students in the sixth-, eighth-, 10th-, and 12th-grades (Washington State Department of Social and Health Services, 2006). Results from the 2006 Health Youth Survey in the northern region of Washington State showed a greater lifetime use of alcohol, tobacco, and marijuana among sixth- and eighth-grade females, and a greater lifetime use of methamphetamines among eighth-grade females compared to the state level (Maike, 2007). There was a greater 30-day use of alcohol and marijuana by sixth- and eighthgrade females, and greater 30-day use of tobacco by eighth-grade females compared to the state level. Results of the 2006 survey showed rates of alcohol use increased threefold between sixth-and eighth grades (from 5.1% to 17.5%) in this region. Eight percent 3

(8%) of eighth grade respondents reported to have been under the influence of alcohol or under the influence of marijuana at school on one or more times compared to six percent (6%) at the state level (Maike). Gender Identity There is an association between gender identity and the illegal drug use of adolescent females (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis, Marsiglia, & Hecht, 2002; Kulis et al., 2003). Gender identity is also referred to as gender orientation (Harter, Waters, Whitesell, & Kastelic, 1998) and gender schema (Mercer & Durham, 1999). Condry (1984), however, described gender orientation as the second of three stages individuals progress through as gender identity is developed. Condry’s first stage, gender awareness, occurs at approximately three years of age when there is awareness of male and female and a personal distinction can be made. Condry’s second stage, gender orientation, begins at approximately six years of age when children look beyond cues for appropriate behavior and begin to imitate and model behavior. The last stage, gender identity, Condry reported as beginning in adolescence when certain gender appropriate behaviors become part of an individual’s personal identity. For the purpose of this dissertation, the term gender identity is used to define the masculine or feminine personality traits that females between the ages of 12 and 19 determine are personally appropriate. The term gender identity refers to the subjective experience of masculinity or femininity, including the behaviors, attitude, and characteristics that are part of an individual’s social being (Condry, 1984; Kulis et al., 2002). Gender identity also refers to the degree an individual conforms to gendered cultural stereotypes or internalizes societal 4

pressures for gender conventionality (Diamond, 2002; Yunger, Carver, & Perry, 2004). Gender identity is a personal orientation, as masculine and feminine characteristics are not mutually exclusive; both masculine and feminine characteristics can be present in one individual (Horwitz & While, 1987; McCreary, Newcomb, & Sadava, 1999). Several studies conducted in urban settings linked the gender identity of adolescent females to illegal drug use (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis et al., 2002; Kulis et al., 2003). The results of the urban studies suggest looking at the adolescent female population in other settings to see if the relationship between gender identity and substance use exists in the other contexts. What factors are instrumental in the decision to begin or continue early substance use is puzzling. If a correlation between gender identity and the substance use of adolescent females was established in several contexts, the information would be valuable for prevention scientists. Previous research has shown that both drinking behavior and drunkenness are seen as acceptable and consistent with the traditional male gender but not the female gender (Landrine, Bardwell, & Dean, 1988; Lemle & Mishkind, 1989). Adolescents ascribe to these beliefs. According to Chassin, Tetzolff, and Hershey (1985), teenage boys believe drinking in males will improve social status, but teenage girls do not believe the same holds true for females (Deb, Mitra, & Mukherjee, 2001). Lara-Cantu (1989) described gender identity by separating attitudes and behaviors into four separate categories: affective femininity, aggressive masculinity, assertive masculinity, and submissive femininity. According to Lara-Cantu, affective femininity is distinguished by the following characteristics: cheerful, sensitive to the needs of others, compassionate, gentle, and cooperative. Aggressive masculinity is distinguished by the 5

following characteristics: ambitious, dominant, aggressive, uses harsh language, rude, lazy, and rebellious. Assertive masculinity is distinguished by the following characteristics: leadership, self-reliance, makes decisions easily, strong personality, mature, thoughtful, and able to plan. Submissive femininity is distinguished by the following characteristics: shy, dislikes risks, hesitant, resigned, submissive, and conformist. While the labels do include masculinity and femininity in the titles, according to Lara-Cantu, females often have characteristics of assertive and aggressive masculinity and males often have characteristics of affective and submissive femininity. Including masculinity and femininity in the titles is not meant to limit the behaviors to one sex. The titles simply describe the behaviors that are traditionally or stereotypically masculine and feminine behaviors. Peer Relationships Peer relationships have also been linked to adolescent female substance use (Arata, Stafford, & Tims, 2003; D'Amico, Ellickson, Collins, Martino, & Klein, 2005; Henry & Kobus, 2007; Pearson & Mitchell, 2000; Oetting, Deffenbacher, & Donnermeyer, 1998; Oetting & Donnermeyer, 1998), but this link is not as well established in rural settings due to the lack of research addressing adolescent substance use in rural areas (Atvar & Spencer, 2002; Epstein, Botvin, & Spoth, 2003; Pilgrim, Abbey, & Kershaw, 2004; Shears, Edwards, & Stanley, 2006). This association was considered worth investigating further in a rural setting; Chopak (1993) reported that for rural adolescents, peer behavior is the most significant predictor of involvement in risky behavior related to health concerns.

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Adolescent females are susceptible to peer influence. Adolescent females are oriented toward relationships, a fact which suggests that girls may be susceptible to peer pressure, affected by friends with problem behaviors, and reactive to peer disapproval or approval of illegal drug use (Nolen-Hoeksema & Girgus, 1994; Pearson & Mitchell, 2000). Adolescent females, according to Walters (2006), do not want to be alienated from a peer group. Mezzich, Gincola, Lu, Parks, Ratica, and Dunn (1999) stated that drug involvement by an older male sexual partner increases the likelihood a female will initiate drug use. Early maturing females are particularly at risk; the early maturing female is more likely to associate with an older male sexual partner and the male often introduces substance use into the relationship. The Importance of Studying Adolescent Females in a Rural Community The literature addressing gender identity, peer relationships, and rural communities indicates that students (particularly females) attending rural, middle schools are particularly at risk for illegal drug use and peers are likely to play a pivotal role in the behavior. Adolescent females in rural environments may be at more risk than females in urban settings (Howard, Walker, Walker, Cotton, & Compton, 1999; Ruiz, Stevens, McKnight, Godley, & Shane, 2005; Scaramella, & Keyes, 2001). A rural environment or population is defined as a population between 2,000 and 20,000 individuals, or a population with less than 2,000 individuals located less than two hours (by car) from an urban area (Aloise-Young, Wayman, & Edwards, 2002). A suburban population is defined as a population of over 20,000 individuals located near a large metropolitan area or located in a region that includes several large towns within one geographical area

