- Email: [email protected]
Incarcerated adolescents' attributions for drug and alcohol use
._(ddic,liveB~~ha~iors. Vol. 17.pp.227-235. 1992
0306-4603/92$5.00 - .OO
Copyright 0 1992 Pergamon Press Ltd.
Printed in the USA. Ail rights reserved.
INCARCERATED ADOLESCENTS’ AITRIBUTIONS ALCOHOL USE
FOR DRUG AND
JAMES R. MCKAY University of Pennsylvania
RONALD T. MURPHY, JAMES McGUIRE,
and TIMOTHY
R. RIVINUS
Brown University
STEPHEN A. MAISTO VAMC, Brockton, MA, and Brown University Abstract - Incarcerated adolescents’ attributions for drug use were investigated. A new 50item questionnaire, the Inventory of Drug Taking Situations (IDTS). was used to assess reasons for use. The IDTS yields eight subscales corresponding to risky situations identified by Marlatt and others. On the IDTS, subjects indicate how frequently they used their drug of chotce when confronted with each risky situation. The IDTS scales had good internal consistency and higher scores were significantly associated with self-reports of drug use frequency. Furthermore, IDTS scores were most valid for the type of drug the measure was filled out about. Adolescents reported that they tended to use more frequently in response to positive and/or interpersonal experiences, as opposed to negative and/or internal ones. Positive, negative, interpersonal, and internal reasons for use were all equally correlated with frequency of use. In the most heavily drug-involved adolescents, however, negative reasons were more highly correlated with frequency of use than positive reasons. Treatment implications are discussed.
Substance abusers’ perceptions of their reasons for using have been a rich source of information about factors associated with drinking and drug use episodes. In studies of adult alcoholics and addicts, substance abuse episodes are most frequently attributed to negative factors, such as unpleasant emotional states and conflicts with others (Annis & Davis, 1989; Maisto, O’Farrell, Connors, McKay, & Pelcovits, 1988; Marlatt & Gordon, 1985). Adolescents and college students, on the other hand, appear to attribute their substance use more frequently to positive factors, such as to feel good or to celebrate with friends (Johnston & O’Malley, 1986; Wechsler & Rohman, 198 1). The questionnaires used to assess reasons for substances use in survey research on high school and college students, however, generally consist ofa relatively small number of items that have been included because of their face validity. Conclusions about reasons for use are drawn on the basis of responses to individual items, rather than on the basis of scale scores. While these studies have generated interesting initial information on reasons for use, there is a need for further investigations of adolescent substance abusers in which more comprehensive and sophisticated measures of reasons for use are included. Another limitation of previous studies of adolescents’ reasons for substance use is that they have typically only involved adolescents who are functioning well enough to be in high school (cf. Johnston & O’Malley, 1986). Adolescents with severe behavior Preparation of this manuscript was supported in part by NIAAA Grants AAO7812. AA07459. and AA08443 to Richard Longabaugh, Principal Investigator, and in part by a NIDA Center Grant DA05 186 to Charles O’Brien. Principal Investigator. Requests for reprints should be sent to James R. McKay, University of Pennsylvania, Treatment Research Center, 3900 Chestnut St.. Philadelphia, PA I9 104. 227
7
22s
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R. MCKAY et al
problems. such as conduct disorder. have not been included in previous research on reasons for substance use. Information about the attributions these adolescents make for their substance use may prove useful in devising interventions for this difficult-totreat group. In adult substance abusers, for example, studies of reasons for use and relapse attributions have generated a number of treatment approaches, including relapse prevention strategies (Annis & Davis, 1989; Marlatt & Gordon. 1985). Recently, Annis and Martin (1985) developed an adolescent version ofthe Inventory ofDrinking Situations (IDS), an adult reasons for use measure (Annis. 1982). The new measure. the Inventory of Drug-Taking Situations (IDTS), comes in alcohol and drug forms and provides a profile of the situations in which an adolescent has used substances in the recent past. The profile consists of the same eight categories of reasons for use that are included on the IDS. Some items have been rekvorded and new items have been added, however, in order to make the measure more suitable for use with adolescents. The present study examines attributions for substance use in a sample of adolescents who were incarcerated because of severe problem behavior. Information on frequency of use was also assessed with self-report questionnaires. Adolescents’ self-reports of substance use gathered in this way have generally been found to be valid and reliable (Needle, McCubbin, Lorence. & Hochhauser, 1983; Needle, Jou. & Su, 1989; O’Malley, Bachman, & Johnston, 1983). The goals of the study were: 1. To evaluate the reliability (internal consistency) of the Inventory of Drug-Taking Situations (IDTS) when used with behaviorally disturbed adolescents. 2. To identify the most frequently given reasons for use and determine whether certain reasons for use are more highly correlated with frequency of drug use. 3. To determine whether different reasons for use are given by users of marijuana, alcohol, and hard drugs. 4. To examine the specificity of IDTS scores, or the degree to which scores are more highly correlated with the use of the drug the IDTS was filled out about than with the use of other substances. hl E T H 0
D
Subjects The adolescents who participated in the study (n = 92) were incarcerated at the Rhode Island Training School, a prison facility forjuvenile offenders. The demographic data available for this report describe all the adolescents \vho were at the Training School during the period in which the study was conducted, rather than the subset who were in the study. However, approximately 90% of the adolescents at the Training School participated in the present study. The following demographic data thus provide a relatively accurate description of the adolescents who filled out the questionnaires. The adolescents ranged in age from 13 to 19 (M = 16.7). and virtually all were male (95%). Fifty percent of the adolescents were white, 35% were black, 9% were Hispanic, and 6% were other minorities. The median educational level of those at the Training School was 9th grade, with a range of 6th- 12th grade. The adolescents had been incarcerated due to offenses against property (4 lo/o),offenses against people (19%), and drugrelated offenses (48%). These percentages add to over 100% because some of the adolescents had committed several offenses. According to the Diagnostic Interview for Children and Adolescents (DICA-A-R, Reich & Welner, 1988), over 90% of the ado-
Adolescent drug use
21 9
lescents were diagnosed with Conduct Disorder. 40% with an Affective Disorder. and 50% with an Anxiety Disorder. Procedures The questionnaires were administered during a free period shortly after lunch to groups of 3-4 adolescents by a research assistant who was not involved with treatment or administration at the Training School. The adolescents were told that the questionnaires were part of a survey intended to help the staff learn more about past drug and alcohol use by residents of the Training School. They were also told that their replies would remain strictly confidential and no names or subject numbers appeared on the questionnaire packets. The research assistant was available throughout the assessment to clarify any questions that were confusing to the adolescents.
