- Email: [email protected]
Religiosity and Substance Use and Abuse Among Adolescents in the National Comorbidity Survey
Religiosity and Substance Use and Abuse Among Adolescents in the National Comorbidity Survey LISA MILLER, PH.D., MARK DAMES, M.P.H.,
AND
STEVEN GREENWALD, M.S.
ABSTRACT ObJsCtive:To replicate previous findings among adutts of an inverse association between religiosity and substance use among a nationally representative sample of adolescents. Method: Subjects were 676 (328 female and 348 male) addescents in the National Como~idltySurvey who were assessed for substance use and abuse with the Composite International Diagnostic Interview.Religosty was assessed through affiliation with religious denomination and through responseto 7 questions concerning belief and practice. Results: Confirmatory factor analyses replicated in adolescents the 2 religiosity factors of personal devotion and personal conservatism previously identified by Kendler among adults, although the 2 factors were more highly correlated in addescents than in adults. Personal devotion (a personal relationship with the Divine) and affiliationwith more fundamentalist religious denominations were inversely associated with substance use and substance dependence or abuse across a range of substances (alcohol, marijuana, cocaine, or any contraband drug). Personal conservatism (a personal commitment to teaching and living according to creed) was inversely associated with use of alcohol only. Conclusion: Low levels of religiosity may be associated with adolescent onset of substance use and abuse.J. Am. Acad, ChiM Ado/esc. Psychiatry; 2O00,39(9):1190-1197. Key Words: substance dependence, substance abuse, religion, adolescents, National Comorbidity Survey.
Adolescent substance use and dependence has been shown to predict adult substance abuse (Glantz, 1992; Nurco et al., 1997), highlighting the importance of prevention and treatment for substance use and dependence during adolescence. Prevention and treatment for adolescent substance use and dependence can be facilitated through the identification of related risk factors and protective factors. Risk factors identified to date include parental substance abuse, substance use by peers or siblings, sibling deviancy, and a parenting style of affectionless-control; protective factors include involvement in family activity, cohesive Family structure, cultural norms of abstinence, and religion (Catalano et al., 1992; Dusenbury et al., 1992; Foxcroft A c c t p d March 24, 2000. From the Division of Clinicaland Generic Epidemiology and the Division of Child and Adahscent Psychiany, Columbia UnivmityoNew York. The National Comorbidiq Survcy (NCS) data collcrn'on was supported by NIMH grant ROIMH46376 with supplemental support from NIDA and the W T GMnt Foundation (grant 9O13513O). Dr Millcr is supported in p a n by the W T Grant Faculty Scholan Award. The authors thank the rrvirwcn, Dr. Ronald Kcss&r and Dr. Kenneth Kmdlcr, f i r comments on a prior draj of this anich; in particular, thcy thank Dr Kesshrfor sharing data f m m the NCS, Reprint requests to Dr. M i l k Unit 24, NYSI'I, I051 Rivmidt Drive, New York. NY 10032; r-mail: [email protected]. 0890-8567/00/3909-1190020000 by the American Academy of Child and Adolacent Psychiatry.
1190
and Lowe, 1995; Pritchard and Martin, 1996; Segal and Stewart, 1996; W a l l a c e and Badunan, 1991).This investigation focuses specifically on the protective effects of religiosity (broadly defined to include religious belief and practice) against adolescent substance use and abuse. In community samples of adolescents, a protective effect of religiosity against substance use and abuse (most commonly in studies pertaining to alcohol use and abuse) has been established (Amoatengand Bahr, 1986; Catalano et al., 1992; Dusenbury et al., 1992; Foxcroft and Lowe, 1995; Hanson and Engs, 1987; Kent, 1990) with respect to the 3 most frequently investigated variables: personal importance, frequent attendance, and religious denomination. The personal importance of religion was inversely associated with degree of alcohol consumption and use of substances (Amoateng and Bahr, 1986; Faulkner et al., 1989). Frequent attendance of religious services was inversely associated with degree of alcohol consumption, drinking to the point of intoxication, medical problems related to alcohol consumption, and early onset of substance use (Arnoateng and Bahr, 1986; Faulkner et al., 1989; Francis, 1997; Long and Boik, 1993). Adolescents who ascribe to the more fundamentalist of Christian denominations had a later age of onset of alcohol use and
1. A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 , S E P T E M B E R ZOO0
RELIGION A N D SUBSTANCE ABUSE
were more likely to abstain from drinking, as were adolescents of Protestant compared with Catholic denominations (Catalan0 et al., 1992;Dusenbury et al., 1992;Francis, 1997; Parket al., 1990). Generally in the literature, these findings on religiosity and substance use are interpreted to arise from religious coping, defined as the implementation of cognitive and behavioral techniques which are rooted in religion or spirituality (such as prayer, confession, or seeking SUP~OK fiom G d ) to manage suessfd life events (Pargament, 1997, for a review). (For religious reasons, the first author does not write in full the name of G-d.) This study attempts to replicate among adolescents research findings in adults that empirically validate 2 dimensions of religiosity: personal devotion (representing an active personal relationship with the Divine) and personal conservatism (representing a personal choice to teach and adhere closely to creed, in some cases initiated through a “born-again”experience) (Kendler et al., 1997). Kendler derived these 2 dimensions of religiosity from research on a large sample of adult female twins born in Virginia who were predominantly of Christian denominations (mean age = 30.1 years, SD = 7.6). Among Kendler‘s adults, personal devotion and personal conservatism were positively associated with a third dimension of religiosity, institution mnservatism-defined as the degree of fundamentalism in a religious denomination. All 3 dimensions of religiosity were inversely associated with use of cigarettes and alcohol and inversely associated with lifetime diagnosis of nicotine and alcohol dependence. However, specifically among substance users, an inverse association with substance dependence was not found for personal conservatism, only for personal devotion and institutional conservatism. Kendler’s genetic-epidemiological findings might be viewed as consistent with treatment factors in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), the most prevalent forms of treatment in the United States for substance abuse (Hasin and Grant, 1995; Weisner et al., 1995). Consistent with Kendler‘s construct of personal devotion, essential to AA or NA is a partnership with a Higher Power that involves awareness of a benevolent and absolute force, 2-way communication, and personal responsibility (Booth, 1995). Case reports of recovery in AA also highlight strict adherence to the rules, with help, and reinforcement and instruction coming from fellow members in the treatment community (Kus, 1995), consistent with Kendler’s notion of personal conservatism. The reported centrality of personal
devotion and personal conservatism to recovery from substance abuse merits their investigation as protective factors against onset of substance use and substance dependence or abuse in adolescence. In this study we attempt to replicate Kendler‘s findings among a nationally representative sample of adolescents assessed in the National Comorbidity Survey (NCS) (Kessler et al., 1994). We specifically ask the following questions: (1) Are personal devotion and personal conservatism valid dimensions of religiosity among adolescents? (2) Are personal devotion, personal Conservatism, and institutional conservatism inversely associated with substance use and DSM-III-R diagnosis of substance dependence or abuse among adolescents? METHOD Sample
T h e study uses data from adolacents in the NCS, a nationally q r e sentative household survey designed to study patterns and correlates of psychiatric morbidity and comorbidity &der et al., 1994).T h e NCS interviewed 8,098respondents between the ages of 15 and 54 years. T h e mponse rate was 82.4%. Interviews were carried out hx-to-ficc in the homes of the respondens. All participants in the NCS were informed of the procedures of the study and gave written informed consent. (For a complete description of dx sample, see Kessler et d.,1994.) Adolcxents aged 15 to 19 years ( N =676;328 female and 348 male) who responded to all 7 of the religiosity items were included. Mean age was 17.0years (SD = 1.41);272 were middle adolacents aged 15 to 16 years and 404 were late adolescents aged 17 to 19 years. Forty-men percent had graduated from high school; mean family income was $33,427(SD = $34,810).Rates of ethnicity were as follows: 65.4% white, 15.5% African American, 16.7% Hispanic, and 2.4% other. Rates of religious denomination were as follows: 9.5% fundamentalist Protestant, 9% mainline Protestant, 25.1% Baptist, 34.8% Roman Catholic, 13.8% other denominations, and 7.8% none. Measures Diagnosis was based on a version of the World Health Organization Composite International Diagnostic Interview (CIDI) version 1.O (World Health Organization, 1990),a fully structured diagnostic interview designed for use by lay interviewers, modified specifidly for use in the NCS (see Kessler et al., 1994,for a complete description). The CIDI has been shown in a number of studies to have good to excellent reliability (see Wittchen, 1994,for a review). T h e CIDI exclusion NICS were used, such that subjects responding negatively to a screening question were not asked about related symptoms. In this study, substance use was assessed on the basis of the following: ever used alcohol, marijuana, or wcaine; agc of first use of each substance; frequency of use of each substance during the past year; greatest number of alcoholic drinks consumed at one time; the number of uses of marijuana and cocaine during the past year. Diagnosis of substance dependence and substance abuse, as a single category, was criteria. based on DSM-111-R Religiosity was assessed by using responses to the 7 items summarizcd in Table 1. Six of these questions were asked by Kcndlcr et al.
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 39:9, SEPTEMBER 2 0 0 0
1191
MILLER E T AL.
TABLE 1 Factor Loadings of the Two-Factor Model"A m o n g Adolexents in the National Comorbidity Survey Factor Personal Devotion
Item
Personal Conservatism
How important are religious or spiritual beliefs in your daily life?
