National statistics show that substance use and abuse is a much greater threat to the health of adolescents than to that of children in middle childhood. The use of substances like alcohol and tobacco develops very rapidly during early adolescence. However, research suggests that the most persistent drug use and abuse begins in middle childhood and, therefore, warrants understanding of the factors that predict such use during these years.
Alcohol
We have very reliable data on the use of alcohol by adolescents who are in grades 9 through 12 as a result of several national surveys (e.g., Monitoring the Future, a survey sponsored by the National Institute on Drug Abuse, and the Youth Risk Behavior Survey, sponsored by the Centers for Disease Control). We do not, however, have the same national data on alcohol use in children ages 6 to 12. A series of studies, however, examined substance use (both alcohol and tobacco) in approximately 2500 students from grades 6 to 9 who attended seven middle schools in Maryland. Students were studied over multiple years to understand not only the prevalence of alcohol and tobacco use in sixth graders and older students but also the factors that predict early onset and increased use of substances in this age group (Simons-Morton, 2004; Simons-Morton, Haynie, Crump, Saylor, Eitel, & Yu, 1999; Simons-Morton, Haynie, Saylor, Crump, & Chen, 2005). In this sample, 6.5% of sixth graders and 19.6% of eighth graders reported drinking in the past 30 days (Simons-Morton et al., 1999). These figures can be compared to 58% of twelfth graders from a national sample who reported using alcohol in the past month (Johnston, O’Malley, Bachman, & Schulenberg, 2006).
Studies have shown that early drinking behavior (e.g., in sixth grade) can lead to a longer period of increased risk in adolescence and is associated with later alcohol and drug abuse (Grant, 1997) and delinquent and problem behavior (Dawkins, 1997). Factors that predict which children are more likely to initiate early alcohol use are having friends who drink and engage in antisocial behavior, having high expectations about drinking, and having parents who won’t disapprove or don’t monitor drinking behavior (Donovan, 2004; Simons-Morton, 2004). Childhood personality factors, such as impulsivity and a lack of control flexibility, as well as childhood aggression may help to identify which children might be at risk for the early onset of drinking (Lochman, Wells, & Murray, 2007; Wong et al., 2006).
Factors associated with early alcohol use include poorer physical and mental health, low grades in school, low educational aspirations, and engagement in antisocial behavior/delinquency (Perkins & Borden, 2003). Health and psychological consequences of long-term alcohol misuse are liver disease, cancer, cardiovascular disease, and neurological damage as well as psychiatric problems, such as depression, anxiety, and antisocial personality disorder (Naimi et al., 2003; Sher, 2006).
Because early alcohol use has such long-term consequences for both the individual and society at large, a range of prevention programs have been designed to deter children in middle childhood from drinking. One such program is The Coping Power Program, designed to identify aggressive children in elementary school (Lochman et al., 2007). Over an 18-month period, practitioners work intensively with both children and parents to reduce aggressive behavior. The program focuses on improving the child’s social competence and ability to get along with other children, self-regulation and impulse control, school engagement and academic success, and improving parental interactions and interventions. Results have shown that this program produces significant preventative effects in children’s substance use by improving factors presumed to mediate substance use. Children who were involved in the prevention program had lower levels of substance use compared to children who were not in the program (Lochman & Wells, 2004). The success of this program indicates that supporting positive skills in school-age children is one approach to keeping them on a path to healthy development.
Cigarette Smoking
The initiation of smoking appears to occur between grades 7 and 9, and nearly all first use occurs by age 18 [U.S. Department of Health and Human Services (USDHHS), 1994]. A consistent finding among national surveys is that the younger the age at which teens begin to smoke regularly, the more regular and heavier the use and the more likely they are to be nicotine dependent in adulthood (Chassin, Presson, Pitts, & Sherman, 2000). A series of studies that included middle-schoolers found that 7% of sixth graders reported smoking in the past 30 days compared to 20% of eighth graders and 23% of twelfth graders (Faulkner, Farrelly & Hersey, 2000; Johnston et al., 2006; Simons-Morton et al., 1999).
Overall smoking rates for adolescents have declined since peaking in 1996. Declines in smoking rates in all age groups are attributed to the increased cost of cigarettes, the prohibition of adolescent-targeted advertising, more prevalent antismoking messages, and increased negative public images of tobacco companies (Emery et al., 2005; Myers & MacPherson, 2004).
The health risks of smoking include increased respiratory infections, lessened lung capacity, and permanent lung damage (USDHHS, 1994). Recent research also shows that early initiation of smoking retards physical development (e.g., height, weight, and body mass index) in adolescent girls (Stice & Martinez, 2005). Perhaps the greater health risks occur over a longer period of time. Nearly one third of young people who take up smoking in middle childhood and adolescence will eventually die of a smoking-related illness (Gilpin, Choi, Berry, & Pierce, 1999).
