Do Fifth Graders' Attitudes and Intentions Toward Alcohol Use Predict Seventh-Grade Use?

Do Fifth Graders' Attitudes and Intentions Toward Alcohol Use Predict Seventh-Grade Use? JOH N A. WEBB, PH.D., PAUL E. BAER, PH.D.,

J.

GREG GETZ, PH.D.,

Al'l D

ROBERT S. McKELVEY, M.D .

ABSTRACT Objective: To examine the relationship among children's percept ions of peer and parental attitudes toward alcohol use, fifth graders' attitudes toward alcohol use and intentions to use alcohol in junior high school , and alcohol use of these same children as seventh graders. Method: Subjects completed questionnaires as fifth graders that assessed their perception of parents' and peers' attitudes toward alcohol use, children's attitudes toward alcohol use, and intentions to use alcohol in junior high school. They completed a survey in the seventh grade that assessed alcohol use. Results: Path analyses indicated that perceived peer and parental attitudes were directly related to children's fifth-grade attitudes toward alcohol use. Attitudes, in turn , were related to fifth-grade intentions, which were related to seventh-grade alcohol use. Peer and parental attitudes , and children 's attitudes as fifth grade rs, were not directly related to later alcoho l use. Conclusions: Peer and parental attitudes toward alcohol use among fifth graders exert an indirect, rather than direct , influence on later alcohol use. Similarly , attitudes of fifth graders influence later alcohol use through their influence on intentions to use alcohol. Prevention programs should be targeted toward younger children prior to initiation of alcohol use and should address both peer and parental influences on attitudes and intentions to use alcohol. J. Am. Acad. Child Ado/esc. Psychiatry, 1996 , 35(12) :1611-1617. Key Words : alcohol use, prevention, children , adolescents.

Studies that have examined the attitudes of young children toward alcohol use have generally found these attitudes to be uniforml y negative. Spiegler (1983), for example, found that among children between the ages of 6 and 10 years, attitudes toward drinkers became increasingly negative with age. Similarly, Jahoda and Cramond (1972) examined the attitudes of children between the age of 5.5 and 10.5 years. They found that whereas the attitudes of the youngest children toward drinkers were virtually neutral, attitudes became increasingly negative among older children. Fossey (1993) recently replicated this study and also found that children's attitudes became increasingly negative as they grew older. Similar results are reported by others (Casswell et al., 1985).

A ccep ted June 14, 1996. D rs. Webb, Baer, and Getz are with the Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston. D r. M cKelvey is Professor and Head ofthe Department of Child Psychiatry, Princess Ma rgaret Hospital, University of Western Australia, Perth, Australia. Reprint requem to Dr. Webb, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, Houston, TX 7703 0. 0890-8567/ 96/3512-1 611 $03 .0010© 1996 by the American Academy of Child and Adolescent Psychiatry.

J.

Surveys of substance use among adolescents, however, have shown that experimentation with alcohol begins in early adolescence and increases through adolescence. It has been found, for example, that among seventh graders, 26% report using alcohol at least once a month, and 18% report higher levels of use (Webb et al., 1991). Among 10th graders, almost 70% report some alcohol use, and among 12th graders, 90% report alcohol use (Johnston et al., 1993). These data suggest that as children progress from childhood into adolescence, their attitudes toward alcohol use gradually change from being strongly negative to positive, often culminating in experimentation and use as they progress through adolescence. Reid and colleagues (1987) found that among a sample of fifth to eighth graders, attitude toward drug use was one of the strongest predictors of substance use. A previous study, which used the same sample and data as the present study, showed that among fifth and sixth graders, attitudes toward alcohol use were strongly related to intentions to use alcohol in junior high school (Webb et al., 1995). The change from negative to more positive attitudes toward alcohol use as children get older is consistent