0.71
Ob
How often do you attend religious services?
0.63
06
W h e n you have problems in your life how often do you seek spiritual comfort?
0.75
Ob
W h e n you have decisions to make in your daily life, how often do you ask yourself what G d would want you to do?
0.8 1
06
Have you bccn "born again" that is had a turning point in your life when you commit yourself to Jesus?
Ob
0.65
Do you encourage people to believe in Jesus and accept Him as their Savior?
Ob
0.78
The Bible is the actual Word of G-d and is to be taken literally, word for word. (extent agree or disagree)
Ob
0.34
Norc: Confirmatory factory analyscs assuming Thurnston simple structure. Correlation between the 2 factors is r = 0.77, p < .01. Kcndlcr et al.. 1997. Fixed at 0.
(1997). A religiosity item asked in the NCS but not in the Virginia w i n study was, "Doyou encourage people to belirve in Jesus and to accept Him as their Savior?"This item was predicted to load onto personal conservatism. Following the scale developed by the Institute for Social Rcscuch and used by Kcndlcr cf al. (1997), religious denomination was ordered along a continuum of institutional conservatism creating 5 groups: (1) fundamentalist Protestant, (2) Baptist, (3) mainline Protestant, (4) Roman Catholic, and (5) other or unaffiliated.
Statistical Methods Confirmatory factor analysa of the religiosity items using LISREL 7.1 (Joreskog and Sorbom, 1981) were conducted replicating the factor structure previously identified by Kcndlcr et al. (1997). The factor model was estimated in the entire sample and in the samples jointly stratified by gender and by agc (adolescents younger than 17 ycars versus adolcscents 17 ycars or older). Two factors were assumed on the basis of Kcndlcr's finding, and the additional question in the NCS was assumed to load onto the factor of personal conservatism. Factor 1, personal devotion, contained the first 4 items listed in Table 1; factor 2, personal conservatism, contained the last 3 items listed in Table 1. The following parameters were estimated: factor loadings for each item, excepting 2 items (the forth and seventh items listed in Table 1) to give the factors scale; and the variancc-cwariance matrix of the factors. As there is no consensus regarding which goodness-offit measure is best, we report the most commonly reported mcasurcs: the adjusted goodness-of-fit index and the root mean square residual. No external validity had been established for the scales on the original items; therefore, factor scoreswere generated by adding the items which loaded on each of the 2 factors and then transforming the factor scorn to z scores. Degree of substance use for each substance (alcohol, marijuana, cocaine, and any contraband drug) was regressed (simple linear or simple logistic model)on each of the 3 religious variables using SAS (SAS InStitutC, 1988). DSM-III-Rdiagnosis of substance dependence or abux of each substance (alcohol, marijuana, cocaine, or any contraband drug) was rcgrased (simple logistic model) on the same set of predictor variables.
1192
RESULTS Dimensions of Religiosity
Confirmatory factor analysis using the Thurnston simple structure for the 2 factors shows the adjusted goodness-of-fit index to be greater than or equal to 0.9 and the root mean square residual to be less than or equal to 0.09, both in the overall sample and in each of the age by gender strata. Table 1 displays the factor loadings for the entire sample. The 2 factors correlate at the level of r = 0 . 7 7 , c~ .01. Mean z scores on personal devotion were higher for girls (mean = 0.11, SD = 1.0) than for boys (mean = -0.11, SD = 1.O) (t= 2.97, df = 670, p c .005) but did not differ between middle adolescents (mean = -0.3, SD = 0.95) and older adolescents (mean = 0.01, SD = 1.03) ( t =0.58, df= 670, p = .56). Mean z scores on personal conservatism were higher for girls (mean = 0.06, SD = 1.O) than for boys (mean = -0.06, SD = 1.0) (t = 1.67, df = 670,p = .09) at the level of a trend and were higher for older adolescents (mean = 0.08, SD = 1.0) ( t =2.58, df= 670,p c .01) than for middle adolescents (mean = -0.12, SD = 1.O). Personal devotion and personal conservatism declined monotonicallyacross the 5 categories of institutional conservatism, as was found by Kendler et al. (1997). Mean scores of personal devotion and personal conservatism, respectively, were as follows: for hdamentalist Protestant, 0.87 (SD = 0.70) and 0.44 (SD = 0.87); for Baptist, 0.16 (SD = 0.89) and 0.42 (SD = 0.77); fbr mainline Protestant, 0.07 (SD = 1.04) and 0.28 (SD = 0.92); for Catholic, -0.29 (SD = 0.97) and -0.49 (SD = 1.01); for other
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . S E P T E M B E R 2000
R E L I G I O N A N D SUBSTANCE ABUSE
denominations, -0.69 (SD = 0.97) and -0.75 (SD = 0.77); for unaffiliated, -0.01 (SD = 1.01) and -0.17 (SD = 1.02). Institutional conservatism did not vary by sex or age. The Pearson correlation between institutional conservatism and personal devotion was r = 0.37 ( p < .01) and between institutional conservatism and personal conservatism was r = 0.46 ( p < .01).
Personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with use of marijuana or cocaine. An increase of a standard deviation in personal devotion or institutional conservatism, respectively, was found to be associated with a 43% and 17% decreased likelihood of having ever used marijuana and a 50% and 42% decreased likelihood of having ever used cocaine.
Religiosity and Substance Use
Table 2 displays the results of regression analyses in which each of the 3 religiosity variables is used to predict degree of substance use (alcohol, marijuana, and cocaine) controlling for age and sex. All 3 dimensions of religiosity were found to be inversely associated with degree of alcohol consumption. An increase of a standard deviation unit along any of the 3 dimensions of religiosity was associated with a decreased likelihood of between 18% and 38% of having consumed greater than 12 alcoholic drinks in the previous year. A standard deviation change in each dimension of religiosity also was associated with a f d l category shift along the 4category scale (mild, moderate, severe, very severe) of degree of alcohol use.
Religiosity and Substance Dependence or Abuse
Table 3 shows the adjusted odds ratios of a DSM-111-R diagnosis of substance dependence or abuse predicted for each of the 3 religiosity variables controlling for age and sex. Personal devotion and institutional conservatism, but not personal conservatism,were found to be inversely associated with substance dependence or abuse. An increase of a standard deviation in personal devotion was associated with a 33% to 41% decreased likelihood of a DSM-111-R diagnosis of substance dependence or abuse of alcohol, marijuana, any contraband drug, and, at the level of a statistical trend, cocaine. An increase of a standard deviation in institutional conservatism was associated with a 14% to 35% decreased likelihood of a DSM-111-R diagnosis of
TABLE 2 Substance Use and the Three Dimensions of Religiosity Among Adolescents in the National Comorbidity Survey
Alcohol use Age initial use (yr)" >12 Alcoholic drinks in past yearb Greatest consumption in past year".' Marijuana use Ever useb Age initial use (yr)" Frequency use (4 categories)".d Cocaine use Ever useb Age initial use (yr)' Frequency use (4 categories)
Personal Devotion
Personal Conservatism
Institutional Conservatism
0.16 (0.12) 0.62 (0.50-0.76)*** -1.20 (0.40)"
0.22 (O.ll)* 0.74 (0.61-0.90)" -0.88 (0.40)'
0.11 (0.10) 0.82 (0.69-0.97)' -0.91 (0.34)**
0.57 (0.47-0.70)*** 0.40 (0.22) -0.29 (0.18)
0.84 (0.70-1.02) 0.17 (0.20) -0.34 (0.29)
0.83 (0.70-0.98)' -0.05 (0.19) -0.14 (0.15)
0.50 (0.31-0.79)** 0.99 (0.39) -0.79 (0.39)t
0.78 (0.51-1.19) 0.30 (0.39) -0.16 (0.38)
0.58 (0.38-0.90)' -0.48 (0.37) -0.22 (0.36)
Note: Standardized regression coefficients reflecting the association berwcen each of the 3 dimensions of religiosity and substance use. Regression coefficients reflect a change in substance use associated with a standard deviation change in religiosity (e.g., 1 SD above the mean in personal devotion is associated with being 0.16 years older at the time of first alcohol use, a 38% decreased likelihood of having had greater than 12 drinks in the past year, and a 43% decreased likelihood of ever having used marijuana). Regression analyses control for age and sex, such that the general model is substance use = dimension of religiosity t age t sex. Logistic regression conducted with binary outcome variables (ever use and >12 drinks in past year). a Regression coefficient and standard error. Adjusted odds ratio and 95% confidence interval. Four-category scale of most alcohol consumption includes mild, moderate, severe, and very severe use. Four categories of frequency of substance use are rarely, moderate, frequent, and very frequent. t p < .l; ' p < .05; * * p< .01; * * * p< .001.
J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 3 9 : 9 . SEPTEMBER 2 0 0 0
1193
M I L L E R E T AL.