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(Hajat, Steward, & Hayes, 2003). An urban population is defined as a population of 50,000 or more individuals located in one metropolitan area (Aloise-Young et al.). The increased substance use risk for adolescent females in rural contexts may result from several factors. The geographical factors of fewer social opportunities and lack of transportation to available service providers probably contribute to the increased risk (Anderson & Gittler, 2005; Anderson, & Huffine, 2003, Puskar, Tusaie-Mumford, Sereika, & Lamb, 1999; Stewart et al., 1999). The sociocultural factors of valuing autonomy and refraining from discussing personal issues outside the family likely play a role (Anderson & Huffine). Adolescents in rural communities tend to use more alcohol and tobacco than other substances (Howard et al., 1999; Puskar et al., 1999), but all illegal drug use is reportedly equal to or higher in rural areas than in suburban and urban areas (Atvar & Spencer, 2002; National Center on Addiction and Substance Abuse, 2000; Shears et al., 2006). According to Wu, Schlenger, and Galvin (2007), 16 and 17 year-old females were the most recent users of methamphetamines, particularly in rural environments. Lineberry and Bostwick (2006) confirmed that a high rate of methamphetamine use exists in rural communities. Unfortunately, the majority of past research addressing adolescent substance use focused on urban and suburban populations (Fahs et al., 1999; Kulis et al., 2002; Kulis et al., 2003; Nishimura, Hishinuma, Else, Goebert, & Andrade, 2005; Webb, Bray, Getz, & Adams, 2002; Weiss, Caron, Ball, Tapp, Johnson, & Weisz, 2005); rural populations receive very little attention. Parental Influence According to Moffitt (1993) and Dekovic, Buist, and Reitz (2004) significant changes in problem behavior occur over brief periods in early adolescence, especially 8

during the transition to middle school. The literature addressing gender identity, peer relationships, and rural communities indicates that students (particularly females) attending rural, middle schools are particularly at risk for illegal drug use and peers are likely to play a pivotal role in the behavior. Parents also influence adolescent substance use, particularly adolescent females (Crosnoe, Erickson, & Dornbush, 2002; Webb et al., 2002). Weak family bonds for females are said to correlate with adolescent substance use; strong family cohesion is associated with negative attitudes toward substance use (Blanton, Gibbons, Gerrard, Conger, & Smith, 1997; Crosnoe et al., 2002; Pilgrim et al., 2004). Positive relationships at home are said to promote peer relationships that do not support substance use (Blanton et al.). Females are reported to receive more parental monitoring and be more concerned about maintaining a positive relationship with parents. Unfortunately, research on the influence of parenting on illegal drug use in the rural environment is scarce (Kostelecky, 2005; Scheer, Borden, & Donnermeyer, 2000; Pilgrim et al.). As previously stated, students (particularly females) attending rural, middle schools are particularly at risk for substance use; parents (as well as peers) are likely to play a pivotal role in the behavior.

Statement of the Problem Some adolescent females have been observed using more illegal substances now than ever before. Specifically, rural middle school aged females located in northern Washington State have higher rates of lifetime and 30-day use rates for alcohol, tobacco, marijuana, and methamphetamine than the state levels (Maike, 2007). There is concern over the rates and patterns of such illegal substance use by all adolescent females (Blake 9

et al., 2001; Guthrie & Flinchbaugh, 2001a; Guthrie & Flinchbaugh, 2001b; Lennings et al., 2007; Pizer, 1999; Tarasevich, 2001; Wu et al., 2007). There may be a link between gender identity (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis et al., 2002; Kulis et al., 2003), the susceptibility of adolescent females to peer substance use (Pearson & Mitchell, 2000; Oetting et al., 1998; Oetting & Donnermeyer, 1998), and the influence of parents on such behaviors (Corsi, Winch, Kwiatkowski, & Booth, 2007; Crosnoe et al., 2002; Webb et al., 2002). Therefore, this study was created to determine the relationship between gender identity, peer relationships, and parental relationships relative to illegal substance use among rural middle school aged females located in northern Washington State.

Purpose of the Study The purpose of the study was to determine the relationship between gender identity, peer relationships, and parental relationships relative to illegal substance use among rural middle school aged females located in northern Washington State. The study closely replicated a study previously completed by Kulis et al. (2003). In their study Kulis et al. established a relationship between gender identity and the substance use of adolescent females in an urban population in the U.S. Southwest. Extending the results of the Kulis’ study by looking at results of a similar study conducted in a rural environment will add to the knowledge base of the substance abuse prevention field by extending what is known in an urban context to a rural context.

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Research Questions/Hypotheses The following research questions and hypotheses were used as the basis for analyzing the problem for this study: Research Question 1 What is the relationship between gender identity and current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community? Null Hypothesis There is no relationship between gender identity and current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community. Alternative Hypothesis Aggressive masculinity is positively correlated with current use of illegal substances and assertive masculinity, affective femininity, and submissive femininity are inversely correlated with current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community. Research Question 2 What is the relationship between peer relationships and current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community?

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Null Hypothesis There is no relationship between peer relationships and current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community. Alternative Hypothesis Peer relationships are positively correlated with current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting in a northern Washington State community. Research Question 3 What is the relationship between parental relationships and current use of illegal substances among adolescent females age 12 to 15 years a in rural, middle school setting located in a northern Washington State community? Null Hypothesis There is no relationship between parental relationships and current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community. Alternative Hypothesis Parental relationships are inversely correlated with current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community. Research Question 4 Which factor(s) (i.e. gender identity, peer relationships, and/or parental relationships) best predicts current use of illegal substances among adolescent females 12

age 12 to 15 years in a rural, middle school setting located in a northern Washington State community? Null hypothesis Gender identity does not significantly predict current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a Washington State community than peer relationships or parental relationships. Alternative Hypothesis Gender identity is a better significant predictor of current use of illegal substances among adolescent females age 12 to 15 years in a rural, middle school setting located in a northern Washington State community than peer relationships or parental relationships.

Rationale and Significance of the Study Epidemiological data point to the need for substance abuse prevention for adolescent females (Johnston et al., 2005; SAMSHA, 2005). While some use of moodaltering substances is declining among adolescents in general, age specific rates of initial drug use are increasing faster among adolescent females (SAMSHA, 2005). While there is some information concerning adolescent female substance use in urban and suburban areas, there is little empirical data concerning females in rural areas (National Center on Addiction and Substance Abuse, 2000; Shears et al., 2006; Steward et al., 1999). Looking at gender identity, peer relationships, and parental relationships and the possible correlations with the substance use of middle school students in a rural environment will provide needed information to the substance abuse prevention field.

