Preventing CoOccurring Disorders: Prospects and Opportunities

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Preventing Co-Occurring Disorders Prospects
and Opportunities

• J. David Hawkins Ph.D.
• Social Development Research Group
• University of Washington

Data are from the Seattle Social Development
Project supported by grants from the National
Institute on Drug Abuse and the National
Institute of Mental Health.
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• Prevention of co-occurring disorders requires
  identification of malleable risk and protective
  factors that predict comorbidity.

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The Research Base for Prevention of Co-Occurring
Conditions

• Longitudinal studies have identified risk and
  protective factors that predict substance abuse,
  depression, violence and other problem behaviors.

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Predicting Adolescent Problems
Used by permission of Channing Bete Company
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Predicting Adolescent Problems
Used by permission of Channing Bete Company
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Predicting Adolescent Problems
Used by permission of Channing Bete Company
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Predicting Adolescent Problems
Used by permission of Channing Bete Company
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Protective and Promotive Factors

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

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Question

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

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Seattle Social Development Project

• A theory-driven longitudinal study of the
  etiology of prosocial and antisocial behaviors.
• An intervention study nested in the longitudinal
  study.
• Initiated in 1981 in 8 Seattle elementary
  schools.

• Expanded in 1985, to include 18 Seattle
  elementary schools that over-represented students
  from high crime neighborhoods.

• 808 (77) of the 5th grade students in these
  schools and their parents consented to
  participate in the longitudinal study they
  constitute the study sample.

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Study Characteristics

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

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

• Alcohol Use Disorders Only 19.1 (n144)
• More common among men (26.9) than women
  (11.2)
• Major Depression Only 11.9 (n90)
• More common among women (15.7) than men (8.2)
• Comorbid AUD and MDD 7.8 (n59)

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Social Development Model (SDM)
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Questions

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

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Multinomial Logistic Regression Analyses

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

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Summary

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

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Predicting Violence and Depression at Age 21

• Childhood conduct problems at age 10 are
  malleable risk factors for both violence and
  depression at age 21.

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

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

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Questions

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

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Seattle Social Development Project
InterventionTargeted Risk Factors

• School Domain
• Low commitment to school
• Academic failure
• Family Domain
• Poor family management
• Family conflict
• Individual Domain
• Early antisocial behavior
• Favorable attitudes to problem behavior
• Friends who engage in problem behavior
• Early initiation of problem behavior

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Social Development Model (SDM)
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Intervention Goals

• Promote bonding to school and family by
• Enhancing opportunities for involvement in school
  and family
• Enhancing rewards for involvement in school and
  family
• Strengthening childrens social competencies

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SSDP Intervention

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

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

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Seattle Social Development ProjectResults at Age
18
Scale score
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Seattle Social Development ProjectResults by Age
18
plt .05
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Seattle Social Development ProjectResults at Age
18Heavy Alcohol Use
plt .05
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Seattle Social Development Project Effects by
Age 21
plt .05
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Seattle Social Development Project Effects at
Age 21
plt .05
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Seattle Social Development ProjectEffects at Age
21
Prevalence



plt.10 plt.05 plt.01 compared with controls.
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Summary

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

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Conclusion

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

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Implications for Access and Utilization

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

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Involving Schools as Prevention Partners

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

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Access and Utilization

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

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Access and Utilization

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

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Preventing Co-Occurring Disorders Prospects
and Opportunities

• J. David Hawkins Ph.D.
• Social Development Research Group
• School of Social Work
• University of Washington
• www.sdrg.org
• jdh_at_u.washington.edu