Understanding alcohol use and alcohol use disorders from a developmental psychopathology perspective: Research advances, challenges, and future directions.

As part of the special issue of Development and Psychopathology honoring the remarkable contributions of Dr Dante Cicchetti, the current paper attempts to describe the recent contributions that a developmental psychopathology perspective has made in understanding the development of alcohol use and alcohol-related problems over the lifespan. The paper also identifies some of the future challenges and research directions. Because the scope of this task far exceeds the confines of a journal length article this paper does not attempt a comprehensive review. Rather, it builds on an earlier review and commentary that was published in Development and Psychopathology in 2013, with a similar goal.)Building on that work and updating its conclusions and suggestions for future directions, the current paper emphasizes findings from the research areas that were identified for further study in 2013 and the findings that have been published since that time.

Persistent and distressing psychotic-like experiences using adolescent brain cognitive development℠study data.

Childhood psychotic-like experiences (PLEs) are associated with a range of impairments; a subset of children experiencing PLEs will develop psychiatric disorders, including psychotic disorders. A potential distinguishing factor between benign PLEs versus PLEs that are clinically relevant is whether PLEs are distressing and/or persistent. The current study used three waves of Adolescent Brain Cognitive Development℠ (ABCD) study PLEs assessments to examine the extent to which persistent and/or distressing PLEs were associated with relevant baseline risk factors (e.g., cognition) and functioning/mental health service utilization domains. Four groups varying in PLE persistence and distress endorsement were created based on all available data in ABCD Release 3.0, with group membership not contingent on complete data: persistent distressing PLEs (n = 272), transient distressing PLEs (n = 298), persistent non-distressing PLEs (n = 221), and transient non-distressing PLEs (n = 536) groups. Using hierarchical linear models, results indicated youth with distressing PLEs, whether transient or persistent, showed delayed developmental milestones (ß = 0.074, 95%CI:0.013,0.134) and altered structural MRI metrics (ß = -0.0525, 95%CI:-0.100,-0.005). Importantly, distress interacted with PLEs persistence for the domains of functioning/mental health service utilization (ß = 0.079, 95%CI:0.016,0.141), other reported psychopathology (ß = 0.101, 95%CI:0.030,0.170), cognition (ß = -0.052, 95%CI:0.-0.099,-0.002), and environmental adversity (ß = 0.045, 95%CI:0.003,0.0.86; although no family history effects), with the interaction characterized by greatest impairment in the persistent distressing PLEs group. These results have implications for disentangling the importance of distress and persistence for PLEs with regards to impairments, including functional, pathophysiological, and environmental outcomes. These novel longitudinal data underscore that it is often only in the context of distress that persistent PLEs were related to impairments.

A Clinical Psychologist Who Studies Alcohol.

In this article, I describe why I believe the study of alcohol use and its consequences is a rich and rewarding area of scholarly activity that touches on multiple disciplines in the life sciences, the behavioral sciences, and the humanities. I then detail the circuitous path I took to become an alcohol researcher and the various challenges I encountered when starting up my research program at the University of Missouri. A major theme of my journey has been my good fortune encountering generous, brilliant scholars who took an interest in me and my career and who helped guide and assist me over the course of my career. I also highlight selected, other professional activities I've been involved in, focusing on editorial work, quality assurance, and governance of professional societies. While the focus is on my training and work as a psychologist, the overarching theme is the interpersonal context that nurtures careers.

Psychopathology as dynamic markers of alcohol initiation across development: A three-year longitudinal examination.

Sipping, an early form of alcohol initiation, is associated with aspects of psychopathology and personality that reflect long-term risk for harmful alcohol use. In the Adolescent Brain and Cognitive Development cohort (N = 11,872), sipping by age 9-10 was concurrently associated with impulsivity, other aspects of externalizing, and prodromal schizophrenia symptoms. Still, these associations were cross-sectional in nature, leaving open the possibility that these features of psychopathology and personality might not reflect long-term risk for alcohol consumption and related harm across development. Here, we attempted to replicate baseline concurrent associations across three waves of data to extend concurrent associations to prospective ones. Most cross-sectional associations replicated across waves, such that impulsivity, other aspects of externalizing, reward sensitivity (e.g., surgency, sensation seeking), and prodromal schizophrenia symptoms were associated with increased odds of having sipped alcohol by the age of 12. Nevertheless, not all concurrent associations replicated prospectively; impulsigenic features did not reflect long-term risk for sipping. Thus, some psychopathology features appeared to reflect stable risk factors, whereas others appeared to reflect state-dependent risk factors. All told, sipping might not reflect long-term risk for harmful alcohol use, and the nature of sipping may change across development.

