SELECTED PUBLICATIONS

Late adolescence and emerging adulthood are marked by rising depression, anxiety, and substance misuse—problems that often compound in developmental cascades. This invited editorial discusses new longitudinal evidence demonstrating that social support can delay the progression between internalizing symptoms and alcohol misuse over a 7-year period. The study by Volpe, Roche, and Foster shows that higher support slows transitions from first drink to internalizing onset and from internalizing onset to first alcohol use, effectively stretching the timeline before co-occurring problems emerge. These findings reframe social support as a temporal buffer—not merely a protective correlate but a mechanism that alters the speed at which risk unfolds. The piece outlines implications for gender-tailored intervention strategies, emphasizes the urgency of intervening when internalizing symptoms first appear, and indicates policy opportunities to strengthen family, peer, and community support systems. Social support is positioned as a fundamental lever for disrupting these cascades.

We designed a home-based family intervention to address risk of substance use among adolescents in rural and Native American communities. Through a Tribal-University partnership, study aims were to develop, implement and explore effects on proximal risk and protective factors. The study was conducted in or near the Cherokee Nation Reservation in northeastern Oklahoma and was a cluster-randomized trial with 10 high schools randomly assigned to intervention and 10 to delayed intervention group. The study involved a cohort of 919 tenth-grade students, surveyed approximately every six months over three years. Self-reported measures assessed the intervention’s impact on proximal outcomes linked to receipt of specific intervention components. Results indicate successful altering of norms, increased risk perceptions and parental disapproval of substance use. No improvements were found for parent/caregiver support and monitoring, friend support, or anxiety and depressive symptoms. The intervention’s cultural relevance and community involvement were key strengths, particularly in addressing health disparities in rural and Native populations. Despite some limitations, such as unchanged perceptions of social support, the findings suggest that culturally tailored, family-centered interventions can effectively reduce risk factors and increase protective factors. The study contributes to the limited literature on family-focused prevention for Indigenous youth and underscores the importance of community partnerships and culturally inclusive approaches in public health practice.

Adolescent substance use is a critical public health issue in rural and American Indian communities with disparities persisting into young adulthood. This study examines motivations for nonuse as predictors of substance use trajectories among adolescents in a computerized Screening and Brief Intervention in 10 high schools on and near the Cherokee Nation Reservation. Low-risk students (n = 360) reported their motivations for nonuse during the initial Screening and Brief Intervention session, and substance use outcomes (alcohol, cannabis, prescription opioid misuse, vaping) were assessed in subsequent surveys. Results from longitudinal growth curve models indicated that most motivations for nonuse were not associated with differential trajectories of substance use over time. One notable exception was “having positive people in one’s life,” which predicted a significantly lower likelihood of nicotine vaping at the initial follow-up, followed by a faster increase in vaping over subsequent semesters. In secondary wave-specific models, this motivation also predicted reduced cannabis use at the first follow-up, whereas endorsing “it makes me feel bad” predicted higher cannabis use. Reinforcing positive social influences and addressing negative feelings may be an important part of prevention strategies like Screening and Brief Intervention. This study offers new evidence on motivations for nonuse to inform the design of digital prevention tools for underserved rural youth.

Loneliness is a growing public concern among emerging adults, yet little is known about its predictors in rural and reservation-based communities. This study examines whether substance use and mental health symptoms in 12th grade predict loneliness post high school among a rural reservation-based sample. Participants (n = 483) were surveyed in 12th grade (Spring 2024) and again six months into young adulthood (Fall 2024). Independence estimating equations with a Poisson distribution were used to assess the effect of past 30-day substance use (alcohol use, binge drinking, cannabis use, vaping cannabis, and vaping nicotine) and past 2-week mental health (anxiety and depressive symptoms) on loneliness after high school. Substance use and mental health symptoms in 12th grade were significant predictors of post high school loneliness. Alcohol use, binge drinking, cannabis use, and vaping nicotine or cannabis were each associated with a 21–24% increased risk of loneliness. Five-point increases in anxiety and depressive symptoms respectively were associated with 15% and 21% greater risk of loneliness. Prevention efforts targeting substance use and mental health before high school graduation may help reduce the risk of loneliness among rural reservation-based young people as they enter adulthood.

Adolescent substance use is influenced by social support and social norms, which can be protective or risk-enhancing. This study analyzed survey data at baseline and 6-month follow-up from 919 adolescents attending schools on or near the Cherokee Nation Reservation. Generalized linear mixed-effects models assessed the influence of social support from parents/caregivers, teachers, community adults, and peers on alcohol and cannabis use with tests of moderation by injunctive and descriptive norms. Results revealed significant moderation in four of ten models. Parental support had stronger protective effects on alcohol use when parental disapproval was high, and teacher support had stronger protective effects on cannabis use when adult disapproval was high. Community adult support consistently protected against cannabis use. In low-normative contexts, friend support was a risk factor for alcohol use. Findings show the complex interaction of social support and norms with source- and substance-specific effects alongside implications for theory and prevention.

Objectives: To determine the Connect intervention’s effectiveness in reducing substance use among rural and tribal adolescents in northeastern Oklahoma.

Methods: We conducted a 2-arm cluster randomized trial from 2021 to 2024, with 10 high schools per condition.

Results: At baseline, 919 students were enrolled (mean age = 15 years), and the majority were American Indian or White. Alcohol-use days during the past 30 days was reduced by 18% per survey wave in the intervention compared with the control condition (rate ratio [RR] = 0.82; 95% confidence interval [CI] = 0.72, 0.93; t = −3.02; P = .003), binge drinking was reduced by 26% (RR = 0.74; 95% CI = 0.64, 0.86; t = −3.90; P < .001), cannabis use was reduced by 11% (RR = 0.89; 95% CI = 0.80, 1.00; t = −2.03; P = .04), and prescription opioid misuse was reduced by 40% (RR = 0.60; 95% CI = 0.43, 0.85; t = −2.86; P = .004). Model-predicted means revealed the control condition followed the expected developmental trajectory of increased substance use and the intervention condition showed a flat or decreasing use pattern.