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When looking at the rural population of adolescent females, understanding the factors influencing substance use is important. Adolescent females appear susceptible to peer pressure, friends with problem behaviors, and peer disapproval or approval of alcohol, tobacco, and other drug use (Mezzich et al., 1999; Nolen-Hoeksema and Girgus, 1994; Pearson & Mitchell, 2000; Walters, 2006). The susceptibility is likely due to adolescent female orientation toward relationships (Maccoby, 1988; Schulenberg et al., 1999; Wilke, Siebert, Delva, Smith, & Howell, 2005). Gender identity has recently emerged as a potential factor in drug using behavior (Kulis et al., 2002). Several studies conducted in urban settings link the gender identity of adolescent females to substance use (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis et al.; Kulis et al., 2003). If an association between gender identity and the substance use of adolescent females was established in several contexts, prevention scientists could adapt current programs to improve substance abuse prevention programs for adolescent females. The concern for substance abuse prevention for adolescent females goes beyond an increase in substance use (Blake et al., 2001; Guthrie & Flinchbaugh, 2001a; Guthrie & Flinchbaugh, 2001b; Walters, 2006). Adolescent females respond in a particular way to substance use and substance abuse (Dakof, 2000; National Center on Addiction and Substance Abuse, 2006; Opland, Winters, & Stinchfield, 1995; Sarigiani, Ryan, & Petersen, 1999). For alcohol, girls seem to experience a strong addiction and severe withdrawal symptoms and are likely to experience a relapse. There is also evidence to suggest that once females begin drug use, there is a high risk for developing drug dependence (Dakof; Greenfield, 2002). Girls also experience a greater level of intoxication as the result of drinking smaller amounts of alcohol than male counterparts, 14

due to a lower body weight and different rates of metabolism (Greenfield; National Center on Addiction and Substance Abuse, 2006; Opland et al.). Additionally, girls are at risk for certain mental health problems that are highly correlated with substance abuse (Goodkind, Ng, & Sarri, 2006; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; Rosenfield, Phillips, & White, 2006). Specifically, depression, stress, body image dissatisfaction, and a decline in selfesteem are all associated with substance abuse (National Center on Addiction and Substance Abuse). As adults, women experience greater health problems than men resulting from the same level of use (Guthrie & Flinchbaugh, 2001b). The health problems include cirrhosis of the liver (Greenfield, 2002), cardiovascular disease (National Institute on Alcohol Abuse and Alcoholism, 2000), hypertension (Thanhani, Camargo, Stampfer, Curhan, Willett, & Rimm, 2002), cognitive impairment (Greenfield), and bone fractures due to brittle bones (National Center on Addiction and Substance Abuse, 2006). There are unanswered questions regarding gender differences concerning patterns of use (Ahmadi, Maharlooy, & Alishahi, 2004; Amaro et al., 2001). Looking at reasons for substance use and substance abuse, Amaro et al. suggested that particular risk factors, such as dieting and weight concerns, physical or sexual abuse, depression, substance use of a boyfriend, or early onset of puberty, might be significant for adolescent females. The number of girls involved in the juvenile justice system is increasing, which has been cited as a factor also related to substance abuse (Amaro et al.; Goodkind, et al., 2006; Quinn, Poirier, & Garfinkel, 2005). Several authors (Goodkind et al.; Lederman, Dakof, Larrea, & Li, 2004; Quinn et al.) reported that a history of abuse in the adolescent female 15

population, particularly sexual abuse, is highly correlated with involvement in the juvenile justice system. Adolescent females are often arrested for assault and drug offenses, behaviors often related to avoiding abuse and the subsequent psychological effects of abuse (Goodkind et al.). Females frequently experience a sharp decline in selfconcept between 12 and 15 years of age and adolescent females often become involved in illegal drug use to cope with emotions (Opland et al., 1995; Rosenfield, Lennon, & White, 2005). Hussong (2000) reported that a lack of friends and conflicts with friends potentially causing damage to female self-esteem. Bryant, Schulenberg, O’Malley, Bachman, and Johnston (2003) reported that low achieving girls, particularly girls who have difficulty in school, are at risk for cigarette, alcohol, and marijuana use over time due to coping differently with stress or having different social support than high achieving girls. The prevention field is aware of the rise in adolescent female substance use (Johnston et al., 2005; SAMSHA, 2005) and the possible influence of gender identity (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis et al. 2002; Kulis et al., 2003) and peer and family relationships (Pearson & Mitchell, 2000; Oetting et al., 1998; Oetting & Donnermeyer, 1998; Silmere & Stiffman, 2006). What the prevention field is not aware of is whether these factors function in the same manner in a rural environment. With adolescent drug use equal to or greater in rural environments compared to urban and suburban areas (Atvar & Spencer, 2002; National Center on Addiction and Substance Abuse, 2000; Shears, et al., 2006), the potential factors need further research in a rural context. Students (particularly females) attending rural, middle schools are particularly at risk for substance use and gender identity, peer relationships, and family relationships are 16

likely to play a pivotal role in the behavior. Extending the knowledge to the rural context, as this study did, benefits the substance abuse prevention field by addressing problems in the rural community that could lead to substance use in adolescent females. Additionally, the potential exists to improve substance abuse prevention practice by combining the results of this study with the work of other researchers. New information could direct future substance abuse prevention curricula and change the course of what is addressed in substance abuse prevention programs. Researchers concerned about adolescent females have called for more research addressing the substance use of adolescent females (Blake et al., 2001; Guthrie & Flinchbaugh, 2001a; Guthrie & Flinchbaugh, 2001b; Pizer, 1999; Tarasevich, 2001). Researchers focusing on gender identity have called for additional research looking at gender identity (Horowitz & White, 1987; Husefield & Cooper, 1992; Kulis et al. 2002; Kulis et al., 2003). Researchers aware of the lack of information about rural populations have requested research addressing adolescent substance use in rural populations (Atvar & Spencer, 2002; National Center on Addiction and Substance Abuse, 2000; Epstein et al., 2003; Pilgrim et al., 2004; Shears et al., 2006). The study adds to the knowledge base in each of these areas.

Nature of the Study This was a quantitative study approach using a correlational research design because such designs offer the ability to look at possible relationship between variables (Neuman, 2003). This study in particular used the correlational design to examine the relationship between the independent variables, (i.e., gender identity, peer relationships, 17

and family relationships) and the dependent variable (i.e., illegal substance use among adolescent females who are of middle school age in rural community settings). Such associations have traditionally been observed and then analyzed in the studies of related populations found typically in urban areas.

