Substance Use Outcomes in Young Adulthood

Fifteen-Year Follow-Up of a Randomized Trial of a Preventive Intervention for Divorced Families: Effects on Mental Health and

Substance Use Outcomes in Young Adulthood

Sharlene A. Wolchik, Irwin N. Sandler, Jenn-Yun Tein, Nicole E. Mahrer, Roger E. Millsap, Emily Winslow, Clorinda Vélez, Michele M. Porter, Linda J. Luecken, and Amanda Reed

Arizona State University

Objective: This 15-year follow-up assessed the effects of a preventive intervention for divorced families, the New Beginnings Program (NBP), versus a literature control condition (LC). Method: Mothers and their 9- to 12-year-olds (N � 240 families) participated in the trial. Young adults (YAs) reported on their mental health and substance-related disorders, mental health and substance use problems, and substance use. Mothers reported on YA’s mental health and substance use problems. Disorders were assessed over the past 9 years (since previous follow-up) and 15 years (since program entry). Alcohol and marijuana use, other substance use and polydrug use, and mental health problems and substance use problems were assessed over the past month, past year, and past 6 months, respectively. Results: YAs in NBP had a lower incidence of internalizing disorders in the past 9 years (7.55% vs. 24.4%; odds ratio [OR] � .26) and 15 years (15.52% vs. 34.62%; OR � .34) and had a slower rate of onset of internalizing symptoms associated with disorder in the past 9 years (hazard ratio [HR] � .28) and 15 years (HR � .46). NBP males had a lower number of substance-related disorders in the past 9 years (d � 0.40), less polydrug (d � 0.55) and other drug use (d � 0.61) in the past year, and fewer substance use problems (d � 0.50) in the past 6 months than LC males. NBP females used more alcohol in the past month (d � 0.44) than LC females. Conclusions: NBP reduced the incidence of internalizing disorders for females and males and substance-related disorders and substance use for males.

Keywords: divorce, prevention, young adults, mental health, substance use

Although the rate of divorce in the United States has stabi- lized or decreased somewhat since the 1970s (Bramlett & Mosher, 2002; U.S. Census Bureau, 2005), it is estimated that

30%–50% of youths in the United States will experience pa- rental divorce in childhood or adolescence (National Center for Health Statistics, 2008). Although most youths do not experi- ence significant adjustment problems after parental divorce (e.g., Amato, 2001; Hetherington, 1999), there is compelling evidence demonstrating that divorce confers increased risk for multiple problems in childhood and adolescence, including mental health problems and disorders (e.g., Amato, 2001; Fer- gusson, Horwood, & Lynskey, 1994), elevations in substance use (e.g., Eitle, 2006; Paxton, Valois, & Drane, 2007), early onset of sexual activity (Hetherington, 1999), and physical health problems (Troxel & Matthews, 2004). For a sizeable subgroup, the negative effects of parental divorce continue into adulthood. Multiple prospective studies with epidemiologic samples have shown that parental divorce is associated with substantial increases in clinical levels of mental health prob- lems, substance abuse, mental health service use, and psychi- atric hospitalization in adulthood (e.g., Afifi, Boman, Fleisher, & Sareen, 2009; Kessler, Davis, & Kendler, 1997). Illustra- tively, in the National Comorbidity Study, Kessler et al. (1997) found that parental divorce was related to elevated rates of multiple mental (odds ratio [OR] range � 1.39 –2.61) and substance-related (OR range � 1.46 –2.38) disorders, control- ling for demographics including age, sex, race, and family socioeconomic status (SES). Similarly, Chase-Lansdale, Cher- lin, and Kiernan (1995) reported a 39% increase in the odds of being above the clinical cut-point on mental health problems at

This article was published Online First June 10, 2013. Sharlene A. Wolchik, Irwin N. Sandler, Jenn-Yun Tein, Nicole E.

Mahrer, Roger E. Millsap, Emily Winslow, Clorinda Vélez, Michele M. Porter, Linda J. Luecken, and Amanda Reed, Department of Psychology, Arizona State University.