Substance use. Frequency of substance use in the 4 months prior to incarceration nas assessed with a questionnaire which listed 20 substances. For each substance, subjects checked one of the following categories: (0) no use; ( 1) l-2 times in 4 months; (2) 3-5 times in 4 months; (3) l-3 times per month; (4) l-2 times per week; (5) 3-4 times per week: and (6) every day. Due to an error during data collection, information on frequency of drinking was only gathered from 43 subjects. An average frequency of drug use scale was formed by calculating the mean frequency of use of the following drugs: marijuana, cocaine, crack, benzodiazepines, uppers (e.g., amphetamines), heroin, LSD, other hallucinogens, and poppers.’ An index of the frequency of hard drug use was also constructed, which was the average frequency of cocaine, crack. uppers, heroin, and LSD use. Reasonsfor use. The Inventory of Drug-Taking Situations (IDTS) (Annis & Martin, 1985) a 50-item self-report questionnaire, was used to assess the subjects’ perceptions of their reasons for using their drug of choice. Following a classification system based on the work of Marlatt and colleagues (Marlatt & Gordon, 1985). the IDTS is designed to assess eight categories ofdrug use situations: (a) Pleasant Times with Others (PT); (b) Social Pressure to Use (SP); (c) Pleasant Emotions (PE); (d) Urges/Temptations to Use (UR); (e) Unpleasant Emotions (UE); (f) Testing Personal Control (TPC); (g) Conflict with Others (CO); and (h) Physical Discomfort (PD). For each item, subjects indicate how frequently they used their drug of choice (i.e., most frequently used drug) in the 4 months preceding incarceration on a four-item scale, ranging from “never” to “almost always.” Four summary scales were also constructed on the basis of subgroupings proposed by Annis and colleagues (Annis & Davis, 1989; Annis & Martin. 1985): (a) Zntemal Reasons - average of the Unpleasant Emotions, Physical Discomfort, Pleasant Emotions. Testing Personal Control, and Urges to Use scales; (b) Interpersonal Reasons average of the Conflict with Others, Social Pressure to Use, and Pleasant Times with Others scales; (c) Positive Reasons - average of the Pleasant Emotions and Pleasant Times with Others scales; and (d) Negative Reasons - average ofthe Unpleasant Emotions. Physical Discomfort, and Conflict with Others scales. ‘The other drugs in the substance use questionnaire were used relatively infrequently by the adolescents in the sample and were thus not included in this index ofdrug use frequency.
J.A%lES R. hlcKAY et al
230
RESULTS
Frequency of substance me Of the 92 subjects, 80 reported using an illegal substance at some point in the 4 months prior to incarceration. Drug use in the sample was heavy, with many subjects reporting using a number of drugs at least once per week. The frequencies of use for each substance, ranging from no use to 3 or more times per week, are displayed in Table 1. Marijuana was the most frequently used drug, with 55% of the subjects using at least 3 times per week. Cocaine was the next most frequently used drug, with 20% reporting using 3 times per week or more. LSD and other hallucinogens were also used frequently. Of the 43 subjects who were also asked about alcohol use, 42 reported drinking during the 4 months prior to incarceration. Forty percent of these subjects reported drinking at least 3 times per week. Reasons for use The mean values and internal consistencies of the IDTS scales are presented in Table 2. Cronbach’s alphas were above .80 on 7 of 8 scales, indicating good reliability. Reliability was lower on the Physical Discomfort scale (.68). In Table 2, the IDTS scales are ranked in order from most to least frequent reasons for drug use. A repeated measures one-way ANOVA indicated the means of the scales were significantly different (F(7,553) = 37.76, p < .OOl). Overall, the subjects thought that they used drugs most frequently when experiencing Pleasant Times with Others or Social Pressure to Use. Conflict with Others and Physical Discomfort were rated as the least frequent reasons for use. The subjects rated Interpersonal Reasons as stronger determinants of use than Internal Reasons. The means for the two summary scales were 2.63 and 2.41, respectively (F( 1.79) = 3 1.33, p < .OOl). The subjects also rated Positive Reasons (M = 2.8 1) as Table I. Drug use frequencies in the four months preceding incarceration (n = 92) Number ofadolescents Drug Alcohol’ Marijuana Cocaine Crack Uppsrs Barbituates Benzodiazepines Narcotic meds Heroin Methadone Other narcotics LSD
PCP blD.Aa Other hallucinogens” Inhalents’
Popper? Caffrinea Tobacco”
No use I 18
58 78 80 85 ;: 86 91 87 65 84 85 66 83 78 79 ?I
“b’issing data resulted in lower numbers.
< IX/ma.
I-3X/ma.