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with one segment of Ajzen and Fishbein 's (1980) Theory of Reasoned Action, which posits that changes in attitude lead to changes in intentions, which in turn lead to behavior change. Attitudes are generally defined as cognitive schemas, which include an affective component, and are used to evaluate objects (Brigham, 1991). Attitudes may be formed through direct contact with an object, or indirectl y through observation of significant others (Fossey, 1993). Ajzen and Fishbein 's model does not posit a direct relationship between one 's attitude toward a behavior and the percept ion that significant others approve of that behavior. Whereas this may be plausible for adults, it is less plausible with young children. Because young children are likely to have limit ed direct contact with alcohol, their attitudes toward alcohol use are likely to be strongly influenced by their perception of the attitudes of significant others, such as parent s and friends regarding alcohol use. Studi es have consistentl y found a strong relationship between perceptions of peer and parental attitudes and use, and attitudes and use of children and adolescents (Webb et al., 1991, 1995) . Studies have shown that numerous family factors influence initiation of alcohol use by adolescents. These include family disharmony and parental alcohol use (Webb and Baer, 1995), parental and sibling alcoholism (Cloninger er al., 1985), and perceived parental attitudes toward use. Some research has indicated, however, that perceived parental attitudes toward use are of equal or greater importance than actual parental use (H ansen et al., 1987; McDermott, 1984). This has implications for primary prevention programs, because such programs ideally should be targeted toward those who have not yet initiated use. If the sequence of progression from attitudes to intentions to use is correct , it should be possible to target early prevention efforts toward those childr en who are at risk for early initiation of alcohol use, thus preventing, or at least delaying, experimentation with alcohol in early adolescence. Data have shown that alcohol is usually one of the first substances with which individuals experiment before progressing to other substances (Johnston et al., 1993). Indeed, age of initiation of alcohol use has been shown to be strongly related to later substance use among older adolescents (Barnes and Welte , 1986; Newcomb et al., 1986) and to adult substance use (T ennant et al., 1976). Also, if children's perceptions of the att itudes of parents and friends

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influence the attitudes of children toward alcohol use, interventions directed toward younger children could seek to counteract these influences in order to prevent or delay initiation of alcohol use in much the same way that prevention programs for adolescents seek to teach skills to assist in resisting social pressures to use alcohol and other drugs (Borvin et al., 1989). Children's perceptions of peer and parental attitudes, as well as their own attitudes and int entions toward alcohol use, could thu s be seen as risk factors that could be identified well before use is initiated in most cases, possibly enhancing the effectiveness of prevention efforts. The purpose of the present study was to examine the manner in which fifth graders' perceptions of parental and peer attitudes toward alcohol use influenced their attitudes toward alcohol use, their intention s to use alcohol in junior high school, and alcohol use report ed by these same children when they were seventh graders. It was hypothesized that fifth graders' percept ions of peer and parental att itude s toward alcohol use would be related to their attitudes toward alcohol use. These attitudes would in turn be related to intentions to use alcohol among fifth graders, which would in turn be related to their use of alcohol in the sevent h grade, appro ximately 18 months later. Perceived parental and peer attitudes were not hypothesized to be directly related to use, but to exert their influence on use indirectly through their influenc e on children 's attitudes. This implies a causal model in which children's attitudes toward alcohol use are influenced by their perception of peer and parental attitudes toward alcohol use. Children's attitudes, in turn, are related directly to intentions to use alcohol, which in turn are directly related to later alcohol use. Stated differently, intention to use alcohol serves as a mediator between attitudes and later use. This model is graphically displayed in Figure 2.

METHOD Subjects were 119 seventh-grade students who were pare of a cohort that had originally completed questionn aires when th ey were in the fifth grade. The school district from which students were drawn is a suburban, predominantl y white school district near Houston. The cohort was initially composed of 136 subjects. The attri tion rate of 12.5% over 18 month s was prob ably due to absences and mobility, and it approximates the att rition rate typical of longitud inal studies.

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D O AT T IT U D ES/ IN TENT IONS P REDI CT U SE ?

