J. DRUG EDUCATION, Vol.

33(1), 91-105, 2003

RISK, PROTECTION, AND SUBSTANCE USE IN

ADOLESCENTS: A MULTI-SITE MODEL

ELIZABETH SALE, PH.D.

EMT Associates, Inc.
SOLEDAD SAMBRANO, PH.D.
Center for Substance Abuse Prevention
J. FRED SPRINGER, PH.D.
EMT Associates, Inc.
CHARLES W. TURNER, PH.D.
Caliber Associates

ABSTRACT

This article reports findings from a national longitudinal cross-site evaluation

of high-risk youth to clarify the relationships between risk and protective
factors and substance use. Using structural equation modeling, baseline data
on 10,473 youth between the ages of 9 and 18 in 48 high-risk communities
around the nation are analyzed. Youth were assessed on substance use
(cigarette, alcohol, and marijuana use), external risk factors including family,
school, peer and neighborhood influences, and individual risk and protective
factors including self-control, family connectedness, and school connectedness. Findings indicate strong direct relationships between peer and parental
substance use norms and substance use. Individual protective factors, particularly family and school connectedness were strong mediators of individual
substance use. These findings suggest that multi-dimensional prevention
programming stressing the fostering of conventional anti-substance use attitudes among parents and peers, the importance of parental supervision, and
development of strong connections between youth and their family, peers,
and school may be most effective in preventing and reducing substance use
patterns among high-risk youth.

91
2003, Baywood Publishing Co., Inc.

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Substance use is increasingly recognized as one of the nation=s most pervasive,

costly, and challenging health and social problems. The use of alcohol and drug
has resulted in tens of thousands of deaths annually, with the estimated costs of
alcohol and drug abuse in terms of lost earnings alone is estimated to be over $200
billion dollars annually [1]. Additionally, the use, and particularly the early use, of
tobacco, alcohol, marijuana, and other illicit drugs is intricately entwined with
serious personal and social problems, including school failure, crime, family
violence and abuse, and a host of additional social and personal problems that
constitute a continuing national tragedy.
Over the past 30 years, prevention researchers have produced substantial
evidence documenting the relationship between individual and environmental
factors and adolescent substance abuse. The prevention field has clearly recognized the power of social normsthe attitudes and behaviors perceived to prevail
in the social environmentas an influence on youth behavior. Peer influence
is an often-cited reason that youth begin to use substances. Research has established peer attitudes and behaviors as one of the strongest correlates of selfreported substance use [2-7]. Broader social norms (conveyed in the media and
in advertising) and conventional family norms [8] have also been identified
as correlates of use, or resistance to use, among youth. In this study, the peer and
parental substance use-related influences are referred to as substance use norms.
Another related branch of research has focused upon external risk and
protective factors, or those influences in the external environment that go beyond
the direct effects of peer and parental normative influences. These external risk
and protective factors include family dysfunction, poor maternal mental health,
poor family supervision, poor parenting practices, poor school climate, and
neighborhood disorder [9-16]. This body of research has shown that youth who
felt alienated from positive social institutions (family, school, and positive
peers) due to negative environmental factors were more likely to experiment with
alcohol and drugs than youth more connected to positive institutions. Youth
feeling detached from their families, school, and positive peers find deviant peers
with whom they can connect, and these associations lead to early experimentation
and later abuse of cigarettes, alcohol, and other drugs.
Research on the relationships between external risk and protective factors and
adolescent substance use shows strong evidence that negative influences in
children=s lives affect their use patterns. However, it fails to explain why youth
from the same risk environments have different substance use behaviors. Several
researchers have focused on the importance of individual protective factors in
differentiating youth who used and those who did not, while still acknowledging
the important role of external risk factors. Research using an individual protective
factor framework has shown that individuals with social competency, autonomy,
self-control and self-efficacy, were less likely to use than their counterparts
[17-20]. Much of the resiliency research has emphasized the importance of
attachments to positive influences, such as a caring and trusted adult [17]. Most