2 5 IO 6 5 4 8 5 0 0
I-Zx/wk. I6 15 4 0
0
4
4 0 0 2
: 2
-
in each category 1) 3X/wk. I7 51 18 5 4 2 2 5
I5
I
I 5 0 4
6 3 4 3
4
1
0
I 2
3 47
Adolescent drug use
731
Table 2. IDTS scale scores from drug using subjects (n = 80) Inventory of Drug-Taking Situations Scales
hlean
/SD)
Alpha
Pleasant times uith others (PT) Social pressure to use (SP) Pleasant emotions (PE) Urges/temptations to use (UR) Unpleasant emotions (UE) Testing personal control (TPC) Conflict with others (CO) Physical discomfort (PD)
2.87 2.79 2.75 2.59 2.18 -._ ’ ‘9 -J ‘4 -._ 1.95
(.91) (.97) (.97) (.98) (.98) (.9l)
.87 .9l .90 .89 .95 .83 .95 .68
I:;:;
I = never use: 2 = rarely use: 3 = frequently use; 4 = almost always use.
stronger determinants of use than Negative Reasons (M = 2.22: F( 1,79) = 97.98, p < .OO1). The subjects were thus more likely to attribute their substance use to situations involving feeling good and having fun with friends than to situations involving conflict with others or feeling bad. Reasons for use andfrequenc)* of me Correlations between the IDTS scales and the average drug use frequency scale are presented in Table 3. All eight IDTS scales and the four summary scales were significantly correlated with average drug use frequency b < .OOl), with higher scores associated with more frequent use. Drug ofchoice and reasons for use The purpose ofthe analyses in this section was to determine whether reasons for substance use differed as a function of drug of choice. Although subjects were asked to indicate the one substance for which they provided reasons for use when completing the
Table 3. Correlations between IDTS scale scores and average drug use frequency (n = 79) IDTS scales
R
P!easant times with others (PT) Social pressure to use (SP) Pleasant emotions (PE) Urges/temptations to use (UR) Unpleasant emotions (UE) Testing personal control (TPC) Conflict with others (CO) Physical discomfort (PD)
.39 .58 .45 59 .55 .5l .62 .53
IDTS summary scales Positive (PT+PE) Negative(UE+PD+CO) Interpersonal (PT+SP+CO) Intemal(PE+UR+UE+TPC+PD)
.45 .6l .58 .59
All correlations p < .OOI. Drug use frequency = average of marijuana, cocaine, crack, benzodiazepines, uppers. heroin, LSD, other hallucinogens, and poppers use frequency.
232
J -\klES
on the IDTS
I” f !;) (:: = ;,
CoEL?nation of substance:’ Alcohol and marijuana (n Cocaine and marijuana (n LSD and marijuana (It Heroin and marijuana (n LSD and heroin (n Categories of drug users Marijuana (n (n Hard drugs
Alcohol
et al.
drugs of choice. as indicated
Table 1. .Adolescents’ One substance Marijuana Alcohol Cocaine
R. XlcRAY
= = = = = =
‘) IO) 13) 9) I) I)
= 32): = 30):
(n = 15):
Marijuana as drug of choice. LSD, heroin. or cocaine. or one of these in combination with marijuana as drug(s) of choice. Alcohol or alcohol/marijuana as drug(s) of choice.
IDTS, some subjects listed two drugs.2 Drugs and combinations of drugs given by the subjects are listed in Table 4. Subjects were divided into three groups on the basis of their most frequently used substance(s): Marijuana, Hard Drugs, and Alcohol. This categorization system was chosen to distinguish subjects who were primarily involved with alcohol or marijuana from those who were frequent users of harder drugs such as cocaine and LSD. Multivariate analysis of variance (MANOVA) demonstrated that, overall. drug use was more frequent in the Hard Drugs group (Wilkes’ Lambda = .29, F( 18.53) = 7.25, p < .OOl), Univariate analyses revealed that those in the Hard Drugs group reported more frequent use of marijuana, cocaine, crack, benzodiazepines, heroin, LSD. other hallucinogens. MDA, and poppers than those in the other two groups (r, < .05). Although frequency of use was generally somewhat higher in the Alcohol group than in the Marijuana group, the differences were not significant (Wilkes’ Lambda = .80. F( l&53) = .72. ns; univariate tests also all ns). Differences between the three groups in reasons for substance use were first evaluated using MANOVA, with drug group as the independent variable and IDTS scores as the dependent variables. There was a significant difference between groups (Wilkes’ Lamda = .65, F( 16, 134) = 2.04, p = .015). Univariate analyses also showed that the groups differed significantly on each IDTS scale. As can be seen in Table 5. the Hard Drugs group had higher IDTS scores than the Alcohol group on all eight scales, and higher scores than the Marijuana group on seven scales. The Marijuana and Alcohol groups did not differ significantly on any IDTS scale. The rankings of reasons for use in each group nere similar with the exception of Social Pressure to Use. Subjects in the Hard Drugs group rated social pressure as the most important determinant of their use, whereas those in the Marijuana and Alcohol groups ranked it third and fourth, respectively. This did not prove to be a statistically significant difference according to the Tukey test for pairwise comparisons, however. As was the case with the who!e sample, subjects in each group rated positive reasons as more important determinants of their substance use than negative reasons. ‘Three
subjects
did not indicate
what drug they were filling out the IDTS about
‘33
Adolescent drug use
Table 5. IDTS scale scores for Marijuana. Alcohol. and Hard Drug groups Marijuana (n = 32)
IDTS Scale Pleasant times with others Social pressure to use Pleasant emotions Urges/temptations to use Unpleasant emotions Testing personal control Contlict with others Physical discomfort
2.88 x2*** 2.69* 2.43** 2.35* 1’1’ _._ 2.00** 1.84*
Alcohol (N = 15)
Hard Drugs (n = 30)
F
P
3.21 3.41 3.15 3.09 2.94 2.61 2.74 2.28
3.5 12s 4.1 6.0 5.3 4.2 6.1 4.5
.035 ,000 ,021 ,004 .007 ,020 ,003 ,015
2.53* x3*** 2.39** 3 7,** -._ 2.13** 1.95** 2.01* I.708
klarijuana and Alcohol groups did not differ significantly on any IDTS scale. Asterisks denote the degree to which these groups differed from the Hard Drugs group: * p < .05: **p < .Ol: ***p < .OOl.