Theoretical Frameworks Social cognitive theory and primary socialization theory provided the main theoretical frameworks supporting this study. Both theories are based on the principles of social learning theory. Social learning theory states that learning occurs in a social context, and is influenced by the reciprocal nature that exists between a human being and the environment (Bandura, 1977). Rather than relying solely on personal efforts, according to social learning theory, an abundance of learning occurs through observation. Simply stated, learning takes place in a social environment by observing cognitive, affective, social, and psychomotor behavior, then retaining, practicing, and continuing to perform the behavior. Modeled behavior progresses to adopted behavior if the model is admired and the results of the behavior are viewed as positive (Ormrod, 1999). According to social learning theory, deviant behavior and conforming behavior are learned through the same process (Akers & Lee, 1996). Social cognitive theory supports the belief that each individual develops a personal gender identity (Bussey & Bandura, 1999; Bandura & Bussey, 2004). According to social cognitive theory, affective, cognitive, behavioral, biological, and environmental events interact to direct human functioning (Bandura, 2000). Gender identity is advanced by three modes of influence: modeling the behavior of parents, peers, and other 18

significant people in various contexts; discerning possible or gender appropriate behaviors based on the result of personal actions; and learning gender appropriate behaviors from others (Bussey & Bandura). Gender identity is one aspect of an individual’s overall identity and supports the establishment of an individualized selfidentity (Deaux & Stewart, 2001). Primary socialization theory, on the other hand, posits that adolescent substance use results from interaction with the primary sources of socialization: family, school, and close personal relationships (Oetting et al., 1998, Egle, 2005; Rhoads, 2003). While individual characteristics and personality traits are not considered directly related to drug use, they are viewed as influencing drug use due to their affect on primary socialization (Oetting, 1999). The peer and family influences seen in urban areas are predicted by primary socialization theory. The bonds formed in the socialization process with peers and family members act to reinforce attitudes, beliefs, values, and standards of behavior (Oetting; Egle; Rhoads, 2003). During interactions, requirements for behavior are made evident by the sources of socialization; positive feedback and rewards are given for compliance and behavior is reinforced when an individual’s needs are met. Social cognitive theory and primary socialization theory are complimentary and provide a good foundation for the proposed study.

Definition of Terms Adolescence. Adolescence is defined as the years of a child’s life between and including 12 and 19 years of age (Vander Zanden, 2000). Adolescence for the purposes of this study refers to females 12 to 15 years of age. 19

Adolescent substance use. Adolescent substance use is defined as any alcohol, tobacco, or other drug use (Elek, Miller-Day, & Hecht, 2006). Adolescent substance abuse. Adolescent substance abuse is defined as having one or more of four diagnostic criterion items from the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revised (DSM-IV-TR) occurring in a 12-month period (American Psychiatric Association, 2000). The four criterion are: (a) recurrent substance use resulting in failure to fulfill major role obligations, (b) recurrent substance use in situations which are physically hazardous, (c) recurrent substance-related legal problems, (d) continued substance use despite having persistent or recurrent social problems secondary to use. Adolescent substance dependence. Substance dependence for adolescents is defined as having three or more of the seven diagnostic criterion items from the DSM-IVTR occurring in a 12-month period (American Psychiatric Association, 2000). The seven criterion are: (a) tolerance, (b) withdrawal, (c) substance taken in larger amounts and for a longer period than was intended, (d) persistent desire or unsuccessful efforts to cut down or control substance use, (e) great deal of time spent in activities necessary to obtain substance, (f) important social, occupational, or recreational activities given up because of substance use, (g) substance use continued despite knowledge that medical or psychological problems are secondary to use. Affective femininity. A gender identity distinguished by the following characteristics: cheerful, sensitive to the needs of others, compassionate, gentle, and cooperative (Lara-Cantu, 1989). 20

Aggressive masculinity. A gender identity distinguished by the following characteristics: ambitious, dominant, aggressive, uses harsh language, rude, lazy, and rebellious (Lara-Cantu, 1989). Assertive masculinity. A gender identity distinguished by the following characteristics: leadership, self-reliance, makes decisions easily, strong personality, mature, thoughtful, and able to plan (Lara-Cantu, 1989). Gender. Gender refers to the binary description of the sexes as either male or female (Kulis et al., 2002). Gender identity. Gender identity refers to the subjective experience of masculinity or femininity, including the behaviors, attitude, and characteristics that are part of an individual’s social being (Kulis et al., 2002), i.e. the degree to which an individual conforms to gendered cultural stereotypes or internalizes societal pressures for gender conventionality (Diamond, 2002; Kulis et al., 2002; Yunger et al., 2004). For the purposes of the study, gender identity is broken down into four distinct categories: aggressive masculinity, assertive masculinity, affective femininity, and submissive femininity (Kulis et al., 2003). Rural population or rural community. A population between 2,000 and 20,000 individuals, or a population with less than 2,000 individuals located less than two hours (by car) from an urban area (Aloise-Young et al., 2002). Submissive femininity. A gender identity distinguished by the following characteristics: shy, dislikes risks, hesitant, resigned, submissive, and conformist (LaraCantu, 1989). 21

Suburban population. A population of over 20,000 individuals located near a large metropolitan area or located in a region that includes several large towns within one geographical area (Hajat et al., 2003). Urban population. A population of 50,000 or more individuals located in one metropolitan area (Aloise-Young et al., 2002).

Assumptions and Limitations The research design of this study was based on the assumption that reality can be viewed as a network of interacting relationships between the factors under investigation (Davis, 1997). When studying variables related to each other in such a way, such a research design can easily quantify the strength of the relationships between such variables in a study (Hunt, 2000). Hence, this study assumed the variables in question were related in meaningful ways and that the research design was capable of measuring the strength of such relationships (Walker, 2003). Another assumption for this research design was that when correctly utilized, this model could provide significant results that could be generalized to other populations with similar backgrounds living in similar circumstances and environments such as the one chosen for this study. Finally, students completing the survey instrument for this study were expected to do so honestly, given the sensitive nature of the topic (Campanelli, Dielman, & Shope, 1987; O’Malley, Johnston, Bachman, & Schulenberg, 2000). The study had a number of limitations resulting from the research design that did restrict the generalizability of the study’s results to other adolescents. The correlational aspect of the study did not demonstrate causality (Leedy & Ormrod, 2004). Additional 22

events or situations could have influenced the dependent variables and the study design allowed no way to account for other potential influences. The cross-sectional nature of the study was also a limitation. There were several questions addressing gender identity and parent and peer relationships. Parents and peer relationships influence adolescents over time and adolescent changes in self-perception and self-definition are common (Blanton, et al., 1997; Kandel, 1996). Therefore, there would be no guarantee the same patterns shown between the variables would occur at a different time with the same students or at the same time with different middle school students. There were self-reporting, sampling, and measurement limitations as well. There is a danger that student responses did not accurately reflect experiences due to student awareness of the study (Mertens, 2005) or that problem behavior was underestimated due to student suspensions and reduced attendance. The population proposed for the study was limited; the sample included predominantly European American, female middle school students 12 to 15 years of age attending two middle schools in northern Washington State. The schools are located in a rural area of northern Washington State, approximately three hours from any urban area. Even with the limitations, the study provided needed information about the relationship between gender identity, peer relationships, and family relationships in a rural environment and adolescent female substance use.

