Early adolescent psychopathology as a predictor of alcohol use disorders by young adulthood
Introduction
There has been an increased interest in examining the relation between early adolescent psychopathology and the development of alcohol use disorders (AUD) in adulthood. Longitudinal research indicates that behaviors consistent with conduct disorder (CD) symptoms (e.g., aggression, deceitfulness/theft, destruction of property, serious rule violations) are associated with more frequent and intense alcohol use across time (Henry et al., 1993, Miller-Johnson et al., 1998, White et al., 1999), as well as early-onset substance use disorders (for a review see Weinberg et al., 1998). Given the robustness of this relation, some investigators have postulated that early CD symptoms represent the phenotypic expression of a genetically inherited liability for substance use disorders (Tarter et al., 1999). However, there remains substantial heterogeneity among youth with elevated CD symptoms, and evidence indicates that early internalizing problems (e.g., depression, anxiety/withdrawal) and attention-deficit/hyperactivity disorder (ADHD) symptoms may also predict later alcohol use outcomes (Henry et al., 1993, Kaplow et al., 2001, Molina and Pelham, 2003, Pardini et al., 2004). In addition, the co-occurrence of CD symptoms with other forms of early psychopathology may actually identify those adolescents who are at highest risk for later substance use problems (Flory et al., 2003, Miller-Johnson et al., 1998). The goal of the current study will be to examine the relative contribution of different forms of early adolescent psychopathology in predicting AUD by young adulthood. We will also examine the potential interactive effects between early conduct problems and other forms of adolescent psychopathology in identifying boys who are most at risk for later AUD.
There is a substantial amount of evidence indicating that symptoms of CD and substance use disorders tend to co-occur across adolescence (Weinberg et al., 1998). In fact, early substance use is often included as an additional indicator of conduct problems in childhood and adolescence rather than treating the two as separate, yet related, problems (Angold and Costello, 2001). Despite this overlap, longitudinal evidence suggests that adolescent CD symptoms and substance using behaviors represent two distinct dimensions of behavior (Mason and Windle, 2002) that have some unique predictive factors (White et al., 1987). Behaviors consistent with CD symptoms in boys also predict the onset of alcohol use (Clark et al., 1999), escalations in substance using behaviors (Mason and Windle, 2002), and the development of substance use disorders in adolescence (Sung et al., 2004). However, many longitudinal studies in this area have followed boys across relatively brief periods in adolescence and do not account for the influence of other forms of psychopathology that tend to co-occur with both disorders. There is also a dearth of studies examining the interaction between early adolescent conduct disorder symptoms and other forms of externalizing and internalizing psychopathology in predicting the development of alcohol use disorders by young adulthood.
There is ongoing debate about the relation between early ADHD symptoms and later substance use outcomes. Investigations have found that ADHD symptoms are more prevalent in adolescents and adults with substance use disorders than in the general population (for a review see Wilens, 2004). Longitudinal studies have found that children and adolescents exhibiting behaviors consistent with ADHD have high levels of later alcohol use, including more problem use, in comparison to normal control children (Barkley et al., 1990, Molina and Pelham, 2003, Pulkkinen and Pitkänen, 1994). However, many longitudinal studies have found that the relation between ADHD symptoms and later substance use is primarily driven by co-occurring conduct problems (Barkley et al., 1990, Biederman et al., 1997, Clark et al., 1999, Loeber et al., 1999, Pulkkinen and Pitkänen, 1994). While recent investigations with clinic-referred youth suggest that childhood inattentive symptoms may predict adolescent substance use outcomes above and beyond conduct disorder symptoms (Molina and Pelham, 2003), this finding may only be relevant for cigarette use (Burke et al., 2001). In addition, prospective investigations exploring the relation between early adolescent ADHD symptoms and the development of alcohol use disorders remain rare.