Of th e 119 subjects in th e present study, 54 (45%) were ma le and 65 (55%) were female. T he original coho rt was composed of 64 m ales (47%) and 72 (females (53% ). Eth nic composition of th e subjects in the present stu dy was 107 whites (90%), 4 blacks (3%), 3 Hi span ics (4%), 1 Asian (l %), an d 1 American Indian (1% ). O ne subject did not pro vide th is inform ati on. The original coh ort was composed of 120 whites (88 %), 6 blacks (4% ), 7 H ispan ics (7%), 1 Asian (l %) , and 1 Na tive American (l %). At the time th e sevent h-grade survey was admi nistered, stu dents' ages ranged from 12 years, 1 month to 14 years, 9 mo nths. The average age was 12 years, 8 months. T he time period between the admi nistration of the two surveys was 18 months. Attrit ion analyses were conducted to determ ine how subj ects who provided complete data differed from th ose who did not. A discrim inant analysis compared the se two groups on the measures described pr eviously and on ethniciry and gend er. For this analysis, gender and erhniciry were dummy-coded , so that for gender 1 = males, 0 = females, and for ethniciry 1 = white, 0 = nonwhite. Results of thi s analysis indicated th at th e two groups did not differ on the funct ion (X2, 7 df = 10.9, P = .14).

Procedure Subjects completed que stionnaires on two occasions . As fifth grade rs, subjects completed a questionnaire that included 92 items th at assessed intentions to use substances when they were in junior high school and related construc ts. As sevent h graders, su bjects pa rticipa ted in a substance use preventi on program . As part of this program , pr etest and postte st questionnaires were adm inistered. T he qu estionnaire used in the present study has been in use in th is distri ct for more than 10 years. It contains 23 0 items th at assess alcoho l use, atti tudes toward use, and ot her constru cts related to alcoho l use. Psychom etr ic properties of the items used in the present study are repo rted below. Prior to ad minis tra tio n of the qu estionnaire, subjects were informed that a federa lly issued Certifi cate of Co nfidentiality gua rante ed that their respon ses to qu estionnaire items wo uld rem ain confidential.

Int ention s to use alcoho l were assessed by the que stion: " W hen 1 am in junior high schoo l I think I m ight be . . ." with regard to drink ing beer, wine or wine coolers, and liquor. An swers were on a scale where I = not at all, 2 = a littl e, 3 = som e, 4 = quite a bit , 5 = a lot. Analyses of respo nses indica ted th at mo st subjects d id not inte nd to use alcoh ol in junior high school, and m ost who d id intend to use alcoh ol indica ted th at they intended to d rin k " a little." No fifth graders indicated th at they int ended to drink " quite a bit " , or "a lot ." Because of th e limited number of respondents who report ed inte nt ions to use alcohol more than " a littl e," resp on se categories th at indicate d any intended alco ho l use were collapsed. The result was a d ichotomou s rating that ind icated whe th er the individual did or did not intend to use any alcoh ol in junior high school. Amo ng th e original cohort, 92 (69 % ) were classified as not intending to use alcoho l, and 41 (31 %) were classified as intending to use any alcohol. Among the subjects in the present study, 82 (69%) were classified as not intending to use alcohol, and 37 (3 I %) were classified as intending to use alcoho l. One subject did not provide thi s information. For the analyses, intentions were dummy-cod ed so that 0 = nonintenders, and 1 = int en ders. Alcohol use amo ng sevent h graders was assessed by a Guttman scale comprising seven item s which repr esented increasing alcoho l use, to which subjects answered yes or no. Table 1 d isplays the indiv idual items on the G utt man scale an d the percentage of stu dents end orsin g each item. Because items are arran ged in order of increasing use, endorsement of a given item ind icates th at previou s items were also endo rsed. For example, endo rseme nt of the item , " I have had an entire drink of beer, wine, or hard liqu or ," means that th e sub ject also endorsed the previou s two items indica ting lower levels of use. It can be seen th at mos t subjects reported either no use or relatively low levels of use. Ap pro xima tely 82% of respondent s indica ted no use, or having had a sip of alcoho l, or having tried alcohol. N o subjects reported d rinking alcoho l eithe r o nce a week o r daily. Approxima tely 17% of respondents ind icated that they had had an entire dr ink of alcoho l or had felt drunk from drink ing alcohol. The A. for the scale with this sam ple was .73.