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93

often this bonding is seen as an individual (internal) attribute, the young persons
belief that this external connection is meaningful to him or her. Developing a sense
of connectedness [21] to meaningful segments of the environment that provide
and support positive opportunities is an important aspect of the internal protective orientation of young people in high-risk environments. Protective factors
therefore represent the influences, orientations, and behaviors in youths lives
that contribute to positive development and help prevent negative behaviors and
outcomes such as substance use.
AN INTEGRATED MODEL OF ADOLESCENT
SUBSTANCE USE
The analyses in the present study incorporate much of the thinking presented
above regarding the important relationship between substance use norms, external
and internal risk and protective factors, and adolescent substance use. Our model
asserts that external and internal risk and protective factors all influence substance
use behaviors, and that it is the interrelationship between the internal and external
factors, particularly connectedness of youth to their families and school, that are
most critical.
This theory-driven model draws heavily from the work of Hawkins and Weis
[12] and Kumpfer and Turner [22]. Hawkins and Weis=s social development
model was created in the context of juvenile delinquency, and asserted that
the most important units of socialization, family, schools, peers, and community, influence behavior sequentially [12, p. 73]. Juvenile delinquency could
be reduced not by focusing upon single influences, but by examining the ways in
which factors emerge and interact during the different stages in youngsters
lives [12, p. 74]. More specifically, they posit that opportunities for involvement
and interaction must exist in order for youth to become attached and committed
to conventional social values. This attachment and commitment leads to positive
associations with peers, which leads to nondelinquent behaviors. Kumpfer and
Turners social development model supports this research using a sample of
mainly Caucasian youth living in the State of Utah (n = 1800) [22]. This model
recognized the role of family, school, and peers in determining substance use
behaviors among adolescents, and expands the model to include academic
efficacy, or a measure of the degree to which youth felt effective in school. The
present analysis is a further expansion of this research, using a large sample of
high-risk youth.
METHOD
The study uses data from the Center for Substance Abuse Prevention (CSAP)
National Cross-Site Evaluation of High Risk Youth Programs. Forty-eight highrisk youth demonstration programs, funded by CSAP in 1994 and 1995, across the

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nation participated in the study. Programs were implemented to prevent and

reduce the use of alcohol and other drugs among at-risk youth. The evaluation
used a quasi-experimental comparison group design to study the more than 6,000
youth who participated in the 48 demonstration programs, comparing them with
more than 4,500 similar youth in the same communities who were not participating in the programs. The study used the CSAP National Youth Survey (CNYS),
a survey of external and internal risk and protective factors, substance use norms,
and substance use patterns. Youth were interviewed in person either during a
class session for school-based programs, or in an after-school or community
setting for community-based programs by evaluation staff. Testing occurred at
program entry, program completion, six months after program completion, and
18 months after program completion. Youth received small incentives of a $5 cash
equivalent at each administration for participating in the survey. Interviews took
between 45 minutes and 1 2 hours depending upon the age of the youth.
Participants
Youth in the study ranged between the ages of 9 and 18, and more than half
(57 percent) between 11 and 13 years of age when they entered the study. This
concentration of youth in pre- and early-adolescence shows that the prevention
programs in the study recruited and served predominantly children perceived to be
at a transition point that put them at particular risk for substance use initiation.
It also reflects the fact that youth in early adolescence are still relatively accessible
for organized programming because they do not yet drive, hold part-time jobs, or
have the freedom of movement available to older teens.
Because 19 (40 percent) of the programs included in the study targeted female
adolescents exclusively, there are many more females (66 percent) than males
(34 percent) in the total sample. Females are slightly older than males (mean
female age = 12.84; male = 12.76). The programs served a diversity of racial/
ethnic groups. More than 33 percent of the youth were African American and
around 25 percent were Hispanic. Of the remaining youth, approximately
10 percent were Native American, 10 percent were Asian/Pacific Islander, and
10 percent were White/non-Hispanic. Some programs used recruitment procedures that targeted special populations, adding diversity to the youth sample.
Most programs recruited youth from high-risk settings: schools, neighborhoods,
housing developments, or youth organizations. As an alternative, several programs based participant selection on a common individual behavioral or personal
attribute. Specifically, two programs served youth who had been placed in a secure
facility by court order; two programs targeted youth with disabilities (physical and
developmental/emotional); one program focused on young women with histories
of sexual abuse; and one program focused on youth in the foster care system.
Looking at the total pool of youth in the cross-site sample reporting substance use during the previous 30 days at baseline, the rate of use is low (Figure 1).

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Figure 1. Self-reported 30-day substance use at baseline:

percentage of study sample (N = 10,473).