Specificity qf reasons.for drug use To determine the specificity of the IDTS, scores on the four summary scales were correlated separately for Marijuana and Hard Drugs groups with frequency of marijuana and hard drug use. The results are presented in Table 6. For the most part, there was good correspondence between the substances for which the IDTS was filled out and the frequency of use of those substances. In the group that filled out the IDTS about their marijuana use. the IDTS summary scales were more highly correlated with frequency of marijuana use than with hard drug use. In the Hard Drugs group, on the other hand, the IDTS summary scales were more highly correlated with frequency of hard drug use than with marijuana use. Because there were only 15 adolescents in the Alcohol group. the correlations between their IDTS scores and substance use are not included in Table 6. In the Hard Drugs group, the Negative Reasons summary scale was more highly correlated with frequency of hard drug use than the Positive Reasons summary scale (.60 vs. .28). The difference between the two correlations was significant (Hotelling test for difference between two nonindependent correlations, t(27) = 2.66, p < .Ol). In the Marijuana group, on the other hand, the four reasons for use summary scales were correlated about equally with frequency of marijuana use.
Table 6. Correlations between IDTS summary scale scores and drug use by drug of choice groups IDTS summary scales
Frequency of drug use Marijuana
hlarijuana subjects (n = 32) .52** Positive .42’ Negative .54** Interpersonal .50** Internal Hard Drugs subjects (n = 30) .05 Positive .I6 Negative -.02 Interpersonal .25 Internal
Hard Drugs .21 .30 25 .26 .28 .60’** .50** .54**
23-l
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R. McK.4\’
et al.
DISCUSSION
A sample of 93 incarcerated adolescents provided self-reports of their frequency of drug use in the 4 months prior to incarceration. Subjects also completed the Inventory of Drug-Taking Situations (IDTS, Annis & Martin, 1985). a questionnaire designed to assess attributions for drug use in adolescents. Most of the adolescents were frequent drug users, with many reporting use of multiple substances. The results of the study provide support for the reliability and validity of the IDTS, even when it is used with behaviorally disturbed adolescents like those incarcerated at the Training School. The IDTS scales had good internal consistency and higher scores were significantly associated with self-reports of drug use frequency. Furthermore. IDTS scores were most valid for the type of drug the measure was filled out about. The IDTS scores of those for whom marijuana was the drug of choice were correlated with their marijuana use but not their use of hard drugs. Similarly, the IDTS scores of those in the Hard Drugs group lvere correlated with their use of hard drugs but not their use of marijuana. It should be noted, however, that these results may not generalize to less disturbed adolescents. Additional studies with other groups of adolescents will be needed to fully determine the psychometric properties of the IDTS. The adolescents in this sample tended to attribute their use of drugs to positive rather than negative reasons, and to interpersonal rather than internal reasons. In other words, the adolescents were more likely to say they used drugs when feeling good or while out with friends and less likely to attribute their drug use to unpleasant emotions, interpersonal conflict, physical discomfort, or urges to use. Their reported reasons for use were therefore more similar to those given by high school students (Johnston & O’Malley. 1986) than to the attributions of relapsed adult alcoholics (Maisto et al., 1988; Marlatt 61 Gordon, 1985). Adolescents who were frequent users of hard drugs consistently had higher scores on the IDTS scales than those whose drug of choice was either marijuana or alcohol. This replicates the Johnston & O’Malley (1986) study, in which heavy users tended to endorse a greater number of reasons for substance use. The groups were not significantly different, however. on their ranking of the relative importance of each category of reasons for use. In this particular sample of adolescents, the relative importance of various reasons for substance use therefore did not differ as a function of drug of choice. Summary scales measuring negative, positive, internal, and interpersonal reasons for use were all about equally correlated with frequency of drug use. However, in the most heavily drug-involved adolescents (those in the Hard Drugs group), negative reasons were much more strongly correlated with hard drug use than positive reasons. This suggests that these adolescents may have particular difficulty coping with interpersonal conflicts and unpleasant internal states, such as depression, guilt, anger, or anxiety, without resorting to the use of drugs. Annis and Davis (1989) have suggested that the adult version ofthe IDTS, the Inventory of Drinking Situations (IDS), can be used as an aid to planning treatment for alcoholics. High scores on IDS scales suggest areas that need to be targeted for therapeutic interventions, and when the eight scale scores are plotted to form a profile, they give alcoholics visual representations of their vulnerabilities. When treating conduct disordered adolescents with drug abuse problems, an IDTS profile may be a good place to start. Adolescents might be more likely to respond to visual depictions of how they think about their substance use than to verbal information provided by the therapist.
Adolescent drug use
235
REFERENCES Annis, H. M. (1982). Invenfor~ofdrinkingsifftarions. Toronto: Addiction Research Foundation ofOntario. Annis. H. M.. & Davis. C. S. (1989). Relanse orevention. In R. K. Hester. & W.R. Miller fEds.). Handbook ~ , oj’alcoholism treamml approaches (pp. I 70- 182). New York: Pergamon. Annis. H. M., & Martin, G. (1985). Inventor~of‘dnrg-fakingsifltarions. Toronto: Addiction Research Foundation of Ontario. Johnston, L. D., & O’Malley, P. M. (1986). Why do the nation’s students use drugs and alcohol? Self-reported reasons from nine national surveys. The JournolojDrug Issues. 16,29-66. Maisto. S. A., O’Farrell, T. J., Connors, G. J., McKay, J. R., & Pelcovits, M. (1988). Alcoholics’ attributions of factors affecting their relapse to drinking and reasons for terminating.1 relapse Addiclive . episodes. . r
Behaviors. 13, 79-82.
.
.
_
Marlatt. G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Mainlenance slrategies in the treatmem ofaddick~e behaviors. New York: Guilford Press. Needle. R. H., Jou. S., & Su. S. S. (1989). The impact ofchanging methods ofdata collection on the reliability of self-reported drug use of adolescents. American Jor&al if Drug and Alcohol Abuse. 15.275-289. Needle. R. H.. McCubbin, H.. Lorence, J.. & Hochhauser. M. (1983). Reliability and valididv of adolescent self-reported drug use in a family-based study: A methodological report. Thelnfernafiona? Journalojthe Addicrions. l&90 l-9 12. O’iMalley, P. M.. Bachman, J. G.. &Johnston, L. D. (1983). Reliability and consistency in self-reportsofdrug use. The Inrernarional Journal olthe Addictions. 18, 805-824. Reich, W.. & Welner. Z. (1988). Revised versionofche DICAjoradole~cemsage 13-17. St. Louis: Washington University. Wechsler, H., & Rohman, M. (198 I). Extensive users of alcohol among college students. Journal ofSmdies on Alcohol, 42, 149-155.