Measures Perceived parental attitudes towa rd alcoho l use were assessed by using th e following question, asked in reference to each parent: "How does your father (mother) feel abo ut kids your age drinking alcoh ol?" Answers were on a 5-point scale, where 1 = vety much against it, 2 = against it, 3 = does not care abo ut it, 4 = for it, and 5 = vety mu ch for it. The cor relation between mothers' and fathers' rati ngs in th is sample was .57 . Friends' perceived att itudes toward alcoho l use were assessed by using the following question: " H ow do most of your friends feel about kids your age drinking alcoho l?" Answers were o n the same a 5-po int scale as parents' atti tu des. Atti tu de toward alcoh ol use was assessed by the qu estion: " H ow do you feel abo ut kids your age drin king alcoho l?" An swers were on th e same 5-poi nt scale as parental and frien ds' att itu des toward alcoho l use. To assess the validity of th ese last two items, the corr elatio n betwe en each item and the same question asked in reference to th e use of marij uana and ot he r dru gs was calculated. It was expected that altho ugh approval of th e use of marijuan a and o ther drugs would not be as high as that of alcoho l use, the co rrelation between the two qu estion s would be substantial. The correlation between both qu estion s for friends' atti tude was .45. For own att itud es, the correl ation was .50.

Data Analysis The data were analyzed using path an alysis. In path models the re are two types of variables: exogen ou s and endogenous. Exogenous variables are those whose variabil ity is assumed to lie outside th e mod el; tha t is, no attempt is made to specify the factors that explain variabi lity amo ng exogenou s variables. Endogeno us variable s, o n

TABLE 1 Percentage of Seventh G raders Endo rsing Each Item on Guttman Scale of Alcoho l Use Item No items endorsed I have had a sip of an alcoh olic beverage I have tried beer, win e, or hard liqu or once I have had an ent ire dri nk of beer , wine, or har d liqu or I have felt "d runk" from dr ink ing alcoho l Some time in the last week I have had 5 or more glasses of beer, win e, o r ha rd liqu or in o ne day I d rink alcohol at least once a week I drink alcoho l daily

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%

26. 7 24 .2 30.8 8.3 8.3 1.7 0.0 0.0

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the other hand, are those whose variation is explained by exogenous or other endogenous variables in the model. Relationships among variables in a path model are represented by arrows. Two-headed arrows represent correlations among variables, and one-headed arrows represent a hypothesized effect of one variable on another. To test a model, certain restrictions must be imposed. This usually involves setting certain paths to zero and determining how this affects the fit of the model to the data (Pedhazur, 1982). This can be done by comparing the fit of the hypothesized model (with some paths set to zero) with the fit of the full model (with all possible paths included). If the change in value of the X2 test (which indicates how well the model fits the data) is not significant, this suggests that the paths hypothesized to be zero can indeed be eliminated from the nested model without affecting the fit of the model. In the present analysis, elimination of direct paths from the exogenous variables (parental and peer attitudes) to the two endogenous variables (intentions and use) represents the hypothesis that the direct relationship between these variables is zero. The fit of the model can be formally tested through use ofaX2 statistic. A statistically significant X2 value indicates that the hypothesized model does not fit the data. This statistic is, however, inversely related to sample size, and hence it must be interpreted cautiously (Joreskog, 1974), because the larger the sample, the more likely the model will be rejected because of lack of fit, even if the model provides a relatively good fit to the data. A better index of the appropriateness of a model is the goodness-of-fit index, which is not affected by sample size (Pedhazur, 1982). This index can range from zero to one, and it indicates how closely the hypothesized model fits the data compared with the full model. Values that approach one indicate that the model fits the data. An additional source of information are the residual paths from the endogenous variables, which indicate the proportion of variance in an endogenous variable not explained by endogenous variables that are hypothesized to affect it. Large differences in residual paths between the full and hypothesized model may indicate the source of a lack of fit (Pedhazur, 1982).