The most frequently reported substances used were alcohol (18 percent),
cigarettes (18.5 percent), and marijuana (14 percent). Relatively few youth
reported recent use of drugs such as cocaine or crack, speed, tranquilizers, PCP,
and heroin.
The use rates of youth in the cross-site sample were higher than those of the
general population of youth. Table 1 compares use rates of 12- to 17-year olds in
the study sample with those of youth who participated in the 1998 National
Household Survey on Drug Abuse (NHSDA), a randomly sampled general population survey of persons 12-years-old and older [23]. Use rates for the NHSDA
population are considerably lower than those of the cross-site sample, indicating
the high-risk nature of the cross-site sample. Although the circumstances of the
NHSDA and the National Cross-Site Evaluation data collection are not identical,
this comparison suggests that the cross-site programs served youth who were at
higher risk for initiating use when young.
To profile the sample, a composite measure of 30-day substance use was
constructed. This composite measure includes the use of any one of three
substancestobacco, alcohol, or marijuanawithin the past 30 days. Figure 2
displays the percentage of youth who reported substance use by age and gender
using this composite measure of 30-day use.
Use rates for younger children remain low until around age 13 and then rise
rapidly until age 16 for females and age 17 for males. Use rates across the age
groups are consistently higher among males than females. Substance use among

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Table 1. Comparison of NHSDA and Cross-Site Substance Use

for 12- to 17-Year-Old Respondents
30-Day cigarette use

30-Day alcohol use

NHSDA

Cross-site

NHSDA

Cross-site

NHSDA

Cross-site

12-13

8.0%

9.6%

4.9%

11.3%

1.7%

5.8%

14-15

18.2%

32.8%

20.9%

31.2%

8.8%

27.0%

16-17

29.3%

51.4%

32.0%

46.4%

14.7%

46.7%

Age

30-Day marijuana use

Note: National Household Survey on Drug Abuse (NHSDA) sample size for 12- to
17-year-olds (n = 6,778); Cross-Site sample size for 12- to 17-year-olds (n = 7,245).

Figure 2. Self-reported 30-day substance use at baseline

by age and gender (N = 10,473).

females levels off at age 16 and remains somewhat constant through age 18. Males
in the 16- and 17-year-old age groups are mainly from very high-risk sites serving
incarcerated males, which accounts for the high use pattern in the age group at
program entry. The lower 30-day use rates for 18-year-olds suggests that the older
youth who participated in the study programs were individuals who were not as
involved in recent drug use as the younger high-school aged youth.

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Measures
The CSAP National Youth Survey designed for the Cross-Site Evaluation
included items in four domains: substance use norms, external risk and protection,
internal risk and protection, and individual substance use. Substance use norms
measures included: 1) perceived parental attitudes toward their child substance
use; 2) perceived peer attitudes toward substance use; and 3) peer substance use.
External risk and protective factor measures included: 1) family supervision;
2) family communication; 3) school prevention environment, or the degree to
which schools convey prevention messages about substance use and positive
personal development; 4) community protection environment, or the degree to
which the respondent participates in organized opportunities in the community;
and 5) neighborhood risk, or the perceptions of neighborhood substance use,
crimes against persons and property. Internal risk and protective factors include
measures of: 1) family bonding; 2) school bonding; 3) self-efficacy; and
4) self-control.
Pathways of Influence among Risk and
Protective Factors and Substance Use
These interrelationships between substance use, substance use norms, external
risk and protive factors, and internal risk and protective factors, were explored
with structural equation modeling using LISREL [24]. Specifically, the pathways
of influence among the risk and protective factors and substance use that were
supported in earlier research were examined using this large sample of high-risk
youth. The model presented in Figure 3 is based on data from the full (both
participant and comparison youth) study sample at baseline.1
The model includes the array of risk and protection factors and substance use
norms described in the previous section.2 The model fits the data well (CFI =
0.90),3 meeting the high standard for good model fit in these kinds of analyses.
Modeling Decisions

To produce a parsimonious model and improve statistical fit, the number of

factors included in the model was reduced analytically. The number of internal
1

Multigroup analyses contrasting treatment and comparison youth demonstrated no substantial

differences in model fit or path coefficients, justifying use of the combined sample of youth at high risk.
All exogenous variables were allowed to correlate. For each latent construct, the items demonstrating
the strongest factor loadings were fixed to 1.0 to scale the latent factors [25].
2
The width of each arrow shaft indicates the strength of the association between the individual
protective factor and substance use; i.e., the degree to which higher protection on the factor relates to
less use. Wider arrows shafts are indicative of stronger relationships.
3
The Comparative Fit Index (CFI) statistic measures the goodness of fit. Models with indices of 0.90
or more are considered to be strong-fitting models.