TABLE 3 Odds Ratios of DSM-111-R Diagnoses of Substance Dependence or Abuse Associated With Religiosity Among Adolescents in the NCS Personal Devotion
DSM-III-R Diagnosis Substance Dependence or Abuse
AOR
(95% CI)
Alcohol Marijuana Cocaine Any contraband drug
0.67 0.67 0.63 0.59
(0.51-0.85) (0.53-0.85) (0.37-1.02) (0.48-0.72)
Personal Conservatism
x2 10.51"' 10.89"' 3.44t 25.52"'
Institutional Conservatism
AOR
(95YoCI)
2'
AOR
0.83 0.93 0.86 0.86
(0.65-1.06) (0.74-1.16) (0.53-1.39) (0.71-1.04)
2.20 0.43 0.40 2.27
0.65 0.88 0.65 0.86
(95%CI) (0.51-0.83) (0.71-1.08) (0.39-1.07) (0.72-1.02)
x2 11.99"' 1.46 2.55t 2.76t
Note: Logistic regression analyses were conducted controlling for age and sex. The general model for logistic regression was DSM-111-R diagnosis = dimension of religiosity + age + sex. Odds ratios represent the likelihood of substance dependence or abuse associated with a standard deviation increase in religiosity. For example, a standard deviation increase in personal devotion is associated with a 67% likelihood (or a 33% decrease in likelihood) of alcohol dependence or abuse.
tp<.1;***p<.001.
substance dependence or abuse of alcohol and, at the level of statistical trend, cocaine or any contraband drug. DISCUSSION
The results of these analyses showed the following: (1) the 2 religiosity dimensions of personal devotion and personal conservatism were more highly correlated among adolescents than in previous studies of adults; (2) personal devotion, personal conservatism, and institutional conservatism were inversely associated with degree of alcohol consumption; (3)personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with use of contraband drugs; and (4) personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with substance dependence or abuse. Contrasting these findings to those of Kendler in his study of adults may yield insight into the developmental path of the association between religiosity and substance use and abuse. Development of Personal Devotion and Personal Conservatism
Whereas personal devotion and personal conservatism were only mildly correlated ( r = 0.33) among Kendler's sample of adults, they were highly correlated ( T = 0.77) among adolescents. There also was a relatively greater association between institutional conservatism and the 2 other religiosity dimensions, personal devotion ( r = 0.37 versus r = 0.18) and personal conservatism ( r = 0.46 versus r = 0.38) among adolescents compared with adults. There were no significant differences in the magnitude of these correlations by gender among adolescents in the NCS, suggesting that age rather than gender may account for the differences in findings between the 2 studies. 1194
The relatively greater association between the 3 dimensions of religiosity in adolescence potentially represents a process of developmental religiosity. Through mutual facilitation the 3 dimensions initially may be formed, later to be followed by a process of differentiation. An example of mutual facilitation might be that involvement in a fundamentalist denomination encourages adolescents to understand daily experience as part of G d s plan, which in turn fosters a relationship with G-d, defined in the research literature as personal devotion. Kendler et al. (1997) found that approximately 29% of the differences between adults in strength of personal devotion are attributable to heritable factors. If personal devotion is in part determined by nonenvironmental fictors, then participation in religious denomination may clari+, define, or augment an innate awareness of G d . Subsequent differentiation between the 3 dimensions of religiosity is consistent with developmental theory by Fowler (1981), who holds that late adolescence and early adulthood marks a window of questioning, modification, or disregard of religious beliefs adopted in childhood from family, peers, and community. Fowler posits that this individuation process hinges on the adolescent's emerging capacity to evaluate religious beliefs on the basis of personal religious experience. That the differences in the findings between adolescents in the NCS and adults in Kendleis study may reflect a path of developmental religiosity gains empirical support from previous research showing a similar path in moral development. Stillwell et al. (1996) show early adult separation-individuation to prompt clarification of personal values, in juxtaposition against those values transmitted from family and community. This process of moral individuation relies on an internal moral sense that is cultivated in childhood through assimilating familial
J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 9 : 9 , S E P T E M B E R 2000
RELIGION A N D SUBSTANCE ABUSE
and community values-a process similar to mutual facilitation between religious denomination and personal devotion. Parallels between process in moral development and findings of this study support the proposed course of developmental religiosity. Specific Protective Effects Against Substance Use and Abuse
Given the relative lack of differentiation between personal devotion, personal conservatism, and institutional conservatism in adolescents, it is noteworthy that (1) the 3 factors showed distinct protective qualities, and (2) the specific protective qualities were largely consistent with Kendler’s findings in adults. Personal devotion and institutional conservatism were strongly inversely associated with the use of a range of substances (alcohol, marijuana, cocaine, or any contraband drug) and strongly inversely associated with substance dependence or abuse; personal conservatism was only moderately inversely associated with alcohol use and was not associated with drug use or substance dependence or abuse. Similarly, among Kendler’s adults all 3 dimensions were inversely associated with substance use, but only personal devotion and institutional Conservatism were inversely associated with degree of substance use or substance dependence among substance users. Kendler infers from his findings that each of “the dimensions of religiosity may have an impact at different points in the causal pathway to substance use and abuse. Traditional religious beliefs may be most important in the decision to ever use a substance, but religious devotion may particularly influence the ability to quit or maintain low levels of use” (Kendler et al., 1997, p. 327). Personal conservatism moreover was inversely associated with alcohol use only, not the more t a b and illicit drug use, suggesting among adolescents its limitations even as a gateway to substance use. Unique protective qualities and specific protective mechanisms within each dimension might be understood on the basis of case reports, theory, and previous research. Personal conservatism, defined as close adherence to creed or liturgy (as in the case of AA), may foster structured living through definitive rules and offer absolute beliefs prohibiting substance use (Kus, 1995). While case reports on adults highlight rigid standards of behavior as useful in recovery from crisis and in prevention against relapse, often adolescents have yet to “bottom-out” (reach a turning point due to personal loss or despair) in the lifetime course of substance abuse. The data from this study suggest that rigid rules may not protect against adolescent
onset of substance dependence or abuse among substance users. Clearly defined rules may buttress resistance to temptation, but once transgressed, such rules seem not to address moderation of substance use. Research on specific protective mechanisms associated with institutional conservatism (relative religious fundamentalism) among adults has identified optimism (Sethi and Seligman, 1993), a sense of purpose (Pargament, 1997), a network of social support based on religious values (Koenig et d., 1988), clarification of personal responsibility (Pargament, 1997; Ti and Frazier, 1998), and the possibility for forgiveness and redemption following substance use or misuse (Park et al., 1990). Personal devotion (representing a personal relationship to the Divine) has been shown in previous research to resolve feelings of loneliness, to fortify regard for self and others (see Natale, 1986, for a review; Sobson, 1978), and to substantiate meaning (Pargament, 1997). Case reports on AA and NA suggest that personal devotion enhances a sense of harmony and engenders spiritual fulfillment. If not fostered through personal devotion, yearnings for transcendence may motivate substance use and abuse (Kus, 1995).These recent case reports echo the view of the early psychologist William James (1904), who understood sub stance use as an attempt to experience a Divine force: The sway of alcohol over mankind is unquestionably due to its power to stimulate the mystical faculties of human nature. . . drunkenness expands, unites and says yes. It is in fact the great exciter of the Yes function in man (p. 304).
Development and Magnitude of Protective Effects
A striking difference between the findings of this study and those of Kendler is in the magnitude of the association between religiosity and substance dependence or abuse. Among Kendler’s sample, a standard deviation increase in any of the 3 dimensions of religiosity was associated with a 18% to 19% decrease in the likelihood of “problem drinking.’’ Among adolescents in the NCS, a standard deviation increase in either personal devotion or degree of religious fundamentalism, respectively, was associated with a 33% and 35% decreased likelihood of a DSM-I..-Rdiagnosis of alcohol dependence or abuse; personal devotion was found to be associated with a 33% decreased likelihood of marijuana dependence or abuse and a 41% decreased likelihood of any contraband drug dependence or abuse. The magnitude of the association between religiosity and substance dependence, therefore, is approximately twice as great in adolescence as in adulthood.
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . SEPTEMBER 2 0 0 0
1195
M I L L E R ET AL.