0306-4603/92$5.00 - .OO
Copyright 0 1992 Pergamon Press Ltd.
Printed in the USA. Ail rights reserved.
INCARCERATED ADOLESCENTS’ AITRIBUTIONS ALCOHOL USE
FOR DRUG AND
JAMES R. MCKAY University of Pennsylvania
RONALD T. MURPHY, JAMES McGUIRE,
and TIMOTHY
R. RIVINUS
Brown University
STEPHEN A. MAISTO VAMC, Brockton, MA, and Brown University Abstract - Incarcerated adolescents’ attributions for drug use were investigated. A new 50item questionnaire, the Inventory of Drug Taking Situations (IDTS). was used to assess reasons for use. The IDTS yields eight subscales corresponding to risky situations identified by Marlatt and others. On the IDTS, subjects indicate how frequently they used their drug of chotce when confronted with each risky situation. The IDTS scales had good internal consistency and higher scores were significantly associated with self-reports of drug use frequency. Furthermore, IDTS scores were most valid for the type of drug the measure was filled out about. Adolescents reported that they tended to use more frequently in response to positive and/or interpersonal experiences, as opposed to negative and/or internal ones. Positive, negative, interpersonal, and internal reasons for use were all equally correlated with frequency of use. In the most heavily drug-involved adolescents, however, negative reasons were more highly correlated with frequency of use than positive reasons. Treatment implications are discussed.
Substance abusers’ perceptions of their reasons for using have been a rich source of information about factors associated with drinking and drug use episodes. In studies of adult alcoholics and addicts, substance abuse episodes are most frequently attributed to negative factors, such as unpleasant emotional states and conflicts with others (Annis & Davis, 1989; Maisto, O’Farrell, Connors, McKay, & Pelcovits, 1988; Marlatt & Gordon, 1985). Adolescents and college students, on the other hand, appear to attribute their substance use more frequently to positive factors, such as to feel good or to celebrate with friends (Johnston & O’Malley, 1986; Wechsler & Rohman, 198 1). The questionnaires used to assess reasons for substances use in survey research on high school and college students, however, generally consist ofa relatively small number of items that have been included because of their face validity. Conclusions about reasons for use are drawn on the basis of responses to individual items, rather than on the basis of scale scores. While these studies have generated interesting initial information on reasons for use, there is a need for further investigations of adolescent substance abusers in which more comprehensive and sophisticated measures of reasons for use are included. Another limitation of previous studies of adolescents’ reasons for substance use is that they have typically only involved adolescents who are functioning well enough to be in high school (cf. Johnston & O’Malley, 1986). Adolescents with severe behavior Preparation of this manuscript was supported in part by NIAAA Grants AAO7812. AA07459. and AA08443 to Richard Longabaugh, Principal Investigator, and in part by a NIDA Center Grant DA05 186 to Charles O’Brien. Principal Investigator. Requests for reprints should be sent to James R. McKay, University of Pennsylvania, Treatment Research Center, 3900 Chestnut St.. Philadelphia, PA I9 104. 227
7
22s
JA\lES
R. MCKAY et al
problems. such as conduct disorder. have not been included in previous research on reasons for substance use. Information about the attributions these adolescents make for their substance use may prove useful in devising interventions for this difficult-totreat group. In adult substance abusers, for example, studies of reasons for use and relapse attributions have generated a number of treatment approaches, including relapse prevention strategies (Annis & Davis, 1989; Marlatt & Gordon. 1985). Recently, Annis and Martin (1985) developed an adolescent version ofthe Inventory ofDrinking Situations (IDS), an adult reasons for use measure (Annis. 1982). The new measure. the Inventory of Drug-Taking Situations (IDTS), comes in alcohol and drug forms and provides a profile of the situations in which an adolescent has used substances in the recent past. The profile consists of the same eight categories of reasons for use that are included on the IDS. Some items have been rekvorded and new items have been added, however, in order to make the measure more suitable for use with adolescents. The present study examines attributions for substance use in a sample of adolescents who were incarcerated because of severe problem behavior. Information on frequency of use was also assessed with self-report questionnaires. Adolescents’ self-reports of substance use gathered in this way have generally been found to be valid and reliable (Needle, McCubbin, Lorence. & Hochhauser, 1983; Needle, Jou. & Su, 1989; O’Malley, Bachman, & Johnston, 1983). The goals of the study were: 1. To evaluate the reliability (internal consistency) of the Inventory of Drug-Taking Situations (IDTS) when used with behaviorally disturbed adolescents. 2. To identify the most frequently given reasons for use and determine whether certain reasons for use are more highly correlated with frequency of drug use. 3. To determine whether different reasons for use are given by users of marijuana, alcohol, and hard drugs. 4. To examine the specificity of IDTS scores, or the degree to which scores are more highly correlated with the use of the drug the IDTS was filled out about than with the use of other substances. hl E T H 0
D
Subjects The adolescents who participated in the study (n = 92) were incarcerated at the Rhode Island Training School, a prison facility forjuvenile offenders. The demographic data available for this report describe all the adolescents \vho were at the Training School during the period in which the study was conducted, rather than the subset who were in the study. However, approximately 90% of the adolescents at the Training School participated in the present study. The following demographic data thus provide a relatively accurate description of the adolescents who filled out the questionnaires. The adolescents ranged in age from 13 to 19 (M = 16.7). and virtually all were male (95%). Fifty percent of the adolescents were white, 35% were black, 9% were Hispanic, and 6% were other minorities. The median educational level of those at the Training School was 9th grade, with a range of 6th- 12th grade. The adolescents had been incarcerated due to offenses against property (4 lo/o),offenses against people (19%), and drugrelated offenses (48%). These percentages add to over 100% because some of the adolescents had committed several offenses. According to the Diagnostic Interview for Children and Adolescents (DICA-A-R, Reich & Welner, 1988), over 90% of the ado-
Adolescent drug use
21 9
lescents were diagnosed with Conduct Disorder. 40% with an Affective Disorder. and 50% with an Anxiety Disorder. Procedures The questionnaires were administered during a free period shortly after lunch to groups of 3-4 adolescents by a research assistant who was not involved with treatment or administration at the Training School. The adolescents were told that the questionnaires were part of a survey intended to help the staff learn more about past drug and alcohol use by residents of the Training School. They were also told that their replies would remain strictly confidential and no names or subject numbers appeared on the questionnaire packets. The research assistant was available throughout the assessment to clarify any questions that were confusing to the adolescents.