Organization of the Remainder of the Study Chapter two reviews the literature related to the research questions. Chapter three describes the research methodology. Chapter four presents an analysis of the data. The 23

study concludes with Chapter five, which presents the study’s summary, conclusions, and recommendations for future research.

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CHAPTER 2 LITERATURE REVIEW The following chapter examines literature pertinent to the theoretical framework of this study, gender identity, peer relationships, and parental relationships in rural environments. Illegal drug use among adolescents is declining, in general, but the rate of use by adolescent females is not declining as fast as the rate for adolescent males (Johnston et al., 2005). Adolescents are experimenting with drug use at younger ages, but the age–specific rates of initial drug use are increasing faster among girls (SAMHSA, 2005).

Theoretical Frameworks Social Cognitive Theory Social cognitive theory served as one of the two theoretical frameworks for this study. Social cognitive theory supports the belief that each individual develops a personal gender identity (Bussey & Bandura, 1999; Bandura & Bussey, 2004). According to social cognitive theory, affective, cognitive, behavioral, biological, and environmental events interact to direct human functioning (Bandura, 2000). Gender identity, specifically, is advanced by three modes of influence: modeling the behavior of parents, peers, and other significant people in various contexts; discerning possible or gender appropriate behaviors based on the result of personal actions; and learning gender appropriate behaviors from others (Bussey & Bandura). Bandura (1986) developed social cognitive theory from concepts originating in social learning theory; social learning theory is a cluster of theories developed to explain human and animal behavior. The three principles 25

of social learning theory are: (a) rewards and punishments influence behavior, (b) human beings often learn through observation, and (c) individuals model behavior by observing others for whom there is a personal identification (Stone, 1999). According to social cognitive theory, personal gender identity develops in early childhood, beginning with an identity that is socially controlled and progressing as a child increases in age to an identity that is self-regulated (Bussey & Bandura, 1992; Bandura & Bussey, 2004). Bussey and Bandura studied gender identity and development in nursery school children and found a progression from socially guided control over gender-linked behavior to self-regulated behavior. Older children (up to 4.5 years) approved of personal behavior seen as acceptable according to gender (p < .0001), but were critical of personal behavior viewed as acceptable to the opposite sex (p < .05). The results supported social cognitive theory’s belief that gender identity develops into a personal identity and supported Bussey’s and Bandura’s hypothesis that gender linked behavior shifts from social sanctions to personal sanctions. Serbin and Sprafkin (1986) studied children three to seven years of age and found support for the personal development of a gender identity. As children increased in age, so did the ability to think beyond traditional sex roles, as measured by a sex typing scale (p < .05). Stern (2005) studied teen characters to determine the type, rate of occurrence, and consequences of adolescent substance use in movies popular with this age group. Stern used social cognitive theory as the framework, stating that characters in films and other media influence viewers. Stern suggested that powerful and attractive characters are the most influential. According to social cognitive theory, one way adolescents learn about substance use is through observing others, modeling behavior, and watching how others 26

are rewarded and go unpunished. In Stern’s analysis of popular movies featuring teenage characters, 80% of the characters who drank and used other drugs were female, 62.5% of those who smoked cigarettes and drank were female, and 81.8% of those who smoked cigarettes and used other drugs were female. If movies are one way to view reality, teens are observing adolescent females involved in multiple substance use. Callas, Flynn, and Worden (2004) surveyed middle school students in rural Vermont and included several psychosocial measures based on social cognitive theory. The measures included perceived peer attitudes toward alcohol and perceived alcohol use by adolescents. Peer norms for attitudes and behavior toward alcohol use proved more important for girls than boys (p < .01). Following peer norms is an example of modeling the behavior of peers and learning gender appropriate behaviors from others, two of the three ways gender identity is advanced (Bussey & Bandura, 1999). According to social cognitive theory, the attributes that contribute to human behavior include: (a) symbolizing capability, (b) vicarious capability, (c) forethought capability, (d) self-regulatory capability, and (e) self-reflective capability (Bandura, 2000). The symbolizing capacity of social cognitive theory says external influences operate through a cognitive process (Bandura, 1989). The human capacity to create symbols to represent the interaction and relationship of events serves as an important mechanism to comprehend and manage the environment. Symbols or mental images serve to store information in memory for use in future behavior. The symbolizing capacity allows human beings to model the behavior of others and to predict the results of future behavior (Stone, 1999). Vicarious capability refers to the human capacity to learn from observing the behavior of others (Bandura, 2000). 27

People learn in two basic ways: by personal actions and/or by observation. Learning by observation, using the vicarious capability, improves the efficiency of learning. Patterns of behavior are quickly formed, trial and error can be avoided, and learning occurs that would otherwise be prohibited due to time, resources, and mobility constraints (Stone, 1999). Language and other social practices would be impossible to transmit without the vicarious capability. Modeling the behavior of others is not simply mimicking the behavior. Personal reflection resulting from observation influences how the observation is used. The vicarious capability and the symbolizing capability work together; information from observations is symbolically coded and then refined and synthesized into different innovations through personal creativity (Stone). Vicarious capability and symbolizing capability play a role in gender identity development. Adolescent females progress in gender identity development by observing and modeling friends, family members, and adults. New behavior is learned and what the behavior symbolizes is incorporated through personal reflection. Vicarious capability and symbolizing capability also play a role in adolescent substance use. Adolescent females learn to use substances primarily from peers. Observing and modeling other adolescents who use alcohol, tobacco, or other drugs allows a teenager to learn the behavior and incorporate what the behavior symbolizes through personal reflection (Oetting & Donnermeyer, 1998). Forethought capability allows individuals to predict the outcome of personal behavior. Social cognitive theory says anticipating the consequences of planned actions can serve as a guide and a motivator for behavior (Bandura, 1989). Previous personal experience and observing the consequences of the behavior of others (vicarious 28