Clorinda Vélez is now at the Department of Psychology, Swarthmore College.

Sharlene A. Wolchik, Irwin N. Sandler, and Michele M. Porter declare the following competing financial interest: Partnership in Family Transi- tions—Programs That Work LLC, which trains and supports providers to deliver the New Beginnings Program. This research was funded by National Institute of Mental Health Grants 5R01MH071707, 5P30MH068685, and 5P30MH039246 (Trial Registration: clinicaltrials .gov; Identifier: NCT01407120). We thank Philip G. Poirier and Linda Sandler for their support throughout this project; the mothers and young adults for their participation; Monique Nuno, Toni Genalo, and Michele McConnaughay for their assistance with data collection and management; the interviewers for their commitment and dedication to this project; and Janna LeRoy for her technical assistance. We also thank the group leaders and graduate students for their assistance with implementing the programs.

Correspondence concerning this article should be addressed to Sharlene A. Wolchik, Prevention Research Center, Department of Psychology, Arizona State University, P.O. Box 876005, Tempe, AZ 85287-6005. E-mail: sharlene.wolchik@asu.edu

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Journal of Consulting and Clinical Psychology © 2013 American Psychological Association 2013, Vol. 81, No. 4, 660–673 0022-006X/13/$12.00 DOI: 10.1037/a0033235

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age 23 as a function of parental divorce, controlling for pre- divorce emotional problems, school achievement, and SES.

Because of the high prevalence of divorce and its association with multiple problem outcomes, divorce has a considerable im- pact on population rates of youth and adult problems (Scott, Mason, & Chapman, 1999). The population attributable risk (PAR; the proportion of an outcome in the population due to a risk factor or percent of cases that could be prevented by removing the factor or its consequences) provides an important perspective on the public health significance of preventive interventions for this at- risk group. Illustratively, using data from a nationally representa- tive survey of adults (Kessler et al., 1997), and controlling for demographics, prior disorders, and adversities, the PAR of parental di- vorce for drug dependence is 23% (OR � 1.73). Given these data, the development and evaluation of interventions for youths in di- vorced families have clear public health significance.

To date, several randomized experimental trials of programs for either youths or parents from divorced families have shown pos- itive short-term effects on youths’ mental health outcomes (Braver, Griffin, & Cookston, 2005; Forgatch & DeGarmo, 1999; Pedro- Carroll & Cowen, 1985; Stolberg & Garrison, 1985; Wolchik, Sandler, Weiss, & Winslow, 2007; Wolchik et al., 2000, 1993). Further, some studies have documented maintenance of these effects 2–9 years following program completion, with a few dem- onstrating program effects when youths were in mid- to late adolescence (DeGarmo & Forgatch, 2005; DeGarmo, Patterson, & Forgatch, 2004; Forgatch, Patterson, DeGarmo, & Beldavs, 2009; Pedro-Carroll, Sutton, & Wyman, 1999; Stolberg & Mahler, 1994). However, two limitations of these follow-up evaluations are notable. First, none have examined program effects on measures of onset (i.e., incidence) of mental health or substance-related disor- ders subsequent to participation in the intervention. Second, none have examined the impact of prevention programs delivered in childhood on outcomes when the offspring are young adults. Examining the effects of prevention programs on the incidence of mental health and substance-related disorders in young adulthood is an important indicator of long-term prevention effects because it has been found that 75% of lifetime cases of such disorders have their onset by age 24 (Kessler, Berglund, Demler, Jin, & Walters, 2005). Illustratively, several of the mental disorders that are asso- ciated with parental divorce and have significant public health burden, such as depression and substance-related disorders, have a median age of onset (Burke, Burke, Regier, & Rae, 1990) and/or increase or peak in prevalence during this stage (e.g., Kessler et al., 2005). Further, research has consistently shown that young adult- hood is a period when individual trajectories related to psychopa- thology become more firmly established so that having a mental disorder in young adulthood has implications for both concurrent and future functioning (e.g., Arnett & Tanner, 2006). For example, chronic, heavy substance use in young adulthood is associated with current and future mental health and physical health difficulties, criminal behavior, and antisocial personality disorders (Arnett & Tanner, 2006).