One potential explanation for the greater protective effect of religiosity in adolescents compared with adults might be understood through Oemng and colleagues’primary socialization theory (Oetting et d., 1998). Oetting et al. assert that religion fosters resilience in adolescence insofir as religion shapes the ‘primary socialization sources” surrounding an adolescent, specifically family, peers, and school. Primary socialization theory might suggest, for example, that adolescents of fundamentalist denominations have peers who do not drink, attend a school with structured activities not involving alcohol, and have parents who socialize without consuming alcohol. Quite apart from what Oetting et al. refer to as the “direct effect” of religion on adolescents, the social world of adolescents in hdamentalist communities may mitigate opportunity for substance use and provide alternative communal activities. Within this account, the relatively greater protective effect of religiosityagainst substance use among adolescents is but an artifact of the tendency of primary socialization sources to exert greater impact on the lifestyle of adolescents compared with adults. Another potential explanation for the relatively greater magnitude of the protective effect of religiosity against sub stance use and abuse among adolescents might be imputed to the direct effect of religiosity. Adolescents, compared with adults, are more likely to be searching for meaning, purpose, and identity, all of which may be addressed by religiosity (see Hyde, 1990, for an extensive review). Groeschel (1983) posits that adolescents are in a developmental window of spiritual “awakening and struggle.” If unaddressed by religion, the heightened desire for transcendence in adclescence may pose a particular risk of substance use. Both explanations of the findings, whether understood through primary socialization theory or by a direct effect of religiosity, may be valid and complementary. For instance, an adolescent of a fundamentalist denomination may both have peers who do not drink and have peers who by speaking about G-d help foster in the adolescent a sense of personal devotion, which in turn exerts a direct effect against substance use. Limitations
Limitations surrounding the use of the NCS to address the stated questions include the following: (1) a direction in the findings cannot be inferred from a cross-sectional study; (2) a potential mediating effect of psychosocial variables (such as parenting style or personality) could not be 1196
investigated as these variables were not central to the goals of the NCS; and (3) findings in a predominantly white Christian sample cannot be generalized to adolescents of non-Christian denomination or of other ethnicities. That the Virginia twin sample is entirely female and born in the South might prompt caution in comparing the findings between the 2 studies. It is unlikely, however, that gender or regionalism account for the contrast in the findings between the 2 studies because (1) there were no significant differences between male and female adolescents in the NCS in factor structure or in the magnitude of the correlations between the factors; and (2) there is a strong similarity between the 2 studies in the pattern of the correlations between the 3 dimensions of religiosity and substance use and abuse. Conclusion
The magnitude of the inverse association between religiosity and substance abuse is approximately twice as great among adolescents as among adults. A 33% to 4 1 % decreased likelihood of substance dependence or abuse and a 47% to 50% decreased likelihood of substance use was associated with a standard deviation increase in personal devotion. A 35% decreased likelihood of alcohol dependence or abuse and a 17% to 42% decreased likelihood of substance use was associated with a standard deviation increase in institutional conservatism. Personal conservatism (to include literal interpretation of the Bible, being “born-again,” and proselytizing) was inversely associated with alcohol use but was not associated with drug use or DSM-III-R diagnosis of substance dependence or abuse. Adolescent onset of substance use and abuse therefore may be intertwined with spiritual yearning or a need for spiritually informed “primary socialization sources,” such as parents, school, or peers. Adolescent onset of substance use and abuse predicts severity of lifetime course of illness (Glantz, 1992; Nurco et al., 1997). In light of the findings of this study, the etiology of this downward spiral may involve an ongoing reciprocal-influence process that degrades religiosity and increases substance use. Low levels of religiosity may be associated with adolescent onset of substance dependence, which precludes normative developmental religiosity, in turn mitigating the protective qualities of religiosity against severity of course-a conceptualization of lifetime course of substance abuse as a “progressivespiritual illness” (Royce, 1995).
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . S E P T E M B E R ZOO0
RELIGION A N D SUBSTANCE ABUSE
Clinical Implications
Treatment for recovery from substance abuse through AA or NA emphasizes the importance of building a relationship with a Higher Power (a form of personal devotion) and of joining a community of people who sustain shared convictions, beliefs, and code of conduct (a dimension of institutional conservatism). In light of the findings of this study, adolescents at high risk (such as those already using substances) might be protected from substance dependence or abuse if they engage with a Higher Power or become involved in a religious community. The data from this study show adolescent substance use and abuse to be inversely associated with both a personal experience of G-d and involvement in relatively fundamentalist denominations. No association was found between substance abuse and a rigid adherence to creed. In contrast to AA or NA for adults who have already "bottomed-out," prevention interventions for adolescents might avoid rigid endorsement of rules, encouraging instead the potential individuation process underlying developmental religiosity: namely, questioning beliefs and rules based on personal religious experience. REFERENCES Amoateng AY, Bahr SJ (1986). Religion, family and adolescent drug abux. Sociol Pmpert 29:53-76 Booth L (1995),A new understanding of spirituality. In: Spirituality and ChemiralDeprndrncy, Kus RJ, ed. Ncw York: Haworrh Prcss Catalan0 R. Morrison D, Wells E, Gillmor M (1992). Ethnic differences in family factors rclatcd to early drug initiation. JStudAlrohol53:208-217 Duscnbury L, Kerner J. Bakcr E. Botvin G (1992), Prcdictors of smoking prcvalcncc among New York Latino youth. Am Jpltblir Health 8255-58 Faulkner KK. Acorn JD, Garvin RB (1989),Prediction of alcohol consumption among frarcrnity pledges. JAlroholDrug Eaur 34: 12-20 FowlerJ (1981).StagesofFaith: ThrI'sychologyofHuman Developmmtandthr Quesrfir Meaning. San Francisco: Harper & Row Foxcroft DR, Lowe G (1995).Adolcxcnr drinking, smoking and othcr substance use involvement: links with pcrccivcd family life.J A d O k 18:159-I77 Francis LJ (1997),Thc impact of personality and rcligion on attitude towards substance use among 13-15 year olds. DrugAlroholDeprnd44:95-103 Glann M D (1992),A dcvclopmcnral psychopathology model of drug abusc vulncrability. In: Vulnerability w Drug Abure, Glann M, Pickens R, cds. Washington, DC:American Psychological Association Groeschel BJ (1983), Spiritual Passages: The Rychology of Spiritual Developmcnt, New York: Crossroads Hanson DJ, Engs RC (1987),Religion and collegiate drinking problems over time. I'syrholo~24:lO-12 H v i n DS, Grant BF (1995).h4 and othcr hclp sccking for alcohol problcms: formcr drinkers in thc US gcncral population. JSubst Abuse 7:281-292
Hyde K (1990), Religion in Childhood and Adolesrmcc. Birmingham, AL: Religion Education Press James W (1904). The Vurirrics of Religiow Expcrimre, Neibur R. ed. New York: Macmillan, 1961 JoreskogKG, Sorbom P (1981),LISREL Usm Gu&. Cambridge, MA: National Educational Rcscarch Kcndlcr KS, Gardner C O , Prcscott CA (1997), Rcligion, psychopathology and substance ux and abuse: a multimeasure. genetic-epidemiologic study. Am JPsychiatry 154322-329 Kent R (1990).Thc rcligiosity and parendchild socialization conncction with adolacent substance abux. In: Pamt-Adohscent Rehtionships. Barber B, Rollins B, eds. Lanham, MD: University Prcss of America, pp 143-165 Kcsslcr RC, McGonaglc KA, Zhao S, Nelson CB (1994), Lifctimc and 12month prcvalcncc of DSM-III-R psychiatric disorders in thc Unitcd Stara. Arch G m I'sychiatry 5 1:8-19 Kocnig HG. George LK, Sicglcr I C (1988).T h c usc of religion and other emotion-regulating coping strategies among older adults. Gerontologist 28:303-310 Kus RJ (1995). Praycr and meditation in addiction rccovery. In: Spirituality and Chemical Drpmdcncy, Kus RJ. cd. Ncw York: Hawonh Pras Long KA, Boik RJ (1993),Prcdicting alcohol use in rural children: a longirudinal study. Nun Res 42:79-86 Natale SM (1986). Loneliness and Spiritual Growth. Birmingham, AL: Religious Education Press Nurco DN. Hanlon TE, OGrady KE, Kinlock TW (1997),The early emerF n c e of narcotic addict typcs. Am JDrugAlcoholAbwc 23:523-542 Ocrting ER. Deffenbachcr JL, Donnermeyer JF (1998),Primary socialization theory: thc role playcd by personal traits in the etiology of drug usc and deviance, 11. Subst Use Misuse 33: 1337-1366 Pargamcnt LI (1997), The I'sychologv of Religion and Coping: Theory. Research and Rartice. New York Guilford Park CL, Cohen LH. Hcrb L (1990).Intrinsic religiousness and religious coping as life strcss modcrators for Catholics versus Protestants. J P m Soc Psychol54:55 1-577 Pritchard ME, Martin MJ (1996), Factors associated with alcohol use in young children. Subst LJseMiswc 3 1 : 6 7 9 6 8 9 Royce JE (1995).Thc cffccts of alcoholism and recovery on spirituality. In: S p i r i d q and C h i r a l D+cy, Kus RJ, ed. New York Haworrh Press SAS Institute (1988),SAS Languuge Gu& (Rehaw 6.03 Editions). Cary, NC: SAS Institutc Segal BM. Stewart J C (1996), Substance use and abuse in adolescence: an overview. Child Psychiatry Hum Dev 26: 193-2 10 Serhi S , Seligman MEP (1993). Optimism and fundamcntalism. Rycho1.G 4:256259 Sobson J G (1978),Lonelincss and faith. JPsychol Theolou 61:104-109 Stillwcll BM, Galvin M. Kopta SM. Padgen RJ (1936).Moral valuation: a third domain of conscicnce functioning. J A m Acad Child Adohsc Psychiaty 35:23&239 Tix AP. Frazier PA (1998),Thc usc of rcligious coping during stressful life events: main cffccts, moderation, and mediation. J Consult CIin Psycho1 66411-422 Wallacc JM, Bachman JG (1991).Explaining racial/cthnic differences in adolescent drug usc: rhc impact of background and lifcsryle. Soc Probl 38:333-357 Weisner C. GrcenfieldT, R w m R (1995).Trcnds in the treatment of alcohol problcms in the US gcncral population, 1979 through 1990. Am /Public Health 85:55-60 Wirrchen HU (1994),Reliability and validity srudics of thc WHO-Composite lntcrnational Diagnostic Interview (CIDI): a critical review. JAychiam Rrr 28:57-84 World Hcalth Organization (1990). Composite International Diagnostic Intrwinu (CIDI), Vmion 1.0. Gencva: World Health Organization
J . A M , A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y . 3 9 : 9 . S E P T E M B E R ZOO0
1197
AND
STEVEN GREENWALD, M.S.