Some investigators have suggested that ADHD symptoms may escalate the risk for negative substance use outcomes only in youth with high levels of CD symptoms (Flory and Lynam, 2003, Molina et al., 1999). Much of this conjecture comes from longitudinal studies indicating that children with high levels of both ADHD and CD symptoms are more likely to exhibit severe and persistent forms of antisocial behavior in comparison to youth with ADHD or CD symptoms alone (for a review see Flory and Lynam, 2003). The relatively few studies examining the interactive effects between ADHD and CD symptoms in predicting substance use outcomes have provided mixed results. Molina et al. (1999) found that children with a comorbid ADHD and CD diagnosis were more likely to report using several substances in comparison to children with either disorder alone. However, many of these findings became non-significant after accounting for the severity of conduct disorder symptoms in the comorbid group. Flory et al. (2003) found that ADHD symptoms were related to increased levels of marijuana and hard drug dependence symptoms only for young adults with a history of significant CD symptoms, but this effect was not observed for alcohol use disorders. Both of these studies were limited by the use of cross-sectional data, making it impossible to determine if CD and ADHD symptoms preceded the onset of the substance use outcomes. The relatively few longitudinal studies that have examined the interaction between ADHD and CD symptoms in predicting later substance use, including problem use, have failed to produce significant findings (Fergusson et al., 1993, Taylor et al., 1996).
There has also been substantial interest in examining the relation between early internalizing problems and later alcohol using behaviors. Much of this research has focused on depressive disorders, which commonly co-occur with substance use problems during adolescence and adulthood (Grant et al., 2004). While exceptions do exist (Hussong and Hicks, 2003), several longitudinal studies have found evidence indicating that childhood depressive symptoms in boys are associated with increased alcohol use (Costello et al., 1999, Henry et al., 1993, Kaplow et al., 2001, Pardini et al., 2004), and a higher rate of substance use disorders (Sung et al., 2004) during adolescence. In addition, depression and dysphoria among male adolescents have been related to increased alcohol involvement in early adulthood, even after controlling for initial levels of substance using behaviors (Locke and Newcomb, 2001). A potential confound in some of these studies is that commonly used measures of childhood depression often include items related to conduct problems (Weiss et al., 1991), which may account for the positive relation between depression and substance use (Kumpulainen and Roine, 2002). However, longitudinal evidence suggests that depression in boys may predict later adolescent alcohol use and substance use disorders, even after controlling for co-occurring conduct problems (Henry et al., 1993, Sung et al., 2004). An important area of future research is examining whether early adolescent depression is associated with the development of alcohol use disorders by early adulthood after accounting for co-occurring CD symptoms.
In contrast to research on depression, higher levels of anxiety/withdrawal in youth tend to be associated with a decreased risk for later substance use problems (Shedler and Block, 1990). While definitions vary across studies, adolescents high in anxiety/withdrawal are often characterized as apprehensive, shy, and timid individuals who are extremely cautious in novel or potentially threatening situations, similar to conceptualizations of behavioral inhibition (Gray, 1991) and harm avoidance (Cloninger et al., 1988). Longitudinal studies have found that characteristics consistent with anxiety/withdrawal are associated with a lower risk of initiating alcohol use in early adolescence (Kaplow et al., 2001, Masse and Tremblay, 1997, Pardini et al., 2004) as well as a lower risk of developing early-onset alcohol abuse (Cloninger et al., 1988). An anxious interpersonal style in adolescence has also been associated with lower problem drinking in adulthood, even after controlling for the influence of conduct problems (Pulkkinen and Pitkänen, 1994). Two primary explanations for this inverse relationship have been proposed. The first suggests that anxious teens are more concerned about the potential negative consequences associated with drinking and illicit drug use, which inhibits them from engaging in these behaviors (Wills et al., 1998, Wills et al., 1999). Second, anxious/withdrawn children may shy away from peer-related social activities where the initiation of problematic substance use typically takes place (Kaplow et al., 2001).
