# Presentation: 024470

## 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.

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

## 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.

##  Predicting Adolescent Problems

*Used by permission of Channing Bete Company*

## Predicting Adolescent Problems

**Predicting Adolescent Problems**

## Predicting Adolescent Problems

**Predicting Adolescent Problems**

## Predicting Adolescent Problems

**Predicting Adolescent Problems**

## 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

## Question  

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

## 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.**

**Notes:**
Review SSDP
Note that we are now completing our age 24 data collection and have completed 751 out of the 808 interviews for 93% retention.  Actually, 15 sample members are known to have died making it 95% of the still-living sample!

Further, we are currently funded for another collection at age 27.

Read highlights of slide.

## 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

## SSDP Panel Retention

**	**** **
**MEAN****AGE****	****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.** **

**Notes:**
Discuss sample retention.

## Prevalences in the Seattle Social Development Project at Age 21

- Alcohol Use Disorders Only _**19.1%**_  (n=144)
-  	More common among men (26.9%) than women (11.2%)
- Major Depression Only _**11.9%**_ (n=90)
-  	More common among women (15.7%) than men (8.2%)
- Comorbid AUD and MDD _**7.8%**_ (n=59)

## Social Development Model (SDM)

## 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?

**Notes:**
Note:  importance of life-span perspective (childhood precursors; young adult consequences)

## 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.

## Slide 17

## Slide 18

## Slide 19

## 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.

## 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.

## Adjusted Odds Ratios (95% Confidence Interval) for Conduct Problems Predicting Age 21 Outcomes(Controlling for Gender, Ethnicity, and Low Income Status)

|  | 
Age 21 Outcomes:
All Cases Included
 |  |
| --- | --- | --- |
| Age 10
self-report | 
Depressive episode | 
       Violence |
|  | 
   |  |
| Conduct problems |   3.86*** (1.93 to 7.70) | 3.47*** (1.79 to 6.75) |

***N *****= 765. *******p***** < .01; ********p *****< .001.**
**Adapted from Mason et al. (2004), Seattle Social Development Project data.**

## Summary

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

## Questions

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

## Seattle Social Development Project InterventionTargeted 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

## Social Development Model (SDM)

## Intervention Goals

**Promote bonding to school and family by:**
**Enhancing opportunities for involvement in school and family**
**Enhancing rewards for involvement in school and family**
**Strengthening children’s social competencies**

## 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.

## 
	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.

**	****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.**

## Seattle Social Development ProjectResults at Age 18

**Scale score**

## Seattle Social Development ProjectResults by Age 18

**p< .05*

## Seattle Social Development ProjectResults at Age 18Heavy Alcohol Use

**p< .05*

## Seattle Social Development Project Effects by Age 21

**p< .05*

## Seattle Social Development Project Effects at Age 21

**p< .05*

## Seattle Social Development ProjectEffects at Age 21

**Seattle Social Development Project*****Effects at Age ******21***

**Prevalence**

*****

- +*p*<.10; **p*<.05; ***p*<.01
- compared with controls.

**+**

******

## 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.

## Conclusion

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

## 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.

## 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.

## 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.

## Access and Utilization

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

## 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](http://www.sdrg.org/)_
- jdh@u.washington.edu