ABSTRACT ObJsCtive:To replicate previous findings among adutts of an inverse association between religiosity and substance use among a nationally representative sample of adolescents. Method: Subjects were 676 (328 female and 348 male) addescents in the National Como~idltySurvey who were assessed for substance use and abuse with the Composite International Diagnostic Interview.Religosty was assessed through affiliation with religious denomination and through responseto 7 questions concerning belief and practice. Results: Confirmatory factor analyses replicated in adolescents the 2 religiosity factors of personal devotion and personal conservatism previously identified by Kendler among adults, although the 2 factors were more highly correlated in addescents than in adults. Personal devotion (a personal relationship with the Divine) and affiliationwith more fundamentalist religious denominations were inversely associated with substance use and substance dependence or abuse across a range of substances (alcohol, marijuana, cocaine, or any contraband drug). Personal conservatism (a personal commitment to teaching and living according to creed) was inversely associated with use of alcohol only. Conclusion: Low levels of religiosity may be associated with adolescent onset of substance use and abuse.J. Am. Acad, ChiM Ado/esc. Psychiatry; 2O00,39(9):1190-1197. Key Words: substance dependence, substance abuse, religion, adolescents, National Comorbidity Survey.
Adolescent substance use and dependence has been shown to predict adult substance abuse (Glantz, 1992; Nurco et al., 1997), highlighting the importance of prevention and treatment for substance use and dependence during adolescence. Prevention and treatment for adolescent substance use and dependence can be facilitated through the identification of related risk factors and protective factors. Risk factors identified to date include parental substance abuse, substance use by peers or siblings, sibling deviancy, and a parenting style of affectionless-control; protective factors include involvement in family activity, cohesive Family structure, cultural norms of abstinence, and religion (Catalano et al., 1992; Dusenbury et al., 1992; Foxcroft A c c t p d March 24, 2000. From the Division of Clinicaland Generic Epidemiology and the Division of Child and Adahscent Psychiany, Columbia UnivmityoNew York. The National Comorbidiq Survcy (NCS) data collcrn'on was supported by NIMH grant ROIMH46376 with supplemental support from NIDA and the W T GMnt Foundation (grant 9O13513O). Dr Millcr is supported in p a n by the W T Grant Faculty Scholan Award. The authors thank the rrvirwcn, Dr. Ronald Kcss&r and Dr. Kenneth Kmdlcr, f i r comments on a prior draj of this anich; in particular, thcy thank Dr Kesshrfor sharing data f m m the NCS, Reprint requests to Dr. M i l k Unit 24, NYSI'I, I051 Rivmidt Drive, New York. NY 10032; r-mail: [email protected]. 0890-8567/00/3909-1190020000 by the American Academy of Child and Adolacent Psychiatry.
1190
and Lowe, 1995; Pritchard and Martin, 1996; Segal and Stewart, 1996; W a l l a c e and Badunan, 1991).This investigation focuses specifically on the protective effects of religiosity (broadly defined to include religious belief and practice) against adolescent substance use and abuse. In community samples of adolescents, a protective effect of religiosity against substance use and abuse (most commonly in studies pertaining to alcohol use and abuse) has been established (Amoatengand Bahr, 1986; Catalano et al., 1992; Dusenbury et al., 1992; Foxcroft and Lowe, 1995; Hanson and Engs, 1987; Kent, 1990) with respect to the 3 most frequently investigated variables: personal importance, frequent attendance, and religious denomination. The personal importance of religion was inversely associated with degree of alcohol consumption and use of substances (Amoateng and Bahr, 1986; Faulkner et al., 1989). Frequent attendance of religious services was inversely associated with degree of alcohol consumption, drinking to the point of intoxication, medical problems related to alcohol consumption, and early onset of substance use (Arnoateng and Bahr, 1986; Faulkner et al., 1989; Francis, 1997; Long and Boik, 1993). Adolescents who ascribe to the more fundamentalist of Christian denominations had a later age of onset of alcohol use and
1. A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 , S E P T E M B E R ZOO0
RELIGION A N D SUBSTANCE ABUSE
were more likely to abstain from drinking, as were adolescents of Protestant compared with Catholic denominations (Catalan0 et al., 1992;Dusenbury et al., 1992;Francis, 1997; Parket al., 1990). Generally in the literature, these findings on religiosity and substance use are interpreted to arise from religious coping, defined as the implementation of cognitive and behavioral techniques which are rooted in religion or spirituality (such as prayer, confession, or seeking SUP~OK fiom G d ) to manage suessfd life events (Pargament, 1997, for a review). (For religious reasons, the first author does not write in full the name of G-d.) This study attempts to replicate among adolescents research findings in adults that empirically validate 2 dimensions of religiosity: personal devotion (representing an active personal relationship with the Divine) and personal conservatism (representing a personal choice to teach and adhere closely to creed, in some cases initiated through a “born-again”experience) (Kendler et al., 1997). Kendler derived these 2 dimensions of religiosity from research on a large sample of adult female twins born in Virginia who were predominantly of Christian denominations (mean age = 30.1 years, SD = 7.6). Among Kendler‘s adults, personal devotion and personal conservatism were positively associated with a third dimension of religiosity, institution mnservatism-defined as the degree of fundamentalism in a religious denomination. All 3 dimensions of religiosity were inversely associated with use of cigarettes and alcohol and inversely associated with lifetime diagnosis of nicotine and alcohol dependence. However, specifically among substance users, an inverse association with substance dependence was not found for personal conservatism, only for personal devotion and institutional conservatism. Kendler’s genetic-epidemiological findings might be viewed as consistent with treatment factors in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), the most prevalent forms of treatment in the United States for substance abuse (Hasin and Grant, 1995; Weisner et al., 1995). Consistent with Kendler‘s construct of personal devotion, essential to AA or NA is a partnership with a Higher Power that involves awareness of a benevolent and absolute force, 2-way communication, and personal responsibility (Booth, 1995). Case reports of recovery in AA also highlight strict adherence to the rules, with help, and reinforcement and instruction coming from fellow members in the treatment community (Kus, 1995), consistent with Kendler’s notion of personal conservatism. The reported centrality of personal
devotion and personal conservatism to recovery from substance abuse merits their investigation as protective factors against onset of substance use and substance dependence or abuse in adolescence. In this study we attempt to replicate Kendler‘s findings among a nationally representative sample of adolescents assessed in the National Comorbidity Survey (NCS) (Kessler et al., 1994). We specifically ask the following questions: (1) Are personal devotion and personal conservatism valid dimensions of religiosity among adolescents? (2) Are personal devotion, personal Conservatism, and institutional conservatism inversely associated with substance use and DSM-III-R diagnosis of substance dependence or abuse among adolescents? METHOD Sample
T h e study uses data from adolacents in the NCS, a nationally q r e sentative household survey designed to study patterns and correlates of psychiatric morbidity and comorbidity &der et al., 1994).T h e NCS interviewed 8,098respondents between the ages of 15 and 54 years. T h e mponse rate was 82.4%. Interviews were carried out hx-to-ficc in the homes of the respondens. All participants in the NCS were informed of the procedures of the study and gave written informed consent. (For a complete description of dx sample, see Kessler et d.,1994.) Adolcxents aged 15 to 19 years ( N =676;328 female and 348 male) who responded to all 7 of the religiosity items were included. Mean age was 17.0years (SD = 1.41);272 were middle adolacents aged 15 to 16 years and 404 were late adolescents aged 17 to 19 years. Forty-men percent had graduated from high school; mean family income was $33,427(SD = $34,810).Rates of ethnicity were as follows: 65.4% white, 15.5% African American, 16.7% Hispanic, and 2.4% other. Rates of religious denomination were as follows: 9.5% fundamentalist Protestant, 9% mainline Protestant, 25.1% Baptist, 34.8% Roman Catholic, 13.8% other denominations, and 7.8% none. Measures Diagnosis was based on a version of the World Health Organization Composite International Diagnostic Interview (CIDI) version 1.O (World Health Organization, 1990),a fully structured diagnostic interview designed for use by lay interviewers, modified specifidly for use in the NCS (see Kessler et al., 1994,for a complete description). The CIDI has been shown in a number of studies to have good to excellent reliability (see Wittchen, 1994,for a review). T h e CIDI exclusion NICS were used, such that subjects responding negatively to a screening question were not asked about related symptoms. In this study, substance use was assessed on the basis of the following: ever used alcohol, marijuana, or wcaine; agc of first use of each substance; frequency of use of each substance during the past year; greatest number of alcoholic drinks consumed at one time; the number of uses of marijuana and cocaine during the past year. Diagnosis of substance dependence and substance abuse, as a single category, was criteria. based on DSM-111-R Religiosity was assessed by using responses to the 7 items summarizcd in Table 1. Six of these questions were asked by Kcndlcr et al.
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 39:9, SEPTEMBER 2 0 0 0
1191
MILLER E T AL.
TABLE 1 Factor Loadings of the Two-Factor Model"A m o n g Adolexents in the National Comorbidity Survey Factor Personal Devotion
Item
Personal Conservatism
How important are religious or spiritual beliefs in your daily life?
0.71
Ob
How often do you attend religious services?
0.63
06
W h e n you have problems in your life how often do you seek spiritual comfort?