Assessment of whether the effects of preventive interventions last into young adulthood is also interesting from a theoretical perspective. Prevention programs are designed to modify social environmental risk and protective factors as well as individual- level competencies and problems. The underlying theory is that changing these risk and protective factors will impact the devel-

opment of problems and disorder at later developmental periods (Coie et al., 1993; National Research Council and Institute of Medicine [NRC/IOM], 2009). Because 75% of mental disorders have their onset by young adulthood, testing the long-term mental health and substance use outcomes in young adulthood of a pre- ventive intervention delivered in childhood provides a stringent test of this theoretical proposition (NRC/IOM, 2009).

This article reports on a 15-year follow-up in young adulthood of a randomized controlled trial that compared a parenting pro- gram for divorced mothers, a dual-component program consisting of the program for mothers and a child coping program, and a literature control condition that were provided when the youths were between ages 9 and 12 (Wolchik et al., 2000). The underlying conceptual model of the program is based on elements from a person–environment transactional framework and a risk and pro- tective factor model. In transactional models, aspects of the social environment affect the development of problems and competen- cies in an individual, which in turn influence the social environ- ment and development of competencies and problems at later developmental stages (e.g., Sameroff, 2000). Derived from epide- miology (Institute of Medicine, 1994), the risk and protective factor model posits that the likelihood of mental health problems is affected by exposure to risk factors and the availability of protec- tive resources. Cummings, Davies, and Campbell’s (2000) “cas- cading pathway model” integrates these two models into a devel- opmental framework. From this perspective, stressful events, such as divorce, can lead to an unfolding of failures to resolve devel- opmental tasks and increase susceptibility to mental health prob- lems and impaired competencies. Parenting is viewed as playing a central role in facilitating children’s successful adaptation, and the skills and resources that are developed in successful resolution of developmental tasks, such as effective coping and academic suc- cess, are viewed as important tools when youths face challenges in subsequent developmental periods.

Prior research has shown (a) positive effects of the parenting program versus the literature control condition on externalizing problems at posttest and 6-month follow-up (Wolchik et al., 2000); (b) positive effects of the parenting program versus the literature control condition and the dual-component condition versus the literature control condition on multiple mental health and sub- stance use outcomes, including mental disorder, at the 6-year follow-up (Wolchik et al., 2002); and (c) no difference in the effects of the parenting program and the dual-component program on mental health outcomes at posttest, 6-month, or 6-year follow-up (Wolchik et al., 2002, 2007, 2000). Mediational analy- ses indicated that improvements in mother–child relationship qual- ity at posttest accounted for program-induced effects on increased coping efficacy and active coping as well as reduced internalizing and externalizing problems for those with high baseline risk for maladjustment at the 6-year follow-up. In addition, improvements in effective discipline at posttest accounted for program-induced effects on reduced externalizing problems at the 6-month follow-up and higher grade point average (GPA) at the 6-year follow-up (Tein, Sandler, MacKinnon, & Wolchik, 2004; Zhou, Sandler, Millsap, Wolchik, & Dawson-McClure, 2008).

The current study examined program effects on the incidence of mental health and substance-related disorders; levels of internal- izing, externalizing, and substance use problems; and frequency of substance use 15 years after participation. Mental health and

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substance-related disorders were assessed in two ways. First, the incidence of disorder with onset during the 9-year period since the last follow-up assessment, which occurred 6 years after program completion, was assessed. Developmentally, this measure repre- sents disorders that have their onset during mid-adolescence to young adulthood. Second, the incidence of mental health and substance-related disorders with onset since program entry (i.e., during the last 15 years) was assessed. The 9-year interval was used so that program effects on incidence of disorder would be distinct from previously reported findings at the 6-year follow-up (Wolchik et al., 2002); the 15-year interval was used to assess the overall effects of the program on incidence of mental health and substance-related disorders. It was hypothesized that young adults (YAs) in the mother program or dual-component program would have a lower incidence of disorders than those in the literature control condition. Given that baseline risk moderated program effects at earlier assessments (Wolchik et al., 2002, 2007, 2000), with stronger effects occurring for those at higher risk at program entry, risk was examined as a moderator. Also, given the associ- ation between gender and mental health problems and substance use in young adulthood (e.g., Johnston, O’Malley, Bachman, & Schulenberg, 2008), gender was examined as a moderator.