capability) both influence forethought. Symbolizing capability works together with forethought capability and allows an individual to predict future events in the present (Stone, 1999). If an adolescent female believes taking on traits of aggressive masculinity will improve personal power in relationships and support control over the environment, the belief will influence gender identity development. If an adolescent female predicts failing to use alcohol, tobacco, or other drugs will result in being ignored or ostracized from a social group, the prediction will influence substance use behavior (Hussong, 2000). Self-regulatory capability allows an individual to direct personal behavior, allowing control over thoughts, feelings, and actions (Bandura, 1989). Self-regulation supports the internalization of certain external controls, which occurs through a process of self-efficacy (the belief that personal actions will produce desired results), feedback, and estimated time to goal achievement (Stone, 1999). The self-reflective capability is the ability to verify or judge personal actions against an indicator of truth (Bandura 2000). The reflection might result from observing the actions of others, comparing personal thoughts to actual results, comparing personal thoughts with the beliefs of others, or evaluating the logic of personal thoughts. Adolescent females reflecting on parental monitoring and parental attachment can support the internalization of parental controls and improve self-regulatory capability (Allen, Moore, Kuperminc, and Bell, 1998). Self-efficacy is an important component of social cognitive theory (Bussey & Bandura, 1999; Locke & Sadler, 2007) and a major factor affecting self-regulation (Stone, 1999; Cho, 2007). Robinson, Telljohann, and Price (1999) studied self-efficacy as a predictor of sixth grade students engaging in sexual intercourse. The authors found that 29

in 96% of the cases, a combination of social support and efficacy expectations predicted sexual behavior for females. As social support and self-efficacy expectations increased, the likelihood of sixth grade females having sexual intercourse decreased. Engaging in sexual intercourse as an adolescent is correlated with adolescent substance use (Conason & Sher, 2006; Fortenberry, 1995; Huba et al., 2003), suggesting the pathways to preventing both behaviors might be similar. Bussey and Bandura (1999) discussed the role of aggression in gender identity as seen through the lens of social cognitive theory. Girls often admire aggression and when rewarded, find aggression relatively easy to adopt. According to Bettencourt and Kernahan (1997), male and female differences in aggressive behavior are actually much smaller than is generally believed and diminish further with age, conditions of aggravation, and aggressive indicators. Mouttapa, Valente, Gallaher, Rohrbach, and Unger (2004) studied sixth grade bullies in a school setting to determine if there were gender differences in bullying. Female bullies had fewer friends than females who were not bullies (p < .0001); however, bullies had a higher number of reciprocated friendships than non-bullies (p < .006), suggesting that female bullies have smaller, more unified friendship groups than females who are not bullies. Mouttapa et al. (2004) stated that nominating friends who are also bullies supports social cognitive theory; friends are modeling the behavior of others who are seen as significant. The study’s results also support the gender identity aspect of social cognitive theory. The females are learning what the friendship group considers gender appropriate behavior from members in the group. These results are significant as this study hypothesized that aggressive masculinity is positively correlated with current alcohol, 30

tobacco, and other drug use and assertive masculinity, affective femininity, and submissive femininity are inversely correlated with current alcohol, tobacco, and other drug use among adolescent females age 12-15 years in rural, middle school settings. The decision for both adolescent males and females to use aggression is also based on the anticipated consequences of an aggressive act (Bussey & Bandura, 1999; Crothers, Field, & Kolbert, 2005; Felix & McMahon, 2007). Girls often anticipate sanctions for aggressive behavior from parents and peers and resort to more indirect aggression. Crick and Grotpeter (1995) hypothesized that the aggression of adolescent females is expressed through a type of aggression that is relational, done by withdrawing from a relationship, spreading rumors, etc. for the purpose of damaging another’s friendship or to create feelings of being excluded from a peer group. The results of the study showed that adolescent females were significantly more aggressive in a relational fashion than adolescent males (p < .001). Crick and Werner (1998) found that males from 9 to 12 years of age had a more positive evaluation of overt aggression than relational aggression (p < .001) and females had a more positive evaluation of relational aggression than overt aggression (p < .05). Boys experience more internal and external criticism when exhibiting behavior traditionally attributed to the opposite sex (Bussey & Bandura, 1992). According to Bussey and Bandura (1999), boys appear more closely associated with same-gender role models than girls and both male peers and fathers sanction male behavior following nontraditional roles. Boys are unlikely to let go of the power granted males unless females are viewed as possessing the same level of power (Bussey & Bandura). Bussey and Bandura (1999) believe that girls are less prone to traditional gender identities than boys. 31

Girls often receive support from peers and parents to follow non-traditional roles and to develop non-traditional identities. Adolescent females finding less resistance to nontraditional gender roles might seriously consider behaviors associated with aggressive masculinity. This gender identity is correlated with substance use in urban and suburban communities (Kulis et al., 2002; Kulis et al., 2003). This study predicted the correlation is also present in rural communities. Finding the correlation in rural environments would strengthen the argument that adolescent female substance use is related to the gender identity of aggressive masculinity. Social cognitive theory describes how and why gender identity influences substance use behavior (Bussey & Bandura, 1999; Callas et al., 2004; Stern, 2005). In past studies, gender identity was related to adult substance use (Chomak & Collins, 1987; Ricciardelli, Williams, & Kiernan, 1998; Williams & Ricciardelli, 1999) and adolescent substance use (Kulis et al., 2002; Kulis et al., 2003). Although use of social cognitive theory in studies of substance use has been limited, the theory could provide the theoretical framework for future studies that address the relationship between gender identity and substance use. For this study, social cognitive theory supported the finding that gender identity is related to adolescent female substance use. Primary Socialization Theory In addition to social cognitive theory, primary socialization theory served as a theoretical framework for this study. Primary socialization theory posits that adolescent substance use results from interaction with the sources of primary socialization, family, school, and close personal relationships (Egle, 2005; Kassel, Evatt, Greenstein, Wardle, Yates, & Veilleux, 2007; Oetting et al., 1998; Rhoads, 2003). Berger and Luckmann 32

(1967) were among the theorists who first used the term “primary socialization”. The term, however, only referred to early socialization that occurred within the context of the family and the existing culture. Oetting (1999) used primary socialization to describe a socialization process that changes with the age of the individual. Preschool children are primarily influenced by the family system. Children who form appropriate bonds and learn age appropriate behaviors are likely to be accepted. The acceptance and the reinforcement form the basis for learning age appropriate behaviors as the child develops. During early school years, socialization remains linked to the family, but is also influenced by the school. Peer relationships are important, but probably do not have the influence observed during adolescence. However, if a child does poorly during the early grade school years or does not like school, an association with peers who have poor social adjustment and who participate in deviant behaviors is likely. These associations often lead to alcohol, tobacco, and other drug use and other forms of deviant behavior (Oetting). According to Flannery, Vazsonyi, Torquati, & Fridrich (1993), vulnerability to peer pressure and peer use of alcohol are the highest predictors of substance use for sixth and seventh grade students. Elek et al. (2006) and Walden, McGue, Iacono, Burt, and Elkins (2004) reported that peer substance use is highly influential in early adolescent substance use. Primary socialization theory posits that during adolescence the primary sources of socialization progress from family and school to include close personal relationships with peers. These sources of socialization interact with the adolescent and in the context of the interaction, prosocial or deviant behaviors are learned (Oetting et al., 1998). During interactions, requirements for behavior are made evident by all the sources of 33