0.75
Ob
W h e n you have decisions to make in your daily life, how often do you ask yourself what G d would want you to do?
0.8 1
06
Have you bccn "born again" that is had a turning point in your life when you commit yourself to Jesus?
Ob
0.65
Do you encourage people to believe in Jesus and accept Him as their Savior?
Ob
0.78
The Bible is the actual Word of G-d and is to be taken literally, word for word. (extent agree or disagree)
Ob
0.34
Norc: Confirmatory factory analyscs assuming Thurnston simple structure. Correlation between the 2 factors is r = 0.77, p < .01. Kcndlcr et al.. 1997. Fixed at 0.
(1997). A religiosity item asked in the NCS but not in the Virginia w i n study was, "Doyou encourage people to belirve in Jesus and to accept Him as their Savior?"This item was predicted to load onto personal conservatism. Following the scale developed by the Institute for Social Rcscuch and used by Kcndlcr cf al. (1997), religious denomination was ordered along a continuum of institutional conservatism creating 5 groups: (1) fundamentalist Protestant, (2) Baptist, (3) mainline Protestant, (4) Roman Catholic, and (5) other or unaffiliated.
Statistical Methods Confirmatory factor analysa of the religiosity items using LISREL 7.1 (Joreskog and Sorbom, 1981) were conducted replicating the factor structure previously identified by Kcndlcr et al. (1997). The factor model was estimated in the entire sample and in the samples jointly stratified by gender and by agc (adolescents younger than 17 ycars versus adolcscents 17 ycars or older). Two factors were assumed on the basis of Kcndlcr's finding, and the additional question in the NCS was assumed to load onto the factor of personal conservatism. Factor 1, personal devotion, contained the first 4 items listed in Table 1; factor 2, personal conservatism, contained the last 3 items listed in Table 1. The following parameters were estimated: factor loadings for each item, excepting 2 items (the forth and seventh items listed in Table 1) to give the factors scale; and the variancc-cwariance matrix of the factors. As there is no consensus regarding which goodness-offit measure is best, we report the most commonly reported mcasurcs: the adjusted goodness-of-fit index and the root mean square residual. No external validity had been established for the scales on the original items; therefore, factor scoreswere generated by adding the items which loaded on each of the 2 factors and then transforming the factor scorn to z scores. Degree of substance use for each substance (alcohol, marijuana, cocaine, and any contraband drug) was regressed (simple linear or simple logistic model)on each of the 3 religious variables using SAS (SAS InStitutC, 1988). DSM-III-Rdiagnosis of substance dependence or abux of each substance (alcohol, marijuana, cocaine, or any contraband drug) was rcgrased (simple logistic model) on the same set of predictor variables.
1192
RESULTS Dimensions of Religiosity
Confirmatory factor analysis using the Thurnston simple structure for the 2 factors shows the adjusted goodness-of-fit index to be greater than or equal to 0.9 and the root mean square residual to be less than or equal to 0.09, both in the overall sample and in each of the age by gender strata. Table 1 displays the factor loadings for the entire sample. The 2 factors correlate at the level of r = 0 . 7 7 , c~ .01. Mean z scores on personal devotion were higher for girls (mean = 0.11, SD = 1.0) than for boys (mean = -0.11, SD = 1.O) (t= 2.97, df = 670, p c .005) but did not differ between middle adolescents (mean = -0.3, SD = 0.95) and older adolescents (mean = 0.01, SD = 1.03) ( t =0.58, df= 670, p = .56). Mean z scores on personal conservatism were higher for girls (mean = 0.06, SD = 1.O) than for boys (mean = -0.06, SD = 1.0) (t = 1.67, df = 670,p = .09) at the level of a trend and were higher for older adolescents (mean = 0.08, SD = 1.0) ( t =2.58, df= 670,p c .01) than for middle adolescents (mean = -0.12, SD = 1.O). Personal devotion and personal conservatism declined monotonicallyacross the 5 categories of institutional conservatism, as was found by Kendler et al. (1997). Mean scores of personal devotion and personal conservatism, respectively, were as follows: for hdamentalist Protestant, 0.87 (SD = 0.70) and 0.44 (SD = 0.87); for Baptist, 0.16 (SD = 0.89) and 0.42 (SD = 0.77); fbr mainline Protestant, 0.07 (SD = 1.04) and 0.28 (SD = 0.92); for Catholic, -0.29 (SD = 0.97) and -0.49 (SD = 1.01); for other
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . S E P T E M B E R 2000
R E L I G I O N A N D SUBSTANCE ABUSE
denominations, -0.69 (SD = 0.97) and -0.75 (SD = 0.77); for unaffiliated, -0.01 (SD = 1.01) and -0.17 (SD = 1.02). Institutional conservatism did not vary by sex or age. The Pearson correlation between institutional conservatism and personal devotion was r = 0.37 ( p < .01) and between institutional conservatism and personal conservatism was r = 0.46 ( p < .01).
Personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with use of marijuana or cocaine. An increase of a standard deviation in personal devotion or institutional conservatism, respectively, was found to be associated with a 43% and 17% decreased likelihood of having ever used marijuana and a 50% and 42% decreased likelihood of having ever used cocaine.
Religiosity and Substance Use
Table 2 displays the results of regression analyses in which each of the 3 religiosity variables is used to predict degree of substance use (alcohol, marijuana, and cocaine) controlling for age and sex. All 3 dimensions of religiosity were found to be inversely associated with degree of alcohol consumption. An increase of a standard deviation unit along any of the 3 dimensions of religiosity was associated with a decreased likelihood of between 18% and 38% of having consumed greater than 12 alcoholic drinks in the previous year. A standard deviation change in each dimension of religiosity also was associated with a f d l category shift along the 4category scale (mild, moderate, severe, very severe) of degree of alcohol use.
Religiosity and Substance Dependence or Abuse
Table 3 shows the adjusted odds ratios of a DSM-111-R diagnosis of substance dependence or abuse predicted for each of the 3 religiosity variables controlling for age and sex. Personal devotion and institutional conservatism, but not personal conservatism,were found to be inversely associated with substance dependence or abuse. An increase of a standard deviation in personal devotion was associated with a 33% to 41% decreased likelihood of a DSM-111-R diagnosis of substance dependence or abuse of alcohol, marijuana, any contraband drug, and, at the level of a statistical trend, cocaine. An increase of a standard deviation in institutional conservatism was associated with a 14% to 35% decreased likelihood of a DSM-111-R diagnosis of
TABLE 2 Substance Use and the Three Dimensions of Religiosity Among Adolescents in the National Comorbidity Survey
Alcohol use Age initial use (yr)" >12 Alcoholic drinks in past yearb Greatest consumption in past year".' Marijuana use Ever useb Age initial use (yr)" Frequency use (4 categories)".d Cocaine use Ever useb Age initial use (yr)' Frequency use (4 categories)
Personal Devotion
Personal Conservatism
Institutional Conservatism
0.16 (0.12) 0.62 (0.50-0.76)*** -1.20 (0.40)"
0.22 (O.ll)* 0.74 (0.61-0.90)" -0.88 (0.40)'
0.11 (0.10) 0.82 (0.69-0.97)' -0.91 (0.34)**
0.57 (0.47-0.70)*** 0.40 (0.22) -0.29 (0.18)
0.84 (0.70-1.02) 0.17 (0.20) -0.34 (0.29)
0.83 (0.70-0.98)' -0.05 (0.19) -0.14 (0.15)
0.50 (0.31-0.79)** 0.99 (0.39) -0.79 (0.39)t
0.78 (0.51-1.19) 0.30 (0.39) -0.16 (0.38)
0.58 (0.38-0.90)' -0.48 (0.37) -0.22 (0.36)
Note: Standardized regression coefficients reflecting the association berwcen each of the 3 dimensions of religiosity and substance use. Regression coefficients reflect a change in substance use associated with a standard deviation change in religiosity (e.g., 1 SD above the mean in personal devotion is associated with being 0.16 years older at the time of first alcohol use, a 38% decreased likelihood of having had greater than 12 drinks in the past year, and a 43% decreased likelihood of ever having used marijuana). Regression analyses control for age and sex, such that the general model is substance use = dimension of religiosity t age t sex. Logistic regression conducted with binary outcome variables (ever use and >12 drinks in past year). a Regression coefficient and standard error. Adjusted odds ratio and 95% confidence interval. Four-category scale of most alcohol consumption includes mild, moderate, severe, and very severe use. Four categories of frequency of substance use are rarely, moderate, frequent, and very frequent. t p < .l; ' p < .05; * * p< .01; * * * p< .001.
J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 3 9 : 9 . SEPTEMBER 2 0 0 0
1193
M I L L E R E T AL.