Substance use. Frequency of substance use in the 4 months prior to incarceration nas assessed with a questionnaire which listed 20 substances. For each substance, subjects checked one of the following categories: (0) no use; ( 1) l-2 times in 4 months; (2) 3-5 times in 4 months; (3) l-3 times per month; (4) l-2 times per week; (5) 3-4 times per week: and (6) every day. Due to an error during data collection, information on frequency of drinking was only gathered from 43 subjects. An average frequency of drug use scale was formed by calculating the mean frequency of use of the following drugs: marijuana, cocaine, crack, benzodiazepines, uppers (e.g., amphetamines), heroin, LSD, other hallucinogens, and poppers.’ An index of the frequency of hard drug use was also constructed, which was the average frequency of cocaine, crack. uppers, heroin, and LSD use. Reasonsfor use. The Inventory of Drug-Taking Situations (IDTS) (Annis & Martin, 1985) a 50-item self-report questionnaire, was used to assess the subjects’ perceptions of their reasons for using their drug of choice. Following a classification system based on the work of Marlatt and colleagues (Marlatt & Gordon, 1985). the IDTS is designed to assess eight categories ofdrug use situations: (a) Pleasant Times with Others (PT); (b) Social Pressure to Use (SP); (c) Pleasant Emotions (PE); (d) Urges/Temptations to Use (UR); (e) Unpleasant Emotions (UE); (f) Testing Personal Control (TPC); (g) Conflict with Others (CO); and (h) Physical Discomfort (PD). For each item, subjects indicate how frequently they used their drug of choice (i.e., most frequently used drug) in the 4 months preceding incarceration on a four-item scale, ranging from “never” to “almost always.” Four summary scales were also constructed on the basis of subgroupings proposed by Annis and colleagues (Annis & Davis, 1989; Annis & Martin. 1985): (a) Zntemal Reasons - average of the Unpleasant Emotions, Physical Discomfort, Pleasant Emotions. Testing Personal Control, and Urges to Use scales; (b) Interpersonal Reasons average of the Conflict with Others, Social Pressure to Use, and Pleasant Times with Others scales; (c) Positive Reasons - average of the Pleasant Emotions and Pleasant Times with Others scales; and (d) Negative Reasons - average ofthe Unpleasant Emotions. Physical Discomfort, and Conflict with Others scales. ‘The other drugs in the substance use questionnaire were used relatively infrequently by the adolescents in the sample and were thus not included in this index ofdrug use frequency.
J.A%lES R. hlcKAY et al
230
RESULTS
Frequency of substance me Of the 92 subjects, 80 reported using an illegal substance at some point in the 4 months prior to incarceration. Drug use in the sample was heavy, with many subjects reporting using a number of drugs at least once per week. The frequencies of use for each substance, ranging from no use to 3 or more times per week, are displayed in Table 1. Marijuana was the most frequently used drug, with 55% of the subjects using at least 3 times per week. Cocaine was the next most frequently used drug, with 20% reporting using 3 times per week or more. LSD and other hallucinogens were also used frequently. Of the 43 subjects who were also asked about alcohol use, 42 reported drinking during the 4 months prior to incarceration. Forty percent of these subjects reported drinking at least 3 times per week. Reasons for use The mean values and internal consistencies of the IDTS scales are presented in Table 2. Cronbach’s alphas were above .80 on 7 of 8 scales, indicating good reliability. Reliability was lower on the Physical Discomfort scale (.68). In Table 2, the IDTS scales are ranked in order from most to least frequent reasons for drug use. A repeated measures one-way ANOVA indicated the means of the scales were significantly different (F(7,553) = 37.76, p < .OOl). Overall, the subjects thought that they used drugs most frequently when experiencing Pleasant Times with Others or Social Pressure to Use. Conflict with Others and Physical Discomfort were rated as the least frequent reasons for use. The subjects rated Interpersonal Reasons as stronger determinants of use than Internal Reasons. The means for the two summary scales were 2.63 and 2.41, respectively (F( 1.79) = 3 1.33, p < .OOl). The subjects also rated Positive Reasons (M = 2.8 1) as Table I. Drug use frequencies in the four months preceding incarceration (n = 92) Number ofadolescents Drug Alcohol’ Marijuana Cocaine Crack Uppsrs Barbituates Benzodiazepines Narcotic meds Heroin Methadone Other narcotics LSD
PCP blD.Aa Other hallucinogens” Inhalents’
Popper? Caffrinea Tobacco”
No use I 18
58 78 80 85 ;: 86 91 87 65 84 85 66 83 78 79 ?I
“b’issing data resulted in lower numbers.
< IX/ma.
I-3X/ma.