socialization; positive feedback and rewards are given for compliance and behavior is reinforced when an individual’s needs are met. The bonds formed in the socialization process act to reinforce attitudes, beliefs, values, and standards of behavior (Oetting, 1999). A problem in bonding with the family, the school, or peers increases the likelihood these interactions with peers will result in deviant behaviors, such as alcohol, tobacco, and other drug use (Bryant et al., 2003; Dielman, 1994; Tarter, Sambrano, & Dunn, 2002). Lopez, Martinez, Martin, Martin, Martin, and Scandroglio (2001) studied how substance use is associated with other factors in young people 15 to 29. What the authors uncovered supported primary socialization theory. Lower satisfaction with school (p < .05) and family (p < .001) were associated with substance use. Individuals who were moderate or selective in substance use showed greater perceived support from the peer group (p < .05) while those who were indiscriminate and frequent substance users showed a lack of peer support and peer satisfaction (p < .05). The interaction between an adolescent and the primary socialization sources is the predominant way patterns of behavior are determined; however, according to primary socialization theory, adolescents do not passively receive information from family, school, or peers (Oetting, 1999). The interaction between the adolescent and the socializing agent is dynamic, with attitudes, beliefs, and values communicated back and forth between the adolescent and the socializing agent. Physical, emotional, and social characteristics of an adolescent affect the socialization process, as these traits influence what the adolescent brings to the relationship. Some theorists (Gerra et al., 2004) believe personality traits are a primary influence for substance use behavior, but according to 34

primary socialization theory, individual characteristics and personality traits are not directly related to alcohol, tobacco, and other drug use. The characteristics and traits are viewed as influencing drug use due to the affect on primary socialization (Oetting, 1999). Characteristics such as depression, low self-esteem, anger, and sensation seeking are seen by primary socialization theory as related to alcohol, tobacco, and other drug use and other deviant behaviors, but only in a secondary manner. Swaim, Oetting, Edwards, and Beauvias (1989) studied the association between emotional distress and adolescent substance use, specifically anger, blame, anxiety, depression, and self-esteem. Self-reports from 563 eleventh and twelfth grade students showed the combined effect of the five variables only accounted for 4.8% of the total substance use variance (p < .05), supporting a premise of primary socialization theory that characteristics such as emotional distress are related to substance use, but only in a secondary way. Donohew, Clayton, Skinner, and Colon (1999) studied whether peer networks and sensation seeking are related to alcohol and marijuana use. The authors found sensation seeking only indirectly affected alcohol and marijuana use, supporting the belief that sensation seeking is related to substance use only in a secondary way. These studies support the foundation of primary socialization theory; the primary influences for substance use are not personality traits, sensation seeking, affective disorders, or emotional distress, but rather the interaction between adolescent and family, school and peers. The research questions were directed toward two of the three primary socialization factors, peer relationships, and parental relationships. E.R. Oetting, the principal developer of primary socialization theory, stated that during adolescence, the family and the school are primary sources of socialization, but 35

peers are highly influential (personal communication, July 16, 2006). The influence of peers during adolescence occurs at different levels (Oetting & Donnermeyer, 1998; Rhoads, 2003). Oetting and Donnermeyer referred to best friends, couples, or small close groups as peer clusters. Peer clusters have the most influence over adolescent behavior. Rhoads found positive relationships between peer clusters and substance use for adolescent living in rural communities (p < .01). Levels of peer drug use and peers asking friends to use drugs were higher for American Indian and Mexican American youth than for European American youth. Peer clusters are not the same as peer groups. Peer groups are formal or informal groups an adolescent might associate with, such as the basketball team or the freshman history class. Peer groups provide an opportunity for adolescents to form peer clusters, but do not have the same level of influence as peer clusters. Both peer clusters and peer groups are part of a larger context, the peer environment (Oetting et al., 1998). The peer environment functions as a secondary socialization source. The peer environment supports prosocial or deviant norms and influences what norms are transmitted in peer clusters. If the peer environment believes that alcohol, tobacco, and other drug use is acceptable, peer clusters can more easily support drug use. According to Oetting and Donnermeyer (1998), problem behaviors are also influenced by cultural and social norms. Primary socialization theory allows for the fact that social groups often stringently insist on gender-role conformity. Female adolescents appear sensitive to social expectations; therefore, parental expectations may have a stronger influence over females compared to males. Sale, Sambrano, Springer, Pena, Pan, and Kasim (2005) reported that improved connections between young Hispanic females 36

and parents work to prevent or delay alcohol use. Oetting and Donnermeyer suggested that troubled adolescent females may be more vulnerable than adolescent males to deviant peers and the peers may play a more significant role in deviant behavior continuing over a long period. Swaim, Oetting, and Cases (1996) studied cigarette use among Mexican American youth and found female smokers were more likely to have peers who encouraged smoking (p < .001). Mezzich et al. (1999) reported that drug involvement by an older male sexual partner increases the likelihood an adolescent female will initiate drug use and, in older girls, the male partner increases the likelihood alcohol, tobacco, and other drug use will escalate. Primary socialization theory explains how and why the socializing agents of family, school, and peers interact with each other to influence adolescent substance use (Oetting & Donnermeyer, 1998). Primary socialization theory is the theoretical framework for many studies addressing adolescent substance use (Donohew et al., 1999; Galliher, Evans, & Weiser, 2007; Kassel et al., 2007; Lopez et al., 2001; Rhoads, 2003; Sale et al., 2005; Swaim et al., 1989; Swaim et al., 1996). Use of the theory in a study of adolescent female substance use and gender identity, peer relationships, and parental relationships in rural environments seems appropriate considering the importance of interpersonal interactions to adolescent females (Maccoby, 1988; Schulenberg et al., 1999; Wilke et al., 2005).