TABLE 3 Odds Ratios of DSM-111-R Diagnoses of Substance Dependence or Abuse Associated With Religiosity Among Adolescents in the NCS Personal Devotion
DSM-III-R Diagnosis Substance Dependence or Abuse
AOR
(95% CI)
Alcohol Marijuana Cocaine Any contraband drug
0.67 0.67 0.63 0.59
(0.51-0.85) (0.53-0.85) (0.37-1.02) (0.48-0.72)
Personal Conservatism
x2 10.51"' 10.89"' 3.44t 25.52"'
Institutional Conservatism
AOR
(95YoCI)
2'
AOR
0.83 0.93 0.86 0.86
(0.65-1.06) (0.74-1.16) (0.53-1.39) (0.71-1.04)
2.20 0.43 0.40 2.27
0.65 0.88 0.65 0.86
(95%CI) (0.51-0.83) (0.71-1.08) (0.39-1.07) (0.72-1.02)
x2 11.99"' 1.46 2.55t 2.76t
Note: Logistic regression analyses were conducted controlling for age and sex. The general model for logistic regression was DSM-111-R diagnosis = dimension of religiosity + age + sex. Odds ratios represent the likelihood of substance dependence or abuse associated with a standard deviation increase in religiosity. For example, a standard deviation increase in personal devotion is associated with a 67% likelihood (or a 33% decrease in likelihood) of alcohol dependence or abuse.
tp<.1;***p<.001.
substance dependence or abuse of alcohol and, at the level of statistical trend, cocaine or any contraband drug. DISCUSSION
The results of these analyses showed the following: (1) the 2 religiosity dimensions of personal devotion and personal conservatism were more highly correlated among adolescents than in previous studies of adults; (2) personal devotion, personal conservatism, and institutional conservatism were inversely associated with degree of alcohol consumption; (3)personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with use of contraband drugs; and (4) personal devotion and institutional conservatism, but not personal conservatism, were inversely associated with substance dependence or abuse. Contrasting these findings to those of Kendler in his study of adults may yield insight into the developmental path of the association between religiosity and substance use and abuse. Development of Personal Devotion and Personal Conservatism
Whereas personal devotion and personal conservatism were only mildly correlated ( r = 0.33) among Kendler's sample of adults, they were highly correlated ( T = 0.77) among adolescents. There also was a relatively greater association between institutional conservatism and the 2 other religiosity dimensions, personal devotion ( r = 0.37 versus r = 0.18) and personal conservatism ( r = 0.46 versus r = 0.38) among adolescents compared with adults. There were no significant differences in the magnitude of these correlations by gender among adolescents in the NCS, suggesting that age rather than gender may account for the differences in findings between the 2 studies. 1194
The relatively greater association between the 3 dimensions of religiosity in adolescence potentially represents a process of developmental religiosity. Through mutual facilitation the 3 dimensions initially may be formed, later to be followed by a process of differentiation. An example of mutual facilitation might be that involvement in a fundamentalist denomination encourages adolescents to understand daily experience as part of G d s plan, which in turn fosters a relationship with G-d, defined in the research literature as personal devotion. Kendler et al. (1997) found that approximately 29% of the differences between adults in strength of personal devotion are attributable to heritable factors. If personal devotion is in part determined by nonenvironmental fictors, then participation in religious denomination may clari+, define, or augment an innate awareness of G d . Subsequent differentiation between the 3 dimensions of religiosity is consistent with developmental theory by Fowler (1981), who holds that late adolescence and early adulthood marks a window of questioning, modification, or disregard of religious beliefs adopted in childhood from family, peers, and community. Fowler posits that this individuation process hinges on the adolescent's emerging capacity to evaluate religious beliefs on the basis of personal religious experience. That the differences in the findings between adolescents in the NCS and adults in Kendleis study may reflect a path of developmental religiosity gains empirical support from previous research showing a similar path in moral development. Stillwell et al. (1996) show early adult separation-individuation to prompt clarification of personal values, in juxtaposition against those values transmitted from family and community. This process of moral individuation relies on an internal moral sense that is cultivated in childhood through assimilating familial
J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 9 : 9 , S E P T E M B E R 2000
RELIGION A N D SUBSTANCE ABUSE
and community values-a process similar to mutual facilitation between religious denomination and personal devotion. Parallels between process in moral development and findings of this study support the proposed course of developmental religiosity. Specific Protective Effects Against Substance Use and Abuse
Given the relative lack of differentiation between personal devotion, personal conservatism, and institutional conservatism in adolescents, it is noteworthy that (1) the 3 factors showed distinct protective qualities, and (2) the specific protective qualities were largely consistent with Kendler’s findings in adults. Personal devotion and institutional conservatism were strongly inversely associated with the use of a range of substances (alcohol, marijuana, cocaine, or any contraband drug) and strongly inversely associated with substance dependence or abuse; personal conservatism was only moderately inversely associated with alcohol use and was not associated with drug use or substance dependence or abuse. Similarly, among Kendler’s adults all 3 dimensions were inversely associated with substance use, but only personal devotion and institutional Conservatism were inversely associated with degree of substance use or substance dependence among substance users. Kendler infers from his findings that each of “the dimensions of religiosity may have an impact at different points in the causal pathway to substance use and abuse. Traditional religious beliefs may be most important in the decision to ever use a substance, but religious devotion may particularly influence the ability to quit or maintain low levels of use” (Kendler et al., 1997, p. 327). Personal conservatism moreover was inversely associated with alcohol use only, not the more t a b and illicit drug use, suggesting among adolescents its limitations even as a gateway to substance use. Unique protective qualities and specific protective mechanisms within each dimension might be understood on the basis of case reports, theory, and previous research. Personal conservatism, defined as close adherence to creed or liturgy (as in the case of AA), may foster structured living through definitive rules and offer absolute beliefs prohibiting substance use (Kus, 1995). While case reports on adults highlight rigid standards of behavior as useful in recovery from crisis and in prevention against relapse, often adolescents have yet to “bottom-out” (reach a turning point due to personal loss or despair) in the lifetime course of substance abuse. The data from this study suggest that rigid rules may not protect against adolescent
onset of substance dependence or abuse among substance users. Clearly defined rules may buttress resistance to temptation, but once transgressed, such rules seem not to address moderation of substance use. Research on specific protective mechanisms associated with institutional conservatism (relative religious fundamentalism) among adults has identified optimism (Sethi and Seligman, 1993), a sense of purpose (Pargament, 1997), a network of social support based on religious values (Koenig et d., 1988), clarification of personal responsibility (Pargament, 1997; Ti and Frazier, 1998), and the possibility for forgiveness and redemption following substance use or misuse (Park et al., 1990). Personal devotion (representing a personal relationship to the Divine) has been shown in previous research to resolve feelings of loneliness, to fortify regard for self and others (see Natale, 1986, for a review; Sobson, 1978), and to substantiate meaning (Pargament, 1997). Case reports on AA and NA suggest that personal devotion enhances a sense of harmony and engenders spiritual fulfillment. If not fostered through personal devotion, yearnings for transcendence may motivate substance use and abuse (Kus, 1995).These recent case reports echo the view of the early psychologist William James (1904), who understood sub stance use as an attempt to experience a Divine force: The sway of alcohol over mankind is unquestionably due to its power to stimulate the mystical faculties of human nature. . . drunkenness expands, unites and says yes. It is in fact the great exciter of the Yes function in man (p. 304).
Development and Magnitude of Protective Effects
A striking difference between the findings of this study and those of Kendler is in the magnitude of the association between religiosity and substance dependence or abuse. Among Kendler’s sample, a standard deviation increase in any of the 3 dimensions of religiosity was associated with a 18% to 19% decrease in the likelihood of “problem drinking.’’ Among adolescents in the NCS, a standard deviation increase in either personal devotion or degree of religious fundamentalism, respectively, was associated with a 33% and 35% decreased likelihood of a DSM-I..-Rdiagnosis of alcohol dependence or abuse; personal devotion was found to be associated with a 33% decreased likelihood of marijuana dependence or abuse and a 41% decreased likelihood of any contraband drug dependence or abuse. The magnitude of the association between religiosity and substance dependence, therefore, is approximately twice as great in adolescence as in adulthood.
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . SEPTEMBER 2 0 0 0
1195
M I L L E R ET AL.
