Impact of a preventive intervention targeting childhood disruptive behavior problems on tobacco and alcohol initiation from age 10 to 13 years

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Abstract

The distal impact of a school based universal preventive intervention targeting disruptive behavior problems on tobacco and alcohol use from age 10 to 13 years was explored. Second grade classrooms (children aged 7 years) were randomly assigned to the intervention or a control condition. Tobacco and alcohol use from age 10 to 13 years was available for 477 children (72% of original sample). The impact of intervention on the initial level and growth in probability of substance use was explored. Results showed that intervention children had lower probabilities of tobacco use over the ages 10–13 years. This effect remains significant when controlling for (male) sex, pre-intervention levels of conduct problems, exposure to prenatal smoking or current parental smoking. For alcohol use, no effect of intervention during childhood was found. However, intervention children reported having a lower probability in alcohol use with age among those children reporting having used in the last week. The results underscore the importance of the early prevention of disruptive behavior problems substance use initiation. Implications for prevention and research are discussed.

Introduction

Childhood disruptive behavior problems (DBP) are linked to a large number of serious negative outcomes. Besides outcomes more directly linked with the behavior problems, such as delinquency and associated mental health diagnoses such as conduct disorder or antisocial personality disorder, childhood disruptive behavior problems are often associated with early onset substance use problems (Elkins et al., 2007, Ernst et al., 2006, Fothergill and Ensminger, 2006, Hu et al., 2008, Kuperman et al., 2005, Patton et al., 2006). Early onset substance use may imply an increase in risk for future substance use. For instance, early onset smoking has been found to predict progression to daily and dependent patterns of tobacco (Costello et al., 1999, Patton et al., 2006) alcohol (Clark, 2004) and illicit drug use (Korhonen et al., 2008) at later ages.

Various prevention programs, developed to prevent the onset or further development of childhood disruptive problems have been found effective in reducing such problems (for an overview, see Greenberg et al., 2001). Given the link between childhood disruptive behavior problems and substance use, such programs have also been reported to impact substance use. The aim of this study is to explore the impact of the Good Behavior Game (GBG) intervention (Barrish et al., 1969, Dolan et al., 1989) on the development of tobacco and alcohol use in children from age 10 to 13 years. The GBG focuses on preventing early elementary school children's aggressive, opposition and ADHD symptoms. In various randomized controlled trials, the program has been shown effective in reducing such problem behaviors (Ialongo et al., 2001, Ialongo et al., 1999, Kellam et al., 1994, Rebok et al., 1996, van Lier et al., 2004, van Lier et al., 2005). The long-term impact of the program on adolescent and adult psychopathology has also been reported. For instance, reduced levels of anxiety and depressive problems in adolescence, which was explained by the fact that GBG children were less likely than controls to be a victim of aggressive behavior in elementary school, were found (Vuijk et al., 2007). Moreover, reduced levels of antisocial personality disorder (Kellam et al., 2008, Petras et al., 2008) suicide ideation (Wilcox et al., 2008), and mental health service use (Poduska et al., 2008) in young adulthood were reported. In addition to reduced levels of psychopathology, the GBG has been associated with lower risk of initiating tobacco use in late childhood and adolescence (Furr-Holden et al., 2004, Kellam and Anthony, 1998, Storr et al., 2002). This reduced rate of tobacco use persisted into young adulthood in which a significant lower proportion of 6% of GBG children, versus 14% of control children reported regular smoking (defined as ≥10 cigarettes per day; Kellam et al., 2008).

Besides replicating the earlier findings in the Baltimore based GBG trials (Kellam et al., 1991) this study, which used data from the Dutch GBG trial which was initiated by the third author (Crijnen et al., 1997), aims to address the impact of the intervention on tobacco and alcohol use from age 10 years onwards, as various studies have shown that both tobacco and alcohol experimentation start at around this age (Clark, 2004, Monshouwer et al., 2004, Verdurmen et al., 2005). This study thus aims to explore the effect of the program on the onset and course of tobacco and alcohol use from age 10 to 13 years, as distal outcomes of a randomized controlled intervention trial that started at age 7 years.

Section snippets

Participants

Children from 13 elementary schools in Rotterdam and Amsterdam, the Netherlands, were recruited in 1999. Initially, 744 children were eligible for inclusion, and for 666 children informed consent by parents or parent substitutes was obtained (90% participation rate). The mean age of these children was 6.9 years (SD = 0.6) at baseline. For more details of the sample, see van Lier et al. (2004). After baseline assessments in first grade, classes were randomly assigned to the GBG or to a control

Descriptive statistics

The percentages of children reporting having smoked less than one cigarette per week or more was 5.7, 9.5, 13.2, and 15.1 at ages 10–13 years respectively. These percentages are in accordance with the general Dutch population (Monshouwer et al., 2004). For alcohol use, 25.2%, 28.5%, 31.6%, and 36.8% at ages 10–13 years respectively reported having drunk alcohol over the past year. Overall 54% of the children reported having used alcohol over the ages of 10–13 years which is in accordance with

Discussion

This study aimed to add to the initial reports of lower rates of substance use among children who had received the GBG intervention (Furr-Holden et al., 2004, Kellam and Anthony, 1998, Kellam et al., 2008, Storr et al., 2002) by exploring the impact of the program in preventing tobacco and alcohol use in childhood/early adolescence. With respect to tobacco use, we found, in accordance with the prior reports that GBG children had a lower probability of onset of tobacco use from age 10 to 13

Conflict of interest

None of the authors have a conflict of interest to disclose.

Acknowledgements

Role of funding source: Funding for this study was provided by grants 242 and 364 from the Sophia. Foundation for Medical Research and by the Ministry of Justice, the Netherlands; the granting agencies had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors: Author Crijnen initiated the GBG intervention study in the Netherlands and was PI of the project

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