Integrating The Prevention of Adolescent Substance Use and Dating Violence: Evidence from Systematic, Epidemiologic, and Intervention Studies
Dating violence (DV) and substance use (SU) are prevalent, co-occurring behavioral health threats among adolescents, yet prevention research has overwhelmingly addressed them in isolation. This three-paper dissertation advances understanding of DV–SU co-occurrence by examining the evidence base for integrated school-based prevention, the normative mechanisms of a leading bystander intervention, and the etiological specificity of adversity–substance pathways. Guided by the Social-Ecological Model, Bystander Intervention Theory, and etiological specificity frameworks (Self-Medication Hypothesis and Social Pain Overlap Theory), the dissertation progresses across three analytical levels: international evidence synthesis, institutional-level mechanism evaluation, and national population-level analysis.Study 1 is a systematic review of randomized controlled trial (RCT) school interventions that prevent both DV and SU outcomes among adolescents worldwide. Searching six databases (PubMed, EMBASE, PsycINFO, CINAHL, CABI, ERIC) and screening 5,413 records, three cluster-RCTs were identified (N = 78,545), evaluating the Green Dot bystander program and the Fourth R curriculum. Risk of bias was assessed with Cochrane’s RoB 2 and evidence quality with GRADE. Green Dot reduced substance-related sexual violence outcomes despite not explicitly targeting SU, while Fourth R reduced physical DV but did not reduce SU outcomes. The identification of only three qualifying RCTs reveals a critical gap in integrated prevention science. Study 2 is a secondary analysis of data from the Kentucky Green Dot cluster-randomized trial (26 high schools, 2010–2014) testing whether the intervention reduced alcohol-related sexual assault victim-blaming (AR-SAVB). Binomial generalized linear mixed models detected a significant delayed treatment effect: AR-SAVB was 15% lower in intervention schools by Year 4 (OR = 0.85; 95% CI: 0.76, 0.95), robust across sensitivity analyses. Substance-related sexual violence outcomes (one's own substance use and due to another's substance use) did not show consistent reductions, and ecological mediation was inconclusive. Findings support multi-year implementation but identify boundary conditions for bystander programs. Study 3 uses 2023 Youth Risk Behavior Survey data (N = 20,103) to test whether adolescent adversities show opioid-specific or general substance associations. Survey-weighted logistic regressions modeled seven composite predictors across five substance outcomes. A stacked-outcome heterogeneity test confirmed that predictor–substance associations differed significantly (p = 0.0075). Bullying was uniquely associated with nonmedical prescription opioid use (NMPOU; 3.8 percentage points; AOR = 1.48) and no other substance. Karlson-Holm-Breen decomposition showed only 10.3% of bullying’s opioid association was mediated by polysubstance involvement, consistent with an opioid-specific distress pathway and Social Pain Overlap Theory. Collectively, these studies demonstrate that integrated outcome evaluation is essential, that bystander interventions shift violence-supportive norms cumulatively over multiple years, and that etiological specificity, particularly the bullying–opioid pathway, provides a targeting principle that current prevention programs have not yet incorporated. The dissertation argues that effective adolescent prevention must be simultaneously integrated across co-occurring risk domains and specific in matching intervention targets to the adversity–substance pathways that drive them.
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