Age Specificity of Effects of Health Problems on Drinking Reduction: A Lifespan Developmental Analysis.

Older adult drinking poses a growing public health concern, especially given the ongoing aging of the United States population. As part of a larger lifespan developmental project contrasting predictors of drinking reductions across different periods of adulthood, we tested age differences in effects of health problems on drinking declines across young adulthood, midlife, and older adulthood. We predicted these effects to be developmentally specific to midlife and older adulthood. We also tested moderation by alcohol use disorder (AUD) symptomatology and by indices of sociodemographic disadvantage (sex and race/ethnicity). Analyses used data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), leveraging NESARC's vast age range (18-90 + ; N = 43,093) and two waves of longitudinal data. Multiple-group cross-lag models tested differences across age groups in cross-lag paths between health problems and alcohol consumption. As hypothesized, health problem effects on drinking reductions were developmentally specific to midlife and older adulthood. However, models testing moderation by AUD symptomatology showed that these adaptive effects of health problems on drinking reductions did not extend to those with one or more AUD symptoms. Little evidence was found for moderation by sex or race/ethnicity. Findings support the notion of health concerns as a pathway to drinking reduction that increases in importance across the adult lifespan. However, given the moderation by AUD symptoms, findings also highlight a need to understand barriers to health-related pathways to drinking reduction among relatively severe midlife and older adult drinkers. These findings hold implications for lifespan developmental tailoring of clinical, public health, and policy interventions.

Alcohol use disorder conceptualizations and diagnoses reflect their sociopolitical context.

The present paper highlights how alcohol use disorder (AUD) conceptualizations and resulting diagnostic criteria have evolved over time in correspondence with interconnected sociopolitical influences in the United States. We highlight four illustrative examples of how DSM-defined alcoholism, abuse/dependence, and AUD have been influenced by sociopolitical factors. In doing so, we emphasize the importance of recognizing and understanding such sociopolitical factors in the application of AUD diagnoses. Last, we offer a roadmap to direct the process of future efforts toward the improved diagnosis of AUD, with an emphasis on pursuing falsifiability, acknowledging researchers' assumptions about human behavior, and collaborating across subfields. Such efforts that center the numerous mechanisms and functions of behavior, rather than signs or symptoms, have the potential to minimize sociopolitical influences in the development of diagnostic criteria and maximize the treatment utility of diagnoses.

Sociodemographic differences in youth alcohol sipping's nomological network.

BACKGROUND: Previous research has established that certain features of personality (e.g., impulsivity), psychopathology (e.g., impulsivity, mood disorder, thought disorder), and contextual factors (e.g., parenting, parental alcohol use) are associated with an increased likelihood of having sipped alcohol in youth, and substance involvement and problems in adolescence and adulthood. What is less clear from the existing literature is whether well-established risk factors of substance use are consistent across sociodemographic characteristics (i.e., gender, race/ethnicity, religious affiliation, income, parental education). METHODS: We used a large, community sample of 9- and 10-year-olds (N = 11,872; 53% female) to examine whether various sociodemographic characteristics moderate the associations between sipping behavior and its various well-established correlates (e.g., impulsivity, behavioral inhibition and activation, psychopathology, parenting, and family conflict). RESULTS: There were small mean level differences in sipping across sociodemographic characteristics. Across sociodemographic characteristics, however, sipping was fairly uniformly associated with youth-reported impulsivity, behavioral activation, prodromal psychosis symptoms, mood and externalizing disorder diagnoses, family environment, and parental alcohol consumption indices. Effects were sometimes slightly more pronounced among groups for which alcohol consumption is relatively nonnormative: Sipping among female youth was slightly more associated with thought disorder psychopathology than among male youth (D = 0.07), and was slightly more associated with some aspects of psychopathology and impulsivity for Black youth than White and Hispanic youth (Ds were 0.07 and 0.09). CONCLUSIONS: Broadly, our findings suggest that the psychosocial correlates of precocious alcohol use are relatively consistent across sociodemographic factors.