One potential explanation for the greater protective effect of religiosity in adolescents compared with adults might be understood through Oemng and colleagues’primary socialization theory (Oetting et d., 1998). Oetting et al. assert that religion fosters resilience in adolescence insofir as religion shapes the ‘primary socialization sources” surrounding an adolescent, specifically family, peers, and school. Primary socialization theory might suggest, for example, that adolescents of fundamentalist denominations have peers who do not drink, attend a school with structured activities not involving alcohol, and have parents who socialize without consuming alcohol. Quite apart from what Oetting et al. refer to as the “direct effect” of religion on adolescents, the social world of adolescents in hdamentalist communities may mitigate opportunity for substance use and provide alternative communal activities. Within this account, the relatively greater protective effect of religiosityagainst substance use among adolescents is but an artifact of the tendency of primary socialization sources to exert greater impact on the lifestyle of adolescents compared with adults. Another potential explanation for the relatively greater magnitude of the protective effect of religiosity against sub stance use and abuse among adolescents might be imputed to the direct effect of religiosity. Adolescents, compared with adults, are more likely to be searching for meaning, purpose, and identity, all of which may be addressed by religiosity (see Hyde, 1990, for an extensive review). Groeschel (1983) posits that adolescents are in a developmental window of spiritual “awakening and struggle.” If unaddressed by religion, the heightened desire for transcendence in adclescence may pose a particular risk of substance use. Both explanations of the findings, whether understood through primary socialization theory or by a direct effect of religiosity, may be valid and complementary. For instance, an adolescent of a fundamentalist denomination may both have peers who do not drink and have peers who by speaking about G-d help foster in the adolescent a sense of personal devotion, which in turn exerts a direct effect against substance use. Limitations
Limitations surrounding the use of the NCS to address the stated questions include the following: (1) a direction in the findings cannot be inferred from a cross-sectional study; (2) a potential mediating effect of psychosocial variables (such as parenting style or personality) could not be 1196
investigated as these variables were not central to the goals of the NCS; and (3) findings in a predominantly white Christian sample cannot be generalized to adolescents of non-Christian denomination or of other ethnicities. That the Virginia twin sample is entirely female and born in the South might prompt caution in comparing the findings between the 2 studies. It is unlikely, however, that gender or regionalism account for the contrast in the findings between the 2 studies because (1) there were no significant differences between male and female adolescents in the NCS in factor structure or in the magnitude of the correlations between the factors; and (2) there is a strong similarity between the 2 studies in the pattern of the correlations between the 3 dimensions of religiosity and substance use and abuse. Conclusion
The magnitude of the inverse association between religiosity and substance abuse is approximately twice as great among adolescents as among adults. A 33% to 4 1 % decreased likelihood of substance dependence or abuse and a 47% to 50% decreased likelihood of substance use was associated with a standard deviation increase in personal devotion. A 35% decreased likelihood of alcohol dependence or abuse and a 17% to 42% decreased likelihood of substance use was associated with a standard deviation increase in institutional conservatism. Personal conservatism (to include literal interpretation of the Bible, being “born-again,” and proselytizing) was inversely associated with alcohol use but was not associated with drug use or DSM-III-R diagnosis of substance dependence or abuse. Adolescent onset of substance use and abuse therefore may be intertwined with spiritual yearning or a need for spiritually informed “primary socialization sources,” such as parents, school, or peers. Adolescent onset of substance use and abuse predicts severity of lifetime course of illness (Glantz, 1992; Nurco et al., 1997). In light of the findings of this study, the etiology of this downward spiral may involve an ongoing reciprocal-influence process that degrades religiosity and increases substance use. Low levels of religiosity may be associated with adolescent onset of substance dependence, which precludes normative developmental religiosity, in turn mitigating the protective qualities of religiosity against severity of course-a conceptualization of lifetime course of substance abuse as a “progressivespiritual illness” (Royce, 1995).
J . A M . A C A D . C H I L D A D O L E S C . PSYCHIATRY, 3 9 : 9 . S E P T E M B E R ZOO0
RELIGION A N D SUBSTANCE ABUSE
Clinical Implications
Treatment for recovery from substance abuse through AA or NA emphasizes the importance of building a relationship with a Higher Power (a form of personal devotion) and of joining a community of people who sustain shared convictions, beliefs, and code of conduct (a dimension of institutional conservatism). In light of the findings of this study, adolescents at high risk (such as those already using substances) might be protected from substance dependence or abuse if they engage with a Higher Power or become involved in a religious community. The data from this study show adolescent substance use and abuse to be inversely associated with both a personal experience of G-d and involvement in relatively fundamentalist denominations. No association was found between substance abuse and a rigid adherence to creed. In contrast to AA or NA for adults who have already "bottomed-out," prevention interventions for adolescents might avoid rigid endorsement of rules, encouraging instead the potential individuation process underlying developmental religiosity: namely, questioning beliefs and rules based on personal religious experience. REFERENCES Amoateng AY, Bahr SJ (1986). Religion, family and adolescent drug abux. Sociol Pmpert 29:53-76 Booth L (1995),A new understanding of spirituality. In: Spirituality and ChemiralDeprndrncy, Kus RJ, ed. Ncw York: Haworrh Prcss Catalan0 R. Morrison D, Wells E, Gillmor M (1992). Ethnic differences in family factors rclatcd to early drug initiation. JStudAlrohol53:208-217 Duscnbury L, Kerner J. Bakcr E. Botvin G (1992), Prcdictors of smoking prcvalcncc among New York Latino youth. Am Jpltblir Health 8255-58 Faulkner KK. Acorn JD, Garvin RB (1989),Prediction of alcohol consumption among frarcrnity pledges. JAlroholDrug Eaur 34: 12-20 FowlerJ (1981).StagesofFaith: ThrI'sychologyofHuman Developmmtandthr Quesrfir Meaning. San Francisco: Harper & Row Foxcroft DR, Lowe G (1995).Adolcxcnr drinking, smoking and othcr substance use involvement: links with pcrccivcd family life.J A d O k 18:159-I77 Francis LJ (1997),Thc impact of personality and rcligion on attitude towards substance use among 13-15 year olds. DrugAlroholDeprnd44:95-103 Glann M D (1992),A dcvclopmcnral psychopathology model of drug abusc vulncrability. In: Vulnerability w Drug Abure, Glann M, Pickens R, cds. Washington, DC:American Psychological Association Groeschel BJ (1983), Spiritual Passages: The Rychology of Spiritual Developmcnt, New York: Crossroads Hanson DJ, Engs RC (1987),Religion and collegiate drinking problems over time. I'syrholo~24:lO-12 H v i n DS, Grant BF (1995).h4 and othcr hclp sccking for alcohol problcms: formcr drinkers in thc US gcncral population. JSubst Abuse 7:281-292
Hyde K (1990), Religion in Childhood and Adolesrmcc. Birmingham, AL: Religion Education Press James W (1904). The Vurirrics of Religiow Expcrimre, Neibur R. ed. New York: Macmillan, 1961 JoreskogKG, Sorbom P (1981),LISREL Usm Gu&. Cambridge, MA: National Educational Rcscarch Kcndlcr KS, Gardner C O , Prcscott CA (1997), Rcligion, psychopathology and substance ux and abuse: a multimeasure. genetic-epidemiologic study. Am JPsychiatry 154322-329 Kent R (1990).Thc rcligiosity and parendchild socialization conncction with adolacent substance abux. In: Pamt-Adohscent Rehtionships. Barber B, Rollins B, eds. Lanham, MD: University Prcss of America, pp 143-165 Kcsslcr RC, McGonaglc KA, Zhao S, Nelson CB (1994), Lifctimc and 12month prcvalcncc of DSM-III-R psychiatric disorders in thc Unitcd Stara. Arch G m I'sychiatry 5 1:8-19 Kocnig HG. George LK, Sicglcr I C (1988).T h c usc of religion and other emotion-regulating coping strategies among older adults. Gerontologist 28:303-310 Kus RJ (1995). Praycr and meditation in addiction rccovery. In: Spirituality and Chemical Drpmdcncy, Kus RJ. cd. Ncw York: Hawonh Pras Long KA, Boik RJ (1993),Prcdicting alcohol use in rural children: a longirudinal study. Nun Res 42:79-86 Natale SM (1986). Loneliness and Spiritual Growth. Birmingham, AL: Religious Education Press Nurco DN. Hanlon TE, OGrady KE, Kinlock TW (1997),The early emerF n c e of narcotic addict typcs. Am JDrugAlcoholAbwc 23:523-542 Ocrting ER. Deffenbachcr JL, Donnermeyer JF (1998),Primary socialization theory: thc role playcd by personal traits in the etiology of drug usc and deviance, 11. Subst Use Misuse 33: 1337-1366 Pargamcnt LI (1997), The I'sychologv of Religion and Coping: Theory. Research and Rartice. New York Guilford Park CL, Cohen LH. Hcrb L (1990).Intrinsic religiousness and religious coping as life strcss modcrators for Catholics versus Protestants. J P m Soc Psychol54:55 1-577 Pritchard ME, Martin MJ (1996), Factors associated with alcohol use in young children. Subst LJseMiswc 3 1 : 6 7 9 6 8 9 Royce JE (1995).Thc cffccts of alcoholism and recovery on spirituality. In: S p i r i d q and C h i r a l D+cy, Kus RJ, ed. New York Haworrh Press SAS Institute (1988),SAS Languuge Gu& (Rehaw 6.03 Editions). Cary, NC: SAS Institutc Segal BM. Stewart J C (1996), Substance use and abuse in adolescence: an overview. Child Psychiatry Hum Dev 26: 193-2 10 Serhi S , Seligman MEP (1993). Optimism and fundamcntalism. Rycho1.G 4:256259 Sobson J G (1978),Lonelincss and faith. JPsychol Theolou 61:104-109 Stillwcll BM, Galvin M. Kopta SM. Padgen RJ (1936).Moral valuation: a third domain of conscicnce functioning. J A m Acad Child Adohsc Psychiaty 35:23&239 Tix AP. Frazier PA (1998),Thc usc of rcligious coping during stressful life events: main cffccts, moderation, and mediation. J Consult CIin Psycho1 66411-422 Wallacc JM, Bachman JG (1991).Explaining racial/cthnic differences in adolescent drug usc: rhc impact of background and lifcsryle. Soc Probl 38:333-357 Weisner C. GrcenfieldT, R w m R (1995).Trcnds in the treatment of alcohol problcms in the US gcncral population, 1979 through 1990. Am /Public Health 85:55-60 Wirrchen HU (1994),Reliability and validity srudics of thc WHO-Composite lntcrnational Diagnostic Interview (CIDI): a critical review. JAychiam Rrr 28:57-84 World Hcalth Organization (1990). Composite International Diagnostic Intrwinu (CIDI), Vmion 1.0. Gencva: World Health Organization
J . A M , A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y . 3 9 : 9 . S E P T E M B E R ZOO0
1197