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Figure 3. Structural equation model of risk and protection factors

and substance use among high-risk youth (N = 10,473).

factors was reduced to three: school connectedness, family connectedness, and

self-control. School connectedness, a newly constructed latent variable, is
composed of the school bonding and self-efficacy items, forming a single measure
that represents the importance of the school as a forum in which youth can realize
self-efficacy. Family connectedness is a latent variable that combines the original
family bonding measure with the family communication measure. The new
measure represents the importance of family as a forum for safe and supportive
communications during the developmental years. Self-control is maintained in
its original form.
In the external risk and protective factors domain, family supervision, school
prevention environment, community protection environment, and neighborhood
risk were included in the model. School performance, a factor combining selfreported measures of grades in school and school attendance, was added to the
model as a latent variable, mediating between school connectedness and peer
substance use. In the substance-use norm domain (parent and peer attitudes and
per use), the model asserts that substance-use norm measures mediate between
external and internal risk and protective factors and substance use. More specifically, the positioning of the peer norm measures (peer attitudes, peer substance
use) implies that the creation of positive friendship groups is an important

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consequence of family and school influences. Youth are involved in positive

peer groups because their families and schools have stressed the importance of
developing positive relationships with peers. The positioning of the parent norm
measure (parental attitudes) implies that family connectedness and family supervision create an environment in which parents= messages carry weight.
Interpreting the Model

The model in Figure 3 supports the relationship between risk and protection
factors and substance use, particularly the roles of family and school. Family
connectedness is a key to the substantial path of influence on substance use shown
in the model. When family connectedness is high, family supervision and parental
attitudes exert strong influences on peer associations and substance use. When
family connectedness is high and parental supervision is high, parental attitudes
carry particular weight. The substantial direct negative effect (coefficient = 0.40)
on substance use indicates that parental attitudes matter in the connected
familyeven when those attitudes are at odds with peer attitudes and behaviors.
School connectedness is also a crucial link in the internal risk and protection path.
Family connectedness and self-control contribute to school connectedness, which
relates to school performance, peer substance use, and ultimately personal
substance use. The measure of school performance (self-reported grades and
attendance) provides an important link in this path. Youth doing well in school
tend to associate with non-using peers and use less. In the community domain,
neighborhood risk is associated with peer substance use as an influence on
personal use, reflecting the importance of social environment in shaping youth
behaviors. Youth living in more dysfunctional neighborhoods are more likely to
associate with substance using peers and use themselves. The model clearly
supports the interactive nature of protective influencesinternal, external, and
normativeagainst substance use.
Pathways of Influence among Males and Females

The model shown in Figure 4 shows the pathway of influence according to

gender. (Coefficients in parentheses are for females.)4 There is a strong fit for
both males and females, and the overall statistical fit of the model is good
(CFI = 0.90). All of the hypothesized paths hold for both gender groups.
Some interesting implications emerge from the few gender differences shown
in the model. Significant differences in the strength of the structural paths emerged
along four paths in the model. School connectedness is a stronger predictor of
reported school performance (grades and school attendance) for females (0.43)
4

All item and factor variances were estimated freely between the group, with equality constraints
placed on the factor loadings and factor correlations.

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Figure 4. Structural equation model for males and females

(males, N = 3,596; females, N = 6,941).

than for males (0.13), suggesting that for females than for males, bonding to school
influences their academic performance. Parental attitudes toward substance use
are slightly more strongly related to personal use for females (0.42) than for
males (0.37). This suggests that females are less likely than males to use if
their parents clearly disapprove of their use. Both paths from neighborhood
risk to peer substance use to the subject=s own substance use are slightly stronger
for males (0.31 and 0.56) than females (0.14 and 0.48). Males are more
influenced by peer and community factors than females. However, these differences are minor within the overall similarity of the paths to substance use for
both genders.
Pathways of Influence among Younger and Older Youth

The models were also analyzed according to the age of youth in the study.
The sample was divided in two groups: 9 to 11 year olds and 12 to 18 year olds.
The unconstrained model fit the data well (CFI = 0.92). (Coefficients in parentheses are for the older youth.) The model is strong for both younger and older
youth.
Several major age-related differences emerge in the model. The first is the
importance of family factors for older youth. Family supervision and parental

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Figure 5. Structural equation model for younger and older youth