A life span developmental investigation of marriage and problem-drinking reduction.

While prior literature has largely focused on marriage effects during young adulthood, it is less clear whether these effects are as strong in middle adulthood. Thus, we investigated age differences in marriage effects on problem-drinking reduction. We employed parallel analyses with two independent samples (analytic-sample Ns of 577 and 441, respectively). Both are high-risk samples by design, with about 50% of participants having a parent with lifetime alcohol use disorder. Both samples have been assessed longitudinally from early young adulthood to the mid-to-late 30s. Separate parallel analyses with these two samples allowed evaluation of the reproducibility of results. Growth models of problem drinking tested marriage as a time-varying predictor and thereby assessed age differences in marriage effects. For both samples, results consistently showed marriage effects to be strongest in early young adulthood and to decrease somewhat monotonically thereafter with age, reaching very small (and nonsignificant) magnitudes by the 30s. Results may reflect that role transitions like marriage have more impact on problem drinking in earlier versus later adulthood, thereby highlighting the importance of life span developmental research for understanding problem-drinking desistance. Our findings can inform intervention strategies aimed at reducing problem drinking by jumpstarting or amplifying natural processes of adult role adaptation.

Meaningful associations in the adolescent brain cognitive development study.

The Adolescent Brain Cognitive Development (ABCD) Study is the largest single-cohort prospective longitudinal study of neurodevelopment and children's health in the United States. A cohort of n = 11,880 children aged 9-10 years (and their parents/guardians) were recruited across 22 sites and are being followed with in-person visits on an annual basis for at least 10 years. The study approximates the US population on several key sociodemographic variables, including sex, race, ethnicity, household income, and parental education. Data collected include assessments of health, mental health, substance use, culture and environment and neurocognition, as well as geocoded exposures, structural and functional magnetic resonance imaging (MRI), and whole-genome genotyping. Here, we describe the ABCD Study aims and design, as well as issues surrounding estimation of meaningful associations using its data, including population inferences, hypothesis testing, power and precision, control of covariates, interpretation of associations, and recommended best practices for reproducible research, analytical procedures and reporting of results.

Delineating Developmental Periods in Adulthood Suggests Age-Related Shifts in the Correlates of Alcohol Use and Problems.

BACKGROUND: Developmental context is related to the propensity to engage in alcohol use, the rate at which alcohol use changes, and the relevance of different risk factors to alcohol use disorder (AUD). Therefore, studies of change should consider developmental nuances, but change is often modeled to follow a uniform pattern, even across distinct developmental periods. METHODS: This study implemented a novel analytic approach to delineate developmental periods of alcohol behavior (n = 478, ages 18 to 35). This approach was further leveraged to examine age-related shifts in the association of impulsivity risk factors (lack of planning, general sensation seeking, alcohol enhancement expectancies) with alcohol behavior (alcohol quantity*frequency, heavy drinking, AUD). RESULTS: A sequence of exploratory and confirmatory latent growth models (LGMs) suggested modeling separate linear change factors for alcohol behavior during the primary college (ages 18 to 21) and postcollege years (21 to 35). Bivariate LGMs estimated correlations for alcohol behavior changes with lack of planning, sensation seeking, and enhancement expectancies during these periods. The rate at which heavy drinking changed during the college years was positively correlated with general sensation seeking and lack of planning during this period (rs = 0.61 to 0.63). These correlations were significantly weaker during the postcollege years (rs = 0.29 to 0.34). Notably, the rate of change in alcohol behavior was strongly correlated with enhancement expectancies during the college (r = 0.45 to 0.70) and postcollege years (r = 0.45 to 0.61). CONCLUSIONS: These findings highlight the importance of sensation seeking and lack of planning with regard to adult alcohol use, particularly in a college environment. There was also a strong link between the rates of change in alcohol behavior and enhancement expectancies across all waves. This study supports the utility of exploratory LGMs for delineating developmental periods of alcohol behavior, which are characterized by different processes.

Incipient alcohol use in childhood: Early alcohol sipping and its relations with psychopathology and personality.