Method

Participants

Participants were YAs and their mothers from 240 divorced families who participated in a randomized controlled trial of a preventive intervention 15 years earlier. Of the YAs interviewed, 50% were female. Average age of YAs was 25.6 (SD � 1.2, range � 24–28). Ethnicity was 88.7% non-Hispanic White, 6.7% Hispanic, 2.1% African American, and 2.5% other. Educational attainment of YAs was as follows: less than high school—2.6%; high school only—22.1%; some college—45.4%; college graduate—29.4%; post-graduate—3.1%. Of the YAs, 51% were married or living as if married. YA median annual income was in the $30,000 range (choices were $5,000 categories ranging from �$5,000 to �$200,000).

The primary method of recruitment for the trial involved the use of randomly selected court records of divorce decrees that in- volved children and were granted within 2 years of the interven- tion’s start. Eighty percent of the sample was recruited in this way; the remainder responded to media advertisements. Families were first sent a letter about the study, which was followed by a phone call to assess eligibility criteria and invite mothers to participate in an in-home recruitment visit. Eligibility was assessed at pretest as well.

Eligibility criteria were (a) divorced in past 2 years; (b) primary residential parent was female; (c) at least one 9- to 12-year-old child resided (at least 50%) with the mother; (d) neither mother nor any child was in treatment for mental health problems; (e) mother had not remarried, did not plan to remarry during the program, and did not have a live-in boyfriend; (f) custody was expected to remain stable; (g) family resided within an hour drive of program site; (h) mother and child could complete assessments in English; (i) child was not learning disabled or in special education; and (j) if diagnosed with attention deficit disorder, child was taking med- ication. The criterion of maternal residential living arrangements

was selected because at the time of the trial, about 80% of children lived primarily with their mothers after divorce (Cancian & Meyer, 1998). In families with multiple children in the age range, one was randomly selected as the target child for the assessment of program effects to ensure independence of responses. Because of the pre- ventive nature of the program and ethical concerns, families were excluded and referred for treatment if the child scored above 17 on the Children’s Depression Inventory (CDI; Kovacs, 1985), en- dorsed an item indicating that she/he wanted to kill herself/himself, or scored above the 97th percentile on the Externalizing Subscale (Child Behavior Checklist [CBCL]; Achenbach, 1991).

The trial was conducted at Arizona State University (ASU) in Tempe, Arizona. The study was approved by the ASU Institutional Review Board. Assessments (i.e., pretest; posttest; and 3-month, 6-month, 6-year, and 15-year follow-ups) were typically con- ducted in the participants’ homes; a few occurred at the university. Interviews for three YAs who lived abroad were conducted via skype; the items in the self-administered questionnaires were read aloud in these cases. The intervention groups were held at the university. Assessments were conducted by trained interviewers who were blind to program condition. Parents and youths older than 18 signed informed consent forms; children signed informed assent forms. Families received $45 compensation for participating in the interviews at pretest, posttest, 3-month, and 6-month follow- ups. At the 6-year follow-up, adolescents and parents each re- ceived $100; at the 15-year follow-up, young adults received $225, and parents received $50.

Sample Size, Power, and Precision

A sample size of 240 was selected so that small to medium effects, the magnitude of the effects found in the pilot study of the mother program (Wolchik et al., 1993), could be detected with power of �.80. Hypothesis tests were conducted using two-tailed tests with � � .05. Assuming the covariates account for 25% of the variance, power to detect small to medium (Cohen’s d � 0.32) effects of mean differences is .80 using analyses of covariance (ANCOVAs). Assuming a 30% base rate of diagnosis in the literature control condition (LC), power is over .90 to detect an OR of 2 with logistic regression. Assuming a .25 control hazard rate, power to detect a risk ratio of .5 is .87 in survival analyses.