RESULTS

Table 2 displays the intercorrelations among the variables in the analysis. It can be seen that the relationship between perceived parental attitudes and children's attitude is statistically significant at the bivariate level; however, perceived parental attitudes are not significantly related to alcohol use in seventh grade, or to intentions in fifth grade, which is consistent with the

hypotheses, since these relationships are hypothesized to be zero in the path model. Fifth-grade perceived peer attitudes and attitude toward use are also not significantly related to seventh-grade use, but are related to fifth-grade intentions, which is also consistent with the hypothesized model. Figure 1 displays the full model, with all paths included. Path values are standardized coefficients. As expected, the paths from perceived parental and peer attitudes to alcohol use, and to intentions, are not statistically significant. The path from fifth-grade attitude to seventh-grade use is also not significant. The path from fifth-grade attitude to fifth-grade intentions, however, is also not statistically significant. Examination of the bivariate correlations (Table 2) indicates that attitude is moderately correlated with intentions (r = .33) but is also correlated with other measures in the equation, particularly perceived parental attitudes (r = .49) and perceived peer attitudes (r = .53); hence, it accounts for relatively little unique variance in fifthgrade intentions when included in the full model. Figure 2 displays the hypothesized model, with paths hypothesized to be zero excluded from the model. In this model, the paths from attitudes to intentions, and the path from intention to use, are simply the bivariate correlations, since neither exogenous variable is hypothesized to directly influence seventh-grade use. In this model, all path coefficients are statistically significant. The only path that showed a large change from the full model was the path from attitude to intentions, which changed from .19 in the full model to .33 in the hypothesized model. Elimination of the paths from other measures with which attitude correlated (perceived parental attitudes and perceived peer attitudes) led to this change. Comparison of the full and hypothesized model yielded a goodness-of-fit index of .92, which indicated

--- --------

TABLE 2 Intercorrelations among Measures

1. 2. 3. 4. 5.

Alcohol use Intentions Attitude Parental attitude Peer attitudes

*p

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< .01; **

2

3

4

.33** .28* .29*

.49** .53**

.33**

5

.29*

.16 .13 .12

P < .001.

------ --- --Fig.1

Full model. ap

< .01; bp < .001.

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DO ATTITUDESIlNTENTlONS PREDICT USE?

Parent Attitudes 1

,-~1 Fig.2 Hypothesized model. "p < .01;

'r < .001.

that the hypothesized model fit the data relatively well. This yielded a Xl of 4.1 (5 df), which was not statistically significant (p > .10). This suggests that elimination of the five paths from the model did not significantly affect the fit of the model. Stated differently, inclusion of these paths would not significantly improve the fit of model. Examination of the residual paths indicated that elimination of the paths resulted in a negligible increase in the residuals in the hypothesized model, as is indicated by the nonsignificant Xl.

DISCUSSION

Results of the analyses indicated support for the hypothesized model. The data suggest that perceived parent and peer attitudes toward alcohol use play a role in the formation of attitudes of fifth graders toward alcohol use. These attitudes in turn affect intentions to use alcohol, which in turn influence alcohol use 18 months later. Similarly, attitudes toward alcohol use affect use indirectly rather than directly, through their influence on intentions. Thus, while factors such as perceived parental and peer attitudes appear to exert relatively little direct influence on later use, they do exert an indirect influence through their effect on students' attitudes toward use and intentions to use alcohol. The results also provide some support for the view of Ajzen and Fishbein's model regarding the relationship among attitudes, intentions, and behavior. Finally, it appears that precursors of early adolescent alcohol use are relatively stable over time and reflect ongoing dispositions as opposed to being episodic. The relationship among attitudes, intentions, and eventual use may be especially relevant during the developmental period involved in the present study. It appears that attitudes toward alcohol use are in the process of changing from negative to more positive