Conclusions: The Connect intervention prevented the typical escalation of substance use during adolescence.

Introduction: This study examines the impacts of anxiety and depressive symptoms on subsequent initiation of alcohol use, cannabis use, and prescription opioid misuse among diverse adolescents attending high schools on or near a Tribal reservation in a rural Great Plains region of the U.S.

Methods: In collaboration with Emory University and a Great Plains Tribal nation's behavioral health organization, a community randomized trial of 20 high schools was conducted to prevent substance misuse. Surveys administered at four time points (fall and spring of 10th and 11th grade) included the GAD-7, PHQ-8, and items assessing lifetime alcohol use, cannabis use, prescription opioid misuse, and covariates (age, gender, race, and food insecurity). The analytic sample included students with data at two or more time points (n = 455) from control schools (k = 10). Approximately half of the sample identified as American Indian only or American Indian/White only, and 36%–39% as White only.

Results: Adjusted generalized estimating equations showed that every 5-point increase in anxiety symptoms was associated with 1.28 and 1.29 times the odds of initiating alcohol and cannabis use respectively the following semester. Similarly, every 5-point increase in depressive symptoms was associated with 1.25, 1.34, and 1.38 times the odds of initiating alcohol use, cannabis use, and prescription opioid misuse respectively the following semester.

Discussion: Results show a consistent 25%–38% increased odds of certain types of substance use initiation following increases in anxiety and depressive symptoms among adolescents. Findings underscore the need for targeted prevention and intervention to address mental health issues among a historically marginalized population. Addressing mental health concerns earlier may mitigate later substance use risks and sequelae for rural and American Indian youth.

Question:  Does Tribal identity moderate the association between pain interference and substance use in American Indian/Alaska Native adolescents living on or near the Cherokee Nation Reservation?

Findings:  In this cross-sectional study among 514 American Indian/Alaska Native adolescents living on or near the Cherokee Nation Reservation, pain interference was associated with alcohol use and prescription opioid misuse. When Tribal identity was high, the association of pain interference with alcohol use was significantly attenuated.

Meaning:  These findings provide evidence to support the protective potential of Tribal identity against alcohol use among American Indian/Alaska Native adolescents.

Purpose: To examine the relationships between individual-level perceived racial/ethnic discrimination and mental health and substance use outcomes by school-level racial composition among American Indian (AI) adolescents.

Method: Self-reported survey data on individual-level variables come from a sample of AI adolescents (n = 510) living in or near the Cherokee Nation during the fall of 2021. School-level data come from publicly available databases. Multilevel linear and logistic regression analyses were performed to test for and examine the interaction between perceived racial/ethnic discrimination and school racial composition in relation to symptoms of anxiety and depression, past 30-day use of alcohol and marijuana, and misuse of prescription opioids.

Results: Adjusted analyses showed a significant interaction effect between discrimination and racial composition on anxiety symptoms, such that the effect of discrimination was more pronounced at lower % AI (10th percentile) than at more equivalently mixed (50th percentile) or higher % AI (90th percentile) school settings. No significant interactions were observed with depressive symptoms or substance use outcomes.

Discussion: School racial compositions of higher percentage AI may buffer the adverse effect of racial/ethnic discrimination on anxiety symptoms among AI adolescents.

Infant and early childhood mental health (IECMH) has been defined as the capacity of infants and young children to regulate their emotions, form secure relationships, and explore their environments. For this special issue, we conducted a review of IECMH outcomes from evaluations of couple- and family-based psychosocial interventions not explicitly designed for trauma exposure published from 2010 through 2019, following Evidence Base Update criteria and the current convention of classifying general categories of intervention approaches rather than the former practice of evaluating specific brand-name packaged programs. Full-text review of 695 articles resulted in 39 articles eligible for categorization into intervention approaches, taking into consideration the theoretical orientation of the treatment, the population served, the intervention participants, the target outcomes, the treatment theory of change, and the degree to which the intervention was standardized across participants. Four intervention approaches were identified in this review as Probably Efficacious: Behavioral Interventions to Support Parents of Toddlers, Interventions to Support Adolescent Mothers, Tiered Interventions to Provide Support Based on Assessed Risk, and Home Visiting Interventions to Provide Individualized Support to Parents. Other intervention approaches were classified as Possibly Efficacious, Experimental, or did not have sufficient evidence in this time period to classify under these criteria. Further research could explore how to ensure that all families who need support can receive it, such as by increasing the reach of effective programs and by decreasing the number of families needing additional support.

Objective: The objective of this article was to assess the impact on behavioral and socioemotional development, 4 to 6 years postintervention (depending on the curriculum), of Legacy for Children™, a public health approach to improve child developmental outcomes among families living in poverty.

Methods: Mothers who were recruited prenatally or at the time of childbirth participated in a set of Legacy parallel design randomized control trials between 2001 and 2009 in Miami, Florida, or Los Angeles, California. Of the initial 574 mother-child dyads, 364 completed at least 1 behavioral or socioemotional outcome measure at the third-grade follow-up. Intention-to-treat analyses compared Legacy and comparison groups on behavioral and socioemotional outcomes.

Results: Children of Legacy mothers in Los Angeles were at lower risk for externalizing behaviors and poor adaptive skills than children whose mothers did not participate in the intervention. No significant outcome differences by group assignment were found in Miami.

Conclusion: Group-based positive parenting interventions such as Legacy may have a sustained impact on children's behavioral and socioemotional development several years after intervention completion.