Measures

Mental health outcomes. The Diagnostic Interview Schedule IV (DIS; Robin et al., 2000) was administered to YAs to assess internalizing and externalizing disorders. The DIS has adequate reliability and validity (Compton & Cottler, 2000) and has been used in numerous epidemiologic studies of mental disorder (e.g., Grant et al., 2004). The presence of disorder was scored according to the DIS manual. YAs met criteria for a disorder if they endorsed the required symptoms and reported that the symptoms caused impairment (problems) in social, occupational, or other areas of functioning. Disorders were classified as internalizing or external- izing based on the consensus of three doctoral-level clinicians.

As noted earlier, the incidence of disorder was assessed over two periods of time: past 9 years and past 15 years. To assess program effects on disorders that were distinct from those reported at the 6-year follow-up, dichotomous disorder scores were created

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based on whether criteria for any externalizing disorder, any internalizing disorder, and any internalizing or externalizing dis- order were met with symptom onset in the past 9 years using the standard DIS methods for dating onset (Robin et al., 2000). To ensure that the disorders reported on the DIS with onset in the last 9 years were new disorders rather than continuations of disorders reported at the 6-year follow-up, scores on the Diagnostic Inter- view Schedule for Children (C-DIS; Shaffer, Fisher, Lucas, Dul- can, & Schwab-Stone, 2000) at the 6-year follow-up were also examined to check that disorders dated as having their onset in the past 9 years were not present when youth were interviewed at the 6-year follow-up (Wolchik et al., 2002; C-DIS, algorithm version J). None of the disorders with onset during the last 9 years represented the continuation of a disorder that was reported at the 6-year follow-up. To assess overall effects of the program on incidence of disorder, the same scores as above were calculated with the time frame being since program entry (during the last 15 years).

To assess recent mental health problems, the internalizing prob- lems and externalizing problems subscales of Adult Self-Report (ASR; YA; Achenbach & Rescorla, 2003) and Adult Behavior Checklist (ABCL; mother; Achenbach & Rescorla, 2003) were used. These scales, which assess mental health problems in the past 6 months, have adequate reliability and validity (Achenbach & Rescorla, 2003). Alphas for internalizing problems were .90 and .92 for YA and mother reports, respectively; alphas for external- izing problems were .84 and .92 for YA and mother reports, respectively. Mother and YA scores were standardized and then averaged.

Substance use outcomes. A dichotomous disorder score for presence of any substance-related disorder and a continuous score for number of substance-related disorders with symptom onset in the last 9 years were assessed using the standard DIS method for dating onset. As with mental health disorders, scores on the C-DIS at the 6-year follow-up were also examined to check that disorders dated as having their onset in the past 9 years were not present when youths were interviewed at the 6-year follow-up. None of the substance-related disorders reported on the DIS with onset during the last 9 years represented a continuation of a disorder reported at the 6-year follow-up. Scores for any substance-related disorder and number of substance-related disorders during the last 15 years were assessed using the standard DIS methods for dating onset.

Age of onset of regular drinking was derived from the DIS. Items from the Monitoring the Future Scale (MTF; Johnston, O’Malley, & Bachman, 1993) were used to assess alcohol use and marijuana use in the past month (1 � 0 occasions, 7 � 40 or more) and other drug use (i.e., mean of ratings for 13 drugs other than alcohol and marijuana; 1 � 0 occasions, 7 � 40 or more) and polydrug use (count of different drugs used) in the past year. The MTF has adequate internal consistency reliability and validity (Johnston et al., 1993). To maximize validity, MTF items were self-administered (Gribble, Miller, Rogers, & Turner, 1999). Sub- stance use problems in the past 6 months were assessed by stan- dardizing and averaging mother (ABCL) and YA (ASR) reports. Achenbach and Rescorla (2003) noted that alpha is not applicable for this subscale. Binge drinking was measured using an adaptation of an item from the Quantity and Frequency of Alcohol and Drugs Scale (Sher, Walitzer, Wood, & Brent, 1991) that assessed the frequency of binge drinking in the past year (1 � less than five