Prior research has shown that sipping of alcohol begins to emerge during childhood and is potentially etiologically significant for later substance use problems. Using a large, community sample of 9- and 10-year-olds (N = 11,872; 53% female), we examined individual differences in precocious alcohol use in the form of alcohol sipping. We focused explicitly on features that are robust and well-demonstrated correlates of, and antecedents to, alcohol excess and related problems later in the lifespan, including youth- and parent-reported externalizing traits (i.e., impulsivity, behavioral inhibition and activation) and psychopathology. Seventeen percent of the sample reported sipping alcohol outside of a religiously sanctioned activity by age 9 or 10. Several aspects of psychopathology and personality emerged as small but reliable correlates of sipping. Nonreligious sipping was related to youth-reported impulsigenic traits, aspects of behavioral activation, prodromal psychotic-like symptoms, and mood disorder diagnoses, as well as parent-reported externalizing disorder diagnoses. Religious sipping was unexpectedly associated with certain aspects of impulsivity. Together, our findings point to the potential importance of impulsivity and other transdiagnostic indicators of psychopathology (e.g., emotion dysregulation, novelty seeking) in the earliest forms of drinking behavior.

Combinatorial Optimization of Clustering Decisions: An Approach to Refine Psychiatric Diagnoses.

Using complete enumeration (e.g., generating all possible subsets of item combinations) to evaluate clustering problems has the benefit of locating globally optimal solutions automatically without the concern of sampling variability. The proposed method is meant to combine clustering variables in such a way as to create groups that are maximally different on a theoretically sound derivation variable(s). After the population of all unique sets is permuted, optimization on some predefined, user-specific function can occur. We apply this technique to optimizing the diagnosis of Alcohol Use Disorder. This is a unique application, from a clustering point of view, in that the decision rule for clustering observations into the "diagnosis" group relies on both the set of items being considered and a predefined threshold on the number of items required to be endorsed for the "diagnosis" to occur. In optimizing diagnostic rules, criteria set sizes can be reduced without a loss of significant information when compared to current and proposed, alternative, diagnostic schemes.

Psychiatric Comorbidity as a Function of Severity: DSM-5 Alcohol Use Disorder and HiTOP Classification of Mental Disorders.

BACKGROUND: Understanding the comorbidity of alcohol use disorder (AUD) and other psychiatric diagnoses has been a long-standing interest of researchers and mental health professionals. Comorbidity is often examined via the diagnostic co-occurrence of discrete, categorical diagnoses, which is incongruent with increasingly supported dimensional approaches of psychiatric classification and diagnosis, and for AUD more specifically. The present study examined associations between DSM-5 AUD and psychiatric symptoms of other DSM-IV and DSM-5 disorders categorically, and dimensionally organized according to the Hierarchical Taxonomy of Psychopathology (HiTOP) spectra (e.g., Internalizing, Disinhibited Externalizing). METHODS: The comorbidity of AUD with other psychological disorders was examined in 2 independent nationally representative samples of past-year drinkers via an initial examination in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) Wave 2 and replicated in NESARC-III. RESULTS: Analyses focusing on psychopathology symptom counts organized by spectra demonstrated that greater AUD severity was associated with a higher number of symptoms across HiTOP spectra. Traditional categorical analyses also demonstrated increasing prevalence as a monotonic function of DSM-5 AUD severity gradients. CONCLUSIONS: This study indicates that AUD and other psychiatric disorder comorbidity implies increased presence of multiple forms of psychopathology with a corresponding increased number of symptoms across hierarchical spectra. Greater AUD severity increases the likelihood of other psychopathology and, when present, "more severe" presentations. That is, on average, a given disorder (e.g., depression) is more severe when copresenting with an AUD, and increases in severity along with the AUD.

The Association Between Alcohol Consumption and Pain Interference in a Nationally Representative Sample: The Moderating Roles of Gender and Alcohol Use Disorder Symptomatology.