(younger (9-11), N = 2,879; older (12-18), N = 7,566).

attitudes are stronger predictors of substance use behavior in youth 12 years and
older than they are for preteens. Some of this difference may be attributed to
reduced variation in the younger group, where positive orientation toward family
is higher in general. Nevertheless, the data indicate that the family continues to
play a critical protective role as youth develop through adolescencedespite the
fact that teens report a decline in family supervision and family connectedness as
they grow older (see Figures 3 and 4).
Second, peers influence older youth more than younger youth. Peer attitudes
and perceptions of peer use are stronger predictors of substance use among older
youth than they are for those younger than 12. This reflects the developing
sensitivity to social perceptions that begins in early adolescence and continues
into adulthood. Third, the path from school connectedness to school performance
is stronger for younger youth than for the older group. This suggests that school
plays a critical role in influencing positive behaviors that may lead to prevention of or reductions in substance use among younger youth. Fourth, school
performance is a stronger predictor of substance use behavior in older youth
than in younger youth. For students 12 and older, the model suggests that poor
grades are associated with substance-using peers and personal substance use.
In sum, school performance, parental supervision, parental attitudes, and peer
attitudes influence youths decisions regarding personal use, especially among
older youth.

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Model Summary
In summary, the model of risk and protection factors for substance use among
high-risk youth is robust. It is based on a large sample of at-risk youth, and it
applies to females and males, and younger and older youth. The model emphasizes
the critical importance of family, peers, and individual protective factors for
buffering youth from substance use. More importantly, it suggests the interdependence of these domains. The key to prevention is not to make youth
insensitive to their social environment, but to ensure that they are strongly
connected to positive, healthy environments. Given the stability of the model
across these important population subgroups, practitioners can use it to address
important questions about which risk and protective factors prevention programs
should be targeting. By reducing to a manageable number the important predictors of substance use, the model should help practitioners focus their resources
efficiently to improve program outcomes.
DISCUSSION
The CSAP National Cross-Site Evaluation of High-Risk Youth Programs has
created an excellent opportunity to expand knowledge about risk and protective
factors and substance use among youth at high risk. The models presented here
bring additional coherence and focus to the ways in which risk, protective, and
normative factors influence substance use among youth. Expanding on prior
research, these models show the indirect and direct relationships among individual, family, peer, school, and community factors using a large sample of
high-risk youth. The model is relatively stable across age and gender. There is
some evidence that family and school influences are more important for females
than males and that peer and neighborhood risk influences are stronger for males.
The models also show the important role that family plays in adolescent substance
use, especially for older youth.
By specifying plausible pathways within and between external, internal, and
normative risk factors and substance use, the model adds detail to understanding why adolescents use. In terms of internal risk and protection, the
analyses have important research implications. The previous literature on
internal risk and protection has proposed numerous attitudes, orientations, and
personal competencies as critical factors in youths use of substances. The
result has been confusion. This analysis suggests a much simpler structure of
important issues. Factors that build connectedness with the external environment (family and school connectedness) are critical deterrents to adolescent
substance use.
The analyses also point to the importance of school as a forum for changing
substance use patterns. Both school connectedness and school performance

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103

show strong associations with individual substance use. Furthermore, this study
shows the strong association between peers and individual substance use. The
relationship between peer and individual substance use is the strongest among
the factors in the model. This finding is supported among males and females, as
well as older and younger youth. Peer effects also serve as a powerful mediator
between individual, family, school, and community factors and individual substance use. Finally, by highlighting the importance of the family and the school,
the model suggests that youth develop important personal competencies (such
as cooperativeness, a positive view of the future, a belief in self, and a feeling of
personal efficacy) through positive orientations to, and interactions with, central
social settings.
These analyses have direct implications for prevention policy and practice.
They confirm the importance of comprehensive prevention that addresses the
range of environmental factors as well as the individual orientations and behaviors
of the youth themselves. The central implication for prevention is the need to build
connections to positive and meaningful social environments for youth. Though
important, just changing the environment, or just changing individual orientations,
is not enough. Protection and positive development requires connection between
the two. Building and supporting these connections is a central challenge to
prevention and a positive promise to youth.

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Direct reprint requests to:

Elizabeth Sale, Ph.D.
Senior Research Associate
EMT Associates, Inc.
2nd Floor
208 North Euclid
St. Louis, MO 63108-1602
e-mail: esale@emt.org