times, 2 � more than 5 times but less than once a month, 3 � 1–3 times a month, 4 � 1–2 times a week, 5 � 3–5 times a week, 6 � every day). This item is highly similar to those typically used to define binge drinking behavior (Johnston, O’Malley, Bachman, & Schulenberg, 2011).

Covariates. Baseline risk, internalizing problems, and self- esteem were used as covariates in all analyses. Risk, as defined by (Dawson-McClure, Sandler, Wolchik, and Millsap (2004), was a composite score (i.e., equally-weighted sum of standardized scores) of the following: (a) mother and child reports of child externalizing problems at baseline (the 33-item externalizing sub- scale of the CBCL [Achenbach, 1991; � � .86] for mother report; the 27-item Divorce Adjustment Project Externalizing Scale [Pro- gram for Prevention Research, 1985; � � .87] for child report) and (b) environmental stressors (i.e., a multicomponent measure of interparental conflict, negative life events that occurred to the child, maternal distress, missed visits with the non-custodial father, current per capita annual income). This composite risk measure had been found to predict child mental health problems in the control group of the randomized trial of New Beginnings Program (NBP) at the 6-year follow-up and to moderate the NBP’s effects on internalizing problems, externalizing problems, substance use, mental disorder, and competence at the 6-year follow-up, such that stronger intervention effects were found for youths at higher risk at program entry (Dawson-McClure et al., 2004). Accordingly, we included the risk measure as a covariate and examined whether risk interacted with NBP’s effects at the 15-year follow-up. The inclusion of internalizing problems and self-esteem was based on results of analyses comparing non-respondents and respondents at the 15-year follow-up on 16 baseline variables (Jurs & Glass, 1971), which showed no significant Attrition � Group interactions but two significant main attrition effects. On average, respondents had significantly lower self-esteem (20.45 vs. 21.53; p � .03) and higher levels of internalizing problems (�0.06 vs. �0.30; p � .03) than non-respondents. Pretest internalizing problems was a com- posite of standardized scores on the CBCL Internalizing subscale (� � .87, mother report), the CDI (� � .87, child report), and Revised Children’s Manifest Anxiety Scale (C. R. Reynolds & Richmond, 1978; � � .90, child report). Pretest self-esteem was assessed with the Self-Perception Profile for Children (Harter, 1985; � � .71, child report).

Intervention and Control Conditions

Intervention conditions. The mother program consisted of 11 group sessions (1.75 hr each) that focused on four family processes that had been shown to predict children’s post-divorce adjustment problems and could potentially be changed by working with moth- ers (Wolchik et al., 2000). The program taught skills to improve mother–child relationship quality and effective discipline, de- crease barriers to father–child contact and reduce children’s ex- posure to interparental conflict. Clinical methods, based on social learning and cognitive behavioral theories, were derived from intervention research (e.g., relationship quality: Guerney, Coufal, & Vogelsong, 1981; discipline: Patterson, 1976; anger manage- ment: Novaco, 1975). The specific skills that were taught in the program are provided in Figure 1. Based on Marlatt and Gordon’s (1985) work, maintenance strategies included leaders providing many opportunities for parents to practice and get feedback on

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program skills and to address problems with their use, giving parents handouts on skills and forms to track use of the skills after the program, and leaders attributing change to maternal efforts. The highly structured program used active learning methods, vid- eotaped modeling, and role plays. Homework assignments focused on practicing the program skills. Two individual sessions were held: One focused on ways to increase use of the program skills; the other focused on ways to increase use of the program skills and ways to decrease barriers to father–child contact. There were 18 mother groups (9 in the mother program condition and 9 in the dual-component condition); average group size was 9 (range � 8–10).

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