2 5 IO 6 5 4 8 5 0 0
I-Zx/wk. I6 15 4 0
0
4
4 0 0 2
: 2
-
in each category 1) 3X/wk. I7 51 18 5 4 2 2 5
I5
I
I 5 0 4
6 3 4 3
4
1
0
I 2
3 47
Adolescent drug use
731
Table 2. IDTS scale scores from drug using subjects (n = 80) Inventory of Drug-Taking Situations Scales
hlean
/SD)
Alpha
Pleasant times uith others (PT) Social pressure to use (SP) Pleasant emotions (PE) Urges/temptations to use (UR) Unpleasant emotions (UE) Testing personal control (TPC) Conflict with others (CO) Physical discomfort (PD)
2.87 2.79 2.75 2.59 2.18 -._ ’ ‘9 -J ‘4 -._ 1.95
(.91) (.97) (.97) (.98) (.98) (.9l)
.87 .9l .90 .89 .95 .83 .95 .68
I:;:;
I = never use: 2 = rarely use: 3 = frequently use; 4 = almost always use.
stronger determinants of use than Negative Reasons (M = 2.22: F( 1,79) = 97.98, p < .OO1). The subjects were thus more likely to attribute their substance use to situations involving feeling good and having fun with friends than to situations involving conflict with others or feeling bad. Reasons for use andfrequenc)* of me Correlations between the IDTS scales and the average drug use frequency scale are presented in Table 3. All eight IDTS scales and the four summary scales were significantly correlated with average drug use frequency b < .OOl), with higher scores associated with more frequent use. Drug ofchoice and reasons for use The purpose ofthe analyses in this section was to determine whether reasons for substance use differed as a function of drug of choice. Although subjects were asked to indicate the one substance for which they provided reasons for use when completing the
Table 3. Correlations between IDTS scale scores and average drug use frequency (n = 79) IDTS scales
R
P!easant times with others (PT) Social pressure to use (SP) Pleasant emotions (PE) Urges/temptations to use (UR) Unpleasant emotions (UE) Testing personal control (TPC) Conflict with others (CO) Physical discomfort (PD)
.39 .58 .45 59 .55 .5l .62 .53
IDTS summary scales Positive (PT+PE) Negative(UE+PD+CO) Interpersonal (PT+SP+CO) Intemal(PE+UR+UE+TPC+PD)
.45 .6l .58 .59
All correlations p < .OOI. Drug use frequency = average of marijuana, cocaine, crack, benzodiazepines, uppers. heroin, LSD, other hallucinogens, and poppers use frequency.
232
J -\klES
on the IDTS
I” f !;) (:: = ;,
CoEL?nation of substance:’ Alcohol and marijuana (n Cocaine and marijuana (n LSD and marijuana (It Heroin and marijuana (n LSD and heroin (n Categories of drug users Marijuana (n (n Hard drugs
Alcohol
et al.
drugs of choice. as indicated
Table 1. .Adolescents’ One substance Marijuana Alcohol Cocaine
R. XlcRAY
= = = = = =
‘) IO) 13) 9) I) I)
= 32): = 30):
(n = 15):
Marijuana as drug of choice. LSD, heroin. or cocaine. or one of these in combination with marijuana as drug(s) of choice. Alcohol or alcohol/marijuana as drug(s) of choice.
IDTS, some subjects listed two drugs.2 Drugs and combinations of drugs given by the subjects are listed in Table 4. Subjects were divided into three groups on the basis of their most frequently used substance(s): Marijuana, Hard Drugs, and Alcohol. This categorization system was chosen to distinguish subjects who were primarily involved with alcohol or marijuana from those who were frequent users of harder drugs such as cocaine and LSD. Multivariate analysis of variance (MANOVA) demonstrated that, overall. drug use was more frequent in the Hard Drugs group (Wilkes’ Lambda = .29, F( 18.53) = 7.25, p < .OOl), Univariate analyses revealed that those in the Hard Drugs group reported more frequent use of marijuana, cocaine, crack, benzodiazepines, heroin, LSD. other hallucinogens. MDA, and poppers than those in the other two groups (r, < .05). Although frequency of use was generally somewhat higher in the Alcohol group than in the Marijuana group, the differences were not significant (Wilkes’ Lambda = .80. F( l&53) = .72. ns; univariate tests also all ns). Differences between the three groups in reasons for substance use were first evaluated using MANOVA, with drug group as the independent variable and IDTS scores as the dependent variables. There was a significant difference between groups (Wilkes’ Lamda = .65, F( 16, 134) = 2.04, p = .015). Univariate analyses also showed that the groups differed significantly on each IDTS scale. As can be seen in Table 5. the Hard Drugs group had higher IDTS scores than the Alcohol group on all eight scales, and higher scores than the Marijuana group on seven scales. The Marijuana and Alcohol groups did not differ significantly on any IDTS scale. The rankings of reasons for use in each group nere similar with the exception of Social Pressure to Use. Subjects in the Hard Drugs group rated social pressure as the most important determinant of their use, whereas those in the Marijuana and Alcohol groups ranked it third and fourth, respectively. This did not prove to be a statistically significant difference according to the Tukey test for pairwise comparisons, however. As was the case with the who!e sample, subjects in each group rated positive reasons as more important determinants of their substance use than negative reasons. ‘Three
subjects
did not indicate
what drug they were filling out the IDTS about
‘33
Adolescent drug use
Table 5. IDTS scale scores for Marijuana. Alcohol. and Hard Drug groups Marijuana (n = 32)
IDTS Scale Pleasant times with others Social pressure to use Pleasant emotions Urges/temptations to use Unpleasant emotions Testing personal control Contlict with others Physical discomfort
2.88 x2*** 2.69* 2.43** 2.35* 1’1’ _._ 2.00** 1.84*
Alcohol (N = 15)
Hard Drugs (n = 30)
F
P
3.21 3.41 3.15 3.09 2.94 2.61 2.74 2.28
3.5 12s 4.1 6.0 5.3 4.2 6.1 4.5
.035 ,000 ,021 ,004 .007 ,020 ,003 ,015
2.53* x3*** 2.39** 3 7,** -._ 2.13** 1.95** 2.01* I.708
klarijuana and Alcohol groups did not differ significantly on any IDTS scale. Asterisks denote the degree to which these groups differed from the Hard Drugs group: * p < .05: **p < .Ol: ***p < .OOl.