BACKGROUND: Prior research on alcohol consumption and pain has yielded inconsistent results regarding the directionality of effects for both consumption-to-pain and pain-to-consumption relations. The present study sought to examine directionality of these relations by testing bidirectional longitudinal associations between consumption and pain interference, a crucial aspect of pain that captures pain-related disability and has been regarded as a valuable measure of treatment outcome. In addition, this study explored possible moderation of these bidirectional longitudinal associations by gender and alcohol use disorder (AUD) symptomatology. METHODS: Analyses included 29,989 current/former drinkers who were interviewed at both waves (2001 and 2004) of the U.S. National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Analyses used self-report data from both waves on past-year average daily volume of alcohol consumed and past-month pain interference (1 item from the Medical Outcomes Study 12-item Short-Form Health Survey [MOS-SF-12]). AUDADIS-IV data from Wave 1 were used to index baseline AUD symptomatology (i.e., symptom count). Cross-lagged panel modeling and multigroup analyses were employed. RESULTS: Regarding the consumption-to-pain-interference relation, in general, higher baseline alcohol consumption was associated with lower subsequent pain interference at follow-up. However, among men with higher AUD-symptom counts, the opposite pattern emerged, with higher baseline alcohol consumption being significantly related to higher subsequent pain interference at follow-up. Regarding the pain-interference-to-consumption relation, higher baseline pain interference was significantly associated with lower subsequent alcohol consumption at follow-up, and no moderating effects were observed. CONCLUSIONS: The distinctive patterns of the consumption-to-pain-interference relation observed among men with elevated AUD symptomatology suggest that this relation might be driven by different mechanisms across different groups of individuals. Specifically, the detrimental effect of alcohol on pain interference might emerge at relatively advanced stages of AUD among men, consistent with Koob's Dark Side of Alcohol Addiction theory in human research.

Prospective Study Examining the Effects of Extreme Drinking on Brain Structure in Emerging Adults.

BACKGROUND: Emerging adulthood is a critical neurodevelopment period in which extreme drinking has a potentially pronounced neurotoxic effect. Therefore, extreme drinking, even a single episode, could be particularly harmful to the developing brain's structure. Relatedly, heavy alcohol use in emerging adults has been associated with structural brain damage, especially in the corpus callosum. However, it is unclear whether and how much a single extreme drinking episode would affect brain morphometry. METHODS: For the first time in the literature, the current study prospectively examined the impact of an extreme drinking episode (i.e., twenty-first birthday celebration) on the brain morphometry of emerging adults immediately following their birthday celebration (n = 50) and approximately 5 weeks post-birthday celebration (n = 29). RESULTS: We found evidence that a single extreme drinking episode was associated with structural changes immediately post-birthday celebration. Specifically, higher twenty-first birthday estimated blood-alcohol concentration was associated with decreased volume of the posterior and central corpus callosum immediately post-birthday celebration. This extreme drinking episode was not associated with further structural changes, or recovery, 5 weeks post-twenty-first birthday celebration. CONCLUSIONS: Overall, results suggest that a single episode of heavy drinking in emerging adulthood may be associated with immediate structural changes of the corpus callosum. Thus, emerging adulthood, which is characterized by high rates of extreme drinking, could be a critical period for targeted prevention and intervention.

Mechanisms of Alcohol Addiction: Bridging Human and Animal Studies.

AIM: The purpose of this brief narrative review is to address the complexities and benefits of extending animal alcohol addiction research to the human domain, emphasizing Allostasis and Incentive Sensitization, two models that inform many pre-clinical and clinical studies. METHODS: The work reviewed includes a range of approaches, including: a) animal and human studies that target the biology of craving and compulsive consumption; b) human investigations that utilize alcohol self-administration and alcohol challenge paradigms, in some cases across 10 years; c) questionnaires that document changes in the positive and negative reinforcing effects of alcohol with increasing severity of addiction; and d) genomic structural equation modeling based on data from animal and human studies. RESULTS: Several general themes emerge from specific study findings. First, positive reinforcement is characteristic of early stage addiction and sometimes diminishes with increasing severity, consistent with both Allostasis and Incentive Sensitization. Second, evidence is less consistent for the predominance of negative reinforcement in later stages of addiction, a key tenant of Allostasis. Finally, there are important individual differences in motivation to drink at a given point in time as well as person-specific change patterns across time. CONCLUSIONS: Key constructs of addiction, like stage and reinforcement, are by necessity operationalized differently in animal and human studies. Similarly, testing the validity of addiction models requires different strategies by the two research domains. Although such differences are challenging, they are not insurmountable, and there is much to be gained in understanding and treating addiction by combining pre-clinical and clinical approaches.