Research shows that the time interval between first use (experimentation) and regular use is quite variable, with an average length of several years (USDHHS, 1994). This finding suggests that there is a small window following first use in which smoking can be either encouraged or discouraged. Factors associated with the increased likelihood of regular cigarette use are accessibility, affordability, peer and parental smoking, academic difficulty, school misbehavior (e.g., skipped classes, truancy, suspensions), and peer encouragement of such misbehaviors (Abroms, Simons- Morton, Haynie, & Chen, 2005; Bryant, Schulenberg, Bachman, O’Malley, & Johnston, 2000; Bryant, Schulenberg, O’Malley, Bachman, & Johnston, 2003). Early experience with nonusing peers, parents who convey nonuse messages and monitor time spent with deviant peers, successful school achievement, high levels of motivation, and commitment to school are protective factors against increased cigarette use over time (Bryant et al., 2003).
At one point you notice a small group of boys and girls gathered around a lounge chair at the pool, smoking cigarettes. Most of the children in this group were smoking, but several were merely observing.
Children and teens who smoke regularly resemble adults in that they report frequent attempts to quit smoking and experience nicotine withdrawal when nicotine abstinent (Colby, Tiffany, Shiffman, & Niaura, 2000). In a review of 17 cessation programs for adolescents, 10 were found to be effective, but with only a 12% success rate. This finding means that it is as difficult for adolescents who are regular smokers to quit smoking as it is for adults (Sussman, Lichtman, Ritt, & Pallonen, 1999). The key lies in prevention, and the most successful prevention programs begin early (grade 6) and are interactive. They teach young teens refusal skills (i.e., how to say “no”), use peer leaders, and emphasize that fewer adolescents actually smoke than teens frequently believe (Tobler et al., 2000). It also appears that recent antitobacco media campaigns may be effective when paired with the prevention components mentioned above (Pechman, 1997).
The risks associated with smoking are severe. Children in middle childhood, however, may also face exposure to cigarettes in a less-than-voluntary capacity: exposure to secondhand smoke.
Other Drugs
Alcohol and tobacco are the drugs of choice for children in middle childhood. Marijuana and inhalants are the next most frequently used drugs. National surveys show that 6.6% of eighth graders have used marijuana in the last 30 days (Johnston et al., 2006). Patterns of marijuana use are similar to patterns of alcohol and tobacco use in that early initiation is a significant predictor of future problems, such as school failure, deviancy, poor physical and mental health in adulthood, and the use of other substances (Ellickson, D’Amico, Collins, & Klein, 2005; Kandel & Chen, 2000).
Raising Healthy Children is an example of a successful intervention program that targeted children in grades 1 and 2 and their families. The program focused on enhancing developmentally appropriate protective factors in the children’s lives to reduce alcohol, tobacco, and marijuana use in grades 6 to 10. The intervention provided the children with opportunities for involvement with positive role models (e.g., family members and teachers who did not use substances); focused on the student’s academic, cognitive, and social skills; gave positive reinforcement for prosocial involvement; and delivered clear standards about substance use. Although this program was unable to prevent use in all children, it was effective in reducing the frequency of alcohol and marijuana use during adolescence (Brown, Catalano, Fleming, Haggerty, & Abbott, 2005).
Inhalants are gases or fumes that can be inhaled from solvents (e.g., spray paint, gasoline, glue) for the purpose of getting high. These drugs appear to be more accessible, easily administered, and affordable to young children and, therefore, are used and abused with more frequency in middle childhood than in later adolescence. In a national sample of eighth graders, 4.2% reported using inhalants in the past 30 days, compared to only 2% of high school seniors (Johnston et al., 2006). (Note that the prevalence rate for both marijuana and inhalants are from samples of older students than those reported for alcohol and tobacco use.) Data from a single state demonstrated that inhalant use begins around the same time as tobacco (11.9 years), much earlier than the use of alcohol (12.8 years) and marijuana (13.8 years) (Mosher, Rotolo, Phillips, Krupski, & Stark, 2004).
Early use of inhalants is associated with long-term use of other drugs, (Wu, Schlenger, & Ringwalt, 2005) as well as a risk of becoming dependent on inhalants or other drugs (Wu, Pilowsky, & Schlenger, 2004). Although not technically referred to as a “gateway drug,” the pattern of use very much suggests that early inhalant use leads to other drug use in later adolescence. Delinquency and mental health problems are also associated with inhalant use (Wu et al., 2004). Inhalant users are at risk for serious pulmonary, cardiac, and blood toxicity. In addition, they are at risk of suffering not only metabolic abnormalities but also permanent neurological damage (Kolecki & Shih, 2004).
Inhalant use is difficult to treat, in part, because chronic users represent a very troubled subgroup of children. Educating youth about the specific risks of inhalants seems to be the key to decreasing use.
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