Specificity qf reasons.for drug use To determine the specificity of the IDTS, scores on the four summary scales were correlated separately for Marijuana and Hard Drugs groups with frequency of marijuana and hard drug use. The results are presented in Table 6. For the most part, there was good correspondence between the substances for which the IDTS was filled out and the frequency of use of those substances. In the group that filled out the IDTS about their marijuana use. the IDTS summary scales were more highly correlated with frequency of marijuana use than with hard drug use. In the Hard Drugs group, on the other hand, the IDTS summary scales were more highly correlated with frequency of hard drug use than with marijuana use. Because there were only 15 adolescents in the Alcohol group. the correlations between their IDTS scores and substance use are not included in Table 6. In the Hard Drugs group, the Negative Reasons summary scale was more highly correlated with frequency of hard drug use than the Positive Reasons summary scale (.60 vs. .28). The difference between the two correlations was significant (Hotelling test for difference between two nonindependent correlations, t(27) = 2.66, p < .Ol). In the Marijuana group, on the other hand, the four reasons for use summary scales were correlated about equally with frequency of marijuana use.
Table 6. Correlations between IDTS summary scale scores and drug use by drug of choice groups IDTS summary scales
Frequency of drug use Marijuana
hlarijuana subjects (n = 32) .52** Positive .42’ Negative .54** Interpersonal .50** Internal Hard Drugs subjects (n = 30) .05 Positive .I6 Negative -.02 Interpersonal .25 Internal
Hard Drugs .21 .30 25 .26 .28 .60’** .50** .54**
23-l
J -\XlES
R. McK.4\’
et al.
DISCUSSION
A sample of 93 incarcerated adolescents provided self-reports of their frequency of drug use in the 4 months prior to incarceration. Subjects also completed the Inventory of Drug-Taking Situations (IDTS, Annis & Martin, 1985). a questionnaire designed to assess attributions for drug use in adolescents. Most of the adolescents were frequent drug users, with many reporting use of multiple substances. The results of the study provide support for the reliability and validity of the IDTS, even when it is used with behaviorally disturbed adolescents like those incarcerated at the Training School. The IDTS scales had good internal consistency and higher scores were significantly associated with self-reports of drug use frequency. Furthermore. IDTS scores were most valid for the type of drug the measure was filled out about. The IDTS scores of those for whom marijuana was the drug of choice were correlated with their marijuana use but not their use of hard drugs. Similarly, the IDTS scores of those in the Hard Drugs group lvere correlated with their use of hard drugs but not their use of marijuana. It should be noted, however, that these results may not generalize to less disturbed adolescents. Additional studies with other groups of adolescents will be needed to fully determine the psychometric properties of the IDTS. The adolescents in this sample tended to attribute their use of drugs to positive rather than negative reasons, and to interpersonal rather than internal reasons. In other words, the adolescents were more likely to say they used drugs when feeling good or while out with friends and less likely to attribute their drug use to unpleasant emotions, interpersonal conflict, physical discomfort, or urges to use. Their reported reasons for use were therefore more similar to those given by high school students (Johnston & O’Malley. 1986) than to the attributions of relapsed adult alcoholics (Maisto et al., 1988; Marlatt 61 Gordon, 1985). Adolescents who were frequent users of hard drugs consistently had higher scores on the IDTS scales than those whose drug of choice was either marijuana or alcohol. This replicates the Johnston & O’Malley (1986) study, in which heavy users tended to endorse a greater number of reasons for substance use. The groups were not significantly different, however. on their ranking of the relative importance of each category of reasons for use. In this particular sample of adolescents, the relative importance of various reasons for substance use therefore did not differ as a function of drug of choice. Summary scales measuring negative, positive, internal, and interpersonal reasons for use were all about equally correlated with frequency of drug use. However, in the most heavily drug-involved adolescents (those in the Hard Drugs group), negative reasons were much more strongly correlated with hard drug use than positive reasons. This suggests that these adolescents may have particular difficulty coping with interpersonal conflicts and unpleasant internal states, such as depression, guilt, anger, or anxiety, without resorting to the use of drugs. Annis and Davis (1989) have suggested that the adult version ofthe IDTS, the Inventory of Drinking Situations (IDS), can be used as an aid to planning treatment for alcoholics. High scores on IDS scales suggest areas that need to be targeted for therapeutic interventions, and when the eight scale scores are plotted to form a profile, they give alcoholics visual representations of their vulnerabilities. When treating conduct disordered adolescents with drug abuse problems, an IDTS profile may be a good place to start. Adolescents might be more likely to respond to visual depictions of how they think about their substance use than to verbal information provided by the therapist.
Adolescent drug use
235
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Behaviors. 13, 79-82.
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Marlatt. G. A., & Gordon, J. R. (Eds.). (1985). Relapse prevention: Mainlenance slrategies in the treatmem ofaddick~e behaviors. New York: Guilford Press. Needle. R. H., Jou. S., & Su. S. S. (1989). The impact ofchanging methods ofdata collection on the reliability of self-reported drug use of adolescents. American Jor&al if Drug and Alcohol Abuse. 15.275-289. Needle. R. H.. McCubbin, H.. Lorence, J.. & Hochhauser. M. (1983). Reliability and valididv of adolescent self-reported drug use in a family-based study: A methodological report. Thelnfernafiona? Journalojthe Addicrions. l&90 l-9 12. O’iMalley, P. M.. Bachman, J. G.. &Johnston, L. D. (1983). Reliability and consistency in self-reportsofdrug use. The Inrernarional Journal olthe Addictions. 18, 805-824. Reich, W.. & Welner. Z. (1988). Revised versionofche DICAjoradole~cemsage 13-17. St. Louis: Washington University. Wechsler, H., & Rohman, M. (198 I). Extensive users of alcohol among college students. Journal ofSmdies on Alcohol, 42, 149-155.