An important area of research that has received little attention is the potential interaction between adolescent internalizing and CD symptoms in predicting later alcohol use problems. Cross-sectional evidence suggests that conduct disorder and major depression may interact to predict substance use disorder symptoms in late adolescence, with comorbid youth exhibiting particularly high levels of dependence symptoms (Marmorstein and Iacono, 2003). Longitudinal evidence indicates that depressive symptoms in early adolescent boys may only be related to later alcohol use among individuals with significant conduct problems (Miller-Johnson et al., 1998). While other studies have failed to replicate this finding (Capaldi and Stoolmiller, 1999), adolescents with elevated depression and conduct problems seem to have particularly poor outcomes. For example, depression among clinic-referred adolescents with conduct disorder has been shown to be a particularly robust predictor of later antisocial personality disorder (Loeber et al., 2002). On the other hand, high levels of anxiety/withdrawal may actually buffer adolescents with significant conduct problems from experiencing long term negative outcomes. Children with CD and an anxiety disorder have been shown to have fewer police contacts, fewer school suspensions, and lower levels of physical aggression than youth with CD alone (Walker et al., 1991). In addition, low fearfulness is associated with a severe form of adolescent antisocial behavior characterized by a callous interpersonal style (Pardini et al., 2003, Pardini, 2006). However, prospective studies assessing the interaction between early CD symptoms and internalizing difficulties in predicting later alcohol use disorders are still needed.
The current study will expand the existing literature by examining the independent relations between several forms of early adolescent psychopathology (i.e., CD symptoms, ADHD symptoms, depression, anxiety/withdrawal) and the development of alcohol use disorders by young adulthood in a longitudinal sample of boys. The possibility that CD symptoms interact with depression and ADHD symptoms to create a multiplicative risk for alcohol use problems will also be explored. Conversely, we will examine whether anxiety/withdrawal can protect children with high CD symptoms from developing alcohol use disorders by young adulthood. This investigation will advance the existing literature in several ways. First, previous longitudinal studies, including those conducted with the current dataset, have not accounted for the co-occurrence between disruptive behaviors and internalizing problems when predicting later alcohol use outcomes (White et al., 2001). Similarly, previous studies have failed to differentiate between internalizing problems related to depression and anxiety/withdrawal when investigating substance use outcomes (Capaldi and Stoolmiller, 1999, Loeber et al., 1999). Research suggests that failing to control for the overlap between these internalizing symptoms can suppress the unique relation between each emotional state and substance use outcomes (Pardini et al., 2004, Wills et al., 1998, Wills et al., 1999). Lastly, studies in this area often focused on early psychopathology as a predictor of frequency or intensity of alcohol use, rather than targeting alcohol use disorders (e.g., White et al., 2001).
Section snippets
Design and sample
This investigation used data collected as part of the Pittsburgh Youth Study (PYS), a longitudinal study aimed at understanding the development of delinquency, substance use, and mental health problems in boys (Loeber et al., 1998). While the PYS consists of three separate grade-based cohorts (commonly referred to as youngest, middle, and oldest samples), only data from the oldest cohort was used because they received intensive alcohol use disorder assessments in young adulthood. The oldest
Descriptive statistics
Descriptive statistics and bivariate correlations for observed predictor and control variables are presented in Table 1. While nearly half of the boys in the study endorsed a prior history of alcohol use at the initial assessment in early adolescence (46%), relatively few endorsed ever experiencing problems as the result of their use (5%). All measures of early adolescent psychopathology were positively intercorrelated. As expected, the highest correlations were between the externalizing
Discussion
A primary goal of the current study was to examine the independent relation between measures of early adolescent psychopathology and the development of alcohol use disorder symptoms and diagnoses by young adulthood. Consistent with prior research, problems related to CD symptoms, ADHD symptoms, depression, and anxiety/withdrawal tended to co-occur in early adolescence. However, after controlling for the co-occurrence between these facets of psychopathology, several unique relations with AUD
Acknowledgements
This study was supported by grants from the National Institute on Drug Abuse (DA411018, DA017482, DA017552), National Institute on Mental Health (MH 48890, MH 50778), and the Office of Juvenile Justice and Delinquency Prevention (96-MU-FX-0012). Additional support was provided to the first author through a National Institute on Mental Health training grant (T32 MH015169). Special thanks to Rebecca Stallings, Ernesta Pardini, Evelyn Wei, and Jamie Pardini.
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