Gender Identity The gender identity of adolescent females is influenced by a struggle between individual autonomy and a connection to others (Slater, Guthrie, & Boyd, 2001). 37

Psychologically, males and females develop differently due, in part, to the roles each gender is directed to play (Eagly, 1983). Feminist theorists Gilligan (1982) and Miller (1986) suggested that boys follow a developmental sequence of closeness-separationidentity; girls start out with closeness, but as adolescence approaches, females develop self-in relation to others. Girls appear focused on interpersonal interactions (Maccoby, 1988; Schulenberg et al., 1999; Wilke et al., 2005.) Brooks-Gunn (1989) expanded this concept, identifying five changes that affect an adolescent girl’s self-definition, relationships, emotional expression, and risk taking behaviors. The five changes are (a) increase in emotional expression and behavioral problems, (b) biological, socialcognitive, and personality changes that affect emotional changes, (c) changes in the parent-child relationship, (d) gender role amplification, and (e) increased sensitivity to social events. Bem (1974) challenged the mental health field to consider flexible concepts of gender identity and to refrain from assuming individuals who follow traditional gender identity roles have better mental health. Spence (1993) also challenged the traditional gender identity concept and developed a mulitfactorial approach to examine gender identity. According to Spence’s mulitfactorial approach, gender identity is influenced by a number of sources; often there is considerable variation in the qualities that come to define a personal gender identity (Koestner & Aube, 1995; Spence; Spence & Hall, 1996). Other authors supported Spence’s challenge (Antill, Cunningham, Russell, & Thompson, 1981; Lara-Cantu, Medina-Mora, & Gutierrez, 1990). Twenge (1997) discovered that from the mid-1970’s to the mid-1990’s women increasingly reported

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traits that are stereotypically reserved for men (p < .0001); however, men’s reported feminine traits changed very little over time (p < .05). Because individuals vary in personal identification of prescribed gender roles, gender identity may be a better predictor than gender for drinking (Chomak & Collins, 1987) and possibly for all substance use. Studying whether gender identity is related to substance use in both adolescent males and females would provide useful information; however, the current rate of substance use by adolescent females indicated a need to focus on the substance use of adolescent females. Kulis et al. (2002) found that dominant or aggressive masculinity was positively associated with substance use for female middle school students (p < .05). Kulis et al. (2003) found an association between the gender identity of aggressive masculinity and the less desirable substance use outcomes of more drug use (p < .001), earlier initiation of drug use (p < .001), and weaker anti-drug norms (p < .001) among predominantly Mexican American middle school students. Chassin et al. (1985) surveyed 266 high school students (51% males) from a southwestern public high school and found adolescents were more likely to drink alcohol when drinking was consistent with a current or an ideal self-concept (boys: p < .0001; girls: p < .03). The students surveyed perceived adolescent drinkers as tough and precocious (p < .001) with no significant differences between males and females. Chassin et al. offered that drinking demonstrates rebellion. Rebelliousness is an attractive image for some adolescents, signifying a sense of power in relationships and a sense of control over the environment (Krenske & McKay, 2000). Chomak and Collins (1987) showed an association for young adult men and women between masculinity and alcohol use, while femininity was linked to less alcohol 39

use for both genders (p < .0001). Ricciardelli et al. (1998) studied adult females (mean age 22.34 years) to examine the relationship among gender characteristics and alcohol consumption and alcohol dependence. Females who scored high on the Alcohol Dependence Scale also scored high on the Undesirable Masculinity subscale of the Australian Sex Role Scale (p < .05). In this study, the subscale used to measure aggressive masculinity was based, in part, on the Undesirable Masculinity subscale. The Undesirable Masculinity subscale measures traits similar to aggressive masculinity. Williams & Ricciardelli (1999) studied young adult males and females (179 males, 243 females) and found that participants scoring high on the Undesirable Masculinity subscale of the Australian Sex Role Scale and scoring low on the Scale of Positive Femininity scored high on measures of alcohol consumption, regardless of gender (p < .01). These studies suggest gender identity might play a significant role in substance use. Lemle and Mishkind (1989) reported that social drinking is a cultural representation of manliness strengthened by the media. Chassin et al. (1985) looked at the influence of social image on an adolescent’s decision to consume alcohol and found teenage boys believe drinking in males will improve social status (p < .03), but teenage girls do not believe the same holds true for females (p < .005). Chassin et al. suggested that alcohol consumption for adolescent females may be more motivated by affect regulation or stress reduction than by social image. As females transition into adolescence and later into adulthood, there is pressure to conform to traditional feminine beliefs and expectations (Harter et al., 1998; Slater et al., 2001; Yunger et al, 2004). Negotiating through the maze to reach a satisfactory gender identity, without looking

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outside for approval and validation or refusing to give up vitality, character, and tenaciousness is often a difficult challenge. There is sufficient evidence in the literature (Kulis et al., 2002; Kulis et al., 2003; Ricciardelli et al., 1998; Williams & Ricciardelli, 1999) to indicate that gender identity might play a significant role in adolescent female substance use in a rural environment. If gender identity predicts substance use behavior in young adolescent populations in urban environments and in young adult populations, gender identity is likely to predict substance use in young adolescent females in a rural environment. Looking at whether this relationship exists in a rural context would add to the knowledge base regarding gender identity and adolescent female substance abuse.

Peer Relationships Peer Influence As a child moves into adolescence, the primary source of influence moves away from parents and families to the peer group (Duncan, Tildesley, Duncan, & Hops, 1995; Engels & ter Bogt, 2001). There is evidence that adolescent females, especially young adolescent females, are particularly susceptible to peer influence, which has been linked to adolescent substance use (Killeya-Jones, & Costanzo, 2007; Oetting, et al., 1998; Oetting & Donnermeyer, 1998; Wills, Resko, Ainette, & Mendoza, 2004). Schulenberg et al. (1999) studied two cohorts of middle school students (N = 1,297, 52% female) from southeastern Michigan in a longitudinal study. Schulenberg et al. (1999) found that perceived exposure to peer drinking in seventh grade contributed to overindulgence of alcohol use between seventh and eighth grade in girls but not in boys (p < .001). Callas et 41

al. (2004) surveyed seventh and eighth grade students (51% female) in rural Vermont and found that beliefs and behaviors of peers around alcohol use was more important for girls than for boys (p < .01). Chopak (1993) reported that for rural female adolescents, perceived behavior by peers was the most significant predictor of involvement in alcohol (p < .05), tobacco (p < .001), and other drug use (p < .05). There is debate in the literature questioning the strength of peer influence for both adolescent males and females regarding substance use (Engels, Knibble, de Vries, Drop, & van Breukelen, 1999); most authors believe peer influence is quite strong, but Kandel (1996) argued that peer influence for substance use is inflated and parent influence is underestimated. Kandel stated that relying on cross-sectional research designs, relying on reports from friends, failing to account for parental influence on friend selection, and failing to account for parental genetic influence prevent reliable results regarding the strength of the peer influence on substance use. Kandel claimed the effects of peers relying on the cross-sectional data and peer behavior perceptions are probably overestimated by a factor of five. According to Engels, Scholte, Lieshout, de Kemp, and Overbeek (2006), the social functions of substance use are overestimated due to the reliance on adolescent self-reports. Duncan et al. (1995) does not agree that peer influence is overestimated. Duncan et al. claimed that of all the social factors influencing adolescent substance use, peer influences prevail, suggesting that peer influences help maintain higher rates of drug use over time. Duncan et al. found that peer influence was related to higher rates of early substance use (p < .01) and higher increases in substance use over an 8-year period (p