during this period, eventually leading to experimentation with alcohol among some early adolescents. This would suggest that preventive interventions may effectively be targeted toward younger children and could seek to modify developing attitudes toward alcohol use. Data from the present study indicate that this would affect children's intentions to use alcohol and could serve to prevent, or at least delay, the onset of later use. As noted previously, age of initiation of alcohol use has been shown to influence substance use patterns among adolescents (Barnes and Welte, 1986) and adults (Tennant et al., 1976). Hence, preventive interventions directed toward children at this age could have an impact on later use. These results further suggest that the content of interventions would need to focus on both family and peer influences on attitudes and use. Although more recent prevention programs have begun to include a family component (Pentz et al., 1989), most prevention programs, in addition to being offered to early adolescents, tend to emphasize peer influences. Whereas peer influences are of importance, these and other data (Webb et al., 1995) suggest that family factors play an important role in use, also. Indeed, a previous study with fifth and sixth graders found that among fifth graders, family influences were more strongly related to intentions, while among sixth graders, peer influences were more important. It may well be that preventive interventions need to be tailored to the developmental level of program recipients, with interventions for younger children emphasizing family influences and those with older children emphasizing peer influences. These data indicate that preventive interventions need to be initiated well before early adolescence and need to target both family and peer influences. Data from some studies indicate that interventions can be effective with children as young as second graders (Abbey et al., 1990). Alcohol use among subjects in this study was at a relatively low level, as would be expected given their age. Hence, the results are applicable primarily to adolescents who have not yet initiated use, or whose use is minimal, for whom primary prevention programs are most appropriate. Use among adolescents increases as they grow older; hence, primary prevention programs are probably inappropriate for older adolescents. Studies have shown that among older adolescents increased alcohol use is associated with increased occurrence of

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other psychiatric disorders, such as depressive disorders, disruptive behavior disorders, drug use disorders, and tobacco use (Rohde et al., 1996). Indeed, the vast majority of older adolescents with alcohol abuse or dependence have other forms of psychopathology. It would be important to assess psychiatric comorbidity among these adolescents, as this would affect the choice ofintervention with older adolescents and their families. The present study is limited in that it was done with a relatively small sample of fifth graders, which consisted primarily of white children. Thus, results may not generalize to students from other school districts, particularly minority students from inner-city schools. Also, data were provided solely by children. The study was, therefore, limited to children's perceptions of the attitudes of their parents and peers toward alcohol use. It may well be that children who intend to use alcohol tend to perceive significant others as more tolerant of such use than they actually are. Future studies would benefit from obtaining information regarding peer and parental attitudes directly from these sources. Furthermore, the manner in which parental and peer attitudes influence children's attitudes is quite complex and may be influenced by numerous factors that were not included in the present study. For example, the correlation between mother and father attitudes was .57 in this sample. While substantial, this suggests that there may often be a discrepancy between the attitudes of parents regarding alcohol use. Furthermore, other family members such as siblings have also been found to influence children's attitudes toward alcohol use. Ideally, future studies should examine factors such as these, which exert an influence on children's attitudes and behavior regarding alcohol use. Clinical Implications

The study's results suggest that clinicians involved in the evaluation and treatment of school-age children should carefully inquire into such patients' perceptions of peer and parental attitudes toward alcohol use as part of routine assessment procedures. Children who perceive positive peer and/or parental attitudes toward alcohol use should be targeted for preventive efforts directed at modifying such perceptions. Preventive efforts might consist of family therapy, family group therapy, and/or peer group therapy aimed at providing information about the dangers of alcohol use, discussing parental and peer attitudes toward alcohol use, and

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reinforcing those attitudes that are not supportive of alcohol use. In addition, clinicians involved with elementary schools in their community may wish to discuss with school officials the possibility of developing preventive intervention programs in the form of parent and peer alcohol information and discussion groups. Such groups would have the dual aims of educating parents and children about the dangers of alcohol use and reinforcing attitudes not supportive of use.

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Tennant FS, Detels R, Clark V (1976), Some childhood antecedents of drug and alcohol abuse. Am J Epidemioll02:377-384 Webb JA, Baer PE (1995), Influence of family disharmony and parental alcohol use on adolescent social skills, self-efficacy, and alcohol use. Addict Behav 20:127-135 Webb JA, Baer PE, Caid CD, Mclaughlin RJ, McKelvey RS (1991),

Concurrent and longitudinal assessment of risk for alcohol use among seventh graders. J Early Adolesc 11:450-458 Webb JA, Baer PE, McKelvey RS (1995), Development of a risk profile for intentions ro use alcohol among fifth and sixth graders. JAm Acad Child Adolesc Psychiatry 34:772-778

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