Are Some Alcohol Use Disorder Criteria More (or Less) Externalizing than Others? Distinguishing Alcohol Use Symptomatology from General Externalizing Psychopathology.

BACKGROUND: The externalizing spectrum contains a range of disinhibition-related conditions, such as conduct disorder, antisocial personality disorder, and substance use disorders. Comorbidity among externalizing disorders is commonly investigated at the syndromal and trait level precluding insight into the relationship of symptoms across externalizing disorders. It is unknown whether comorbidity across externalizing disorders holds constant across highly varied, individual alcohol use disorder (AUD) criteria. AUD criteria range from symptoms reflecting neuroadaptation (e.g., tolerance) to symptoms reflecting behavioral problems (e.g., social problems). The present study aimed to determine the degree to which individual AUD criteria are associated with symptomatology from other externalizing disorders. Characterization of the degree to which AUD criteria reflect neuroadaptation versus behavioral problems can be used to identify symptom profiles, which, in turn, can be used to inform diagnostic and treatment approaches. METHODS: Data from 2 large nationally representative samples were used to examine associations between AUD criteria and externalizing behavior. Psychometric inquiries via multivariate and factor analytic approaches estimated relative associations of externalizing behavior and AUD criteria endorsement, as compared to alcohol consumption. RESULTS: Our results indicate differential relations of externalizing behavior and AUD criteria endorsement. For example, social problems and role interference criteria were most strongly associated with externalizing behavior across analytic approaches, with general and unique associations with externalizing behavior. Additionally, tolerance was most weakly associated with externalizing behavior across approaches. CONCLUSIONS: Results highlight potential etiological heterogeneity among AUD criteria that could guide future diagnostic refinements and aid in the identification of treatment targets.

What Is Addiction? How Can Animal and Human Research Be Used to Advance Research, Diagnosis, and Treatment of Alcohol and Other Substance Use Disorders?

The current article highlights key issues in defining, studying, and treating addiction, a concept related to but distinct from substance use disorders. The discussion is based upon a roundtable discussion at the 2017 annual meeting of the Research Society on Alcoholism where Warren K. Bickel and John C. Crabbe were charged with answering a range of questions posed by Kenneth J. Sher. All the presenters highlighted a number of central concerns for those interested in assessing and treating addiction as well as those seeking to conduct basic preclinical research that is amenable to meaningful translation to the human condition. In addition, the discussion illustrated both the power and limitations of using any single theory to explain multiple phenomena subsumed under the rubric of addiction. Among the major issues examined were the important differences between traditional diagnostic approaches and current concepts of addiction, the difficulty of modeling key aspects of human addiction in nonhuman animals, key aspects of addiction that have, to date, received little empirical attention, and the importance of thinking of recovery as a phenomenon that possibly involves processes distinct from those undergirding the development and maintenance of addiction.

The Efficacy of an Event-Specific, Text Message, Personalized Drinking Feedback Intervention.

Tailgating drinking prior to a football game is a type of event-specific drinking associated with increased alcohol use and related problems. Personalized drinking feedback interventions (PFI) are efficacious in reducing alcohol use and problems. The current study aimed to advance understanding of event-specific interventions by examining: (1) the efficacy of an event-specific, text message PFI on tailgating alcohol outcomes, and (2) the extent to which intervention effects generalize to "typical" alcohol outcomes at 1-month follow-up. College students (N = 130; 71% female; 92% white) who reported tailgating within the past 30 days and binge drinking when tailgating in the past year completed assessments on tailgating and typical alcohol use. They were randomly assigned to one of two text message conditions delivered on the morning of a home football game: event-specific PFI (TXT PFI) or a control condition. Multilevel modeling examined the association of treatment condition on tailgating and 1-month alcohol outcomes. When tailgating, participants in TXT PFI reported lower estimated peak blood alcohol concentration (eBAC) and consumed less drinks than the control condition. At the 1-month "typical" drinking follow-up, participants in TXT PFI reported lower peak eBAC and fewer alcohol-related problems than the control condition. Perceived tailgating drinking norms were found to statistically mediate the relationship between condition and alcohol outcome at tailgating and 1-month follow-ups. Findings provide preliminary support for the efficacy of an event-specific, text message PFI in reducing both tailgating and typical drinking alcohol outcomes. Event-specific TXT PFI can be used for prevention/intervention of alcohol misuse.