Prediction of drug and alcohol abuse in hospitalized adolescents: Comparisons by gender and substance type
Introduction
Adolescent substance abuse is a major public health concern due to its frequency and broad range of negative consequences—which include suicidality, accidental injury, violent behavior, high-risk sexual behavior, academic failure, disrupted development, and psychopathology in adulthood (American Academy of Child and Adolescent Psychiatry (AACAP), 1997; Johnston, O’Malley, Bachman, & Schulenberg, 2005; Rao, Daley, & Hammen, 2000; Rohde, Lewinsohn, Kahler, Seeley, & Brown, 2001; Weinberg, Rahdert, Colliver, & Glanz, 1998; Zoccolillo, Vitaro, & Tremblay, 1999). Moreover, problematic substance use within this age group, and DSM-defined substance use disorder, is even more prevalent within severely emotionally disturbed populations, such as psychiatric inpatients (Greenbaum, Prange, Friedman, & Silver, 1991; Grilo et al., 1995). Among individuals with non-substance-related psychiatric disorders, there is evidence that coexisting substance abuse may result in poor response to treatment and worsening psychopathology (Kofoed, Kania, Walsh, & Atkinson, 1986; Lewinsohn, Rohde, Seeley, Klein, & Gotib, 2000; Myers, Stewart, & Brown, 1998). For these reasons, it is important that we understand the factors associated with the development of substance abuse in adolescents—especially among high-risk populations.
Adolescent substance abuse is a heterogeneous problem—and previous research has indicated that the correlates and risk factors for this set of behaviors may include biological, psychological, and social processes. Studies have suggested that substance abuse in adolescents can have a genetic basis (e.g., Rhee et al., 2003). Non-genetic familial factors have also been suggested, including family conflict, parental neglect, and abuse (AACAP, 1997; Guo, Hill, Hawkins, Catalano, & Abbott, 2002; Weinberg et al., 1998). Both sexual abuse and non-sexual violence have been associated with drug and alcohol abuse in adolescents (Clark, Lesnick, & Hegedus, 1997; Lipschitz, Grilo, Fehon, McGlashan, & Southwick, 2000). Other potential environmental factors include peer substance use and increased orientation of adolescents toward their peers (AACAP, 1997; Bray, Adams, Getz, & McQueen, 2003).
In addition to these familial and social risk factors, several individual psychobiological characteristics—mainly involving affective and behavioral dysregulation—have been identified as potential contributors. These include depressed mood, irritability, inattention, impulsivity, and antisocial tendency (Aalto-Setälä, Marttunen, Tuulio-Henriksson, Poikolainen, & Lönnqvist, 2002; Deykin, Levy, & Wells, 1987; Kuperman et al., 2001; Tapert, Baratta, Abrantes, & Brown, 2002). While these investigations have often been framed in terms of risk, it is also important to consider protective factors—such as problem-solving abilities, prosocial attitudes, and self-esteem. Lastly, it is likely that these biopsychosocial factors interact dynamically, at various developmental stages, to promote—or to protect against—substance abuse in adolescents (Aalto-Setälä et al., 2002; Brook et al., 1998; Guo et al., 2002; Kuperman et al., 2001; Lifrak, McKay, Rostain, Alterman, & O’Brien, 1997; Weinberg et al., 1998).
Relatively less research has considered gender differences in the correlates and risk factors for substance abuse in adolescents. Several studies have approached this question by examining comorbidity differences between males and females with substance abuse problems. These investigations have shown a higher rate of conduct disorder in males, and higher rates of depression and posttraumatic stress disorder in females (Bukstein, Glancy, & Kaminer, 1992; Clark, Pollock et al., 1997; Grilo, Becker, Fehon, Edell, & McGlashan, 1996; Tarter, Kirisci, & Mezzich, 1997). Other studies have examined risk factors in males and females more broadly, but have considered substance use or initiation, and not substance abuse (Brook et al., 1998; Guo et al., 2002; Lifrak et al., 1997; Martin, Milich, Martin, Hartung, & Haigler, 1997; Windle, 1990). Various gender differences have been reported—including a protective effect of some socio-cultural factors for females (Brook et al., 1998; Guo et al., 2002), a deleterious effect of peer support for females (Lifrak et al., 1997), a greater association between self-destructive tendencies and substance use in females (Martin et al., 1997), and greater associations with impulsivity and antisocial tendencies in males (Martin et al., 1997; Windle, 1990). One study did examine problematic alcohol use in the adolescent children of alcoholic parents, and found that externalizing symptoms mediated the relationship between parent antisocial tendencies and alcohol abuse in males, but not in females (Hussong, Curran, & Chassin, 1998). Observing such gender differences can inform us about the manner in which the development of substance abuse may vary between boys and girls, and can have implications for specifying prevention and treatment strategies.
Finally, most studies of the predictors of adolescent substance abuse have considered either alcohol abuse alone, drug abuse alone, or all types substance abuse combined. While there is an extensive literature on the progression from the use or abuse of one substance to the use or abuse of others (Kandel, Yamaguchi, & Chen, 1992; Kuperman et al., 2001), few studies have considered the correlates and risk factors for drug and alcohol abuse separately (Deykin et al., 1987). Only one study, to our knowledge, has examined gender differences as they relate to risk for various substances of abuse—though that study considered only one risk factor (Martin et al., 2002). Comparing types of substance abuse is potentially useful because various substances have different pharmacologic properties, different psychological effects, and different socio-cultural implications—and it is therefore reasonable to think that there may be varying risk factors.
In this study, we examined selected psychosocial correlates of substance abuse in psychiatrically hospitalized adolescents. These correlates reflected psychological functioning as well as environmental factors—and also reflected several of the clinical variables suggested by the literature. We were interested in the extent to which associations may differ according to gender, and also in any differences in correlational patterns with alcohol abuse versus non-alcohol/non-nicotine substance abuse (for which we will use the term “drug abuse”). We utilized dimensional measures of substance abuse, instead of categorical definitions, because dimensional measures more accurately reflect the full range of substance abuse severity, because research has highlighted the clinical significance of sub-threshold substance use in adolescents (Pollock & Martin, 1999), and because of evidence that DSM categorical definitions of substance use disorders may not be appropriate for application to adolescent populations (Harrison, Fulkerson, & Beebe, 1998; Pollock & Martin, 1999; Weinberg et al., 1998).
Section snippets
Participants
Participants were a nearly consecutive series of 462 patients admitted, over a period of 3 years, to the adolescent treatment unit of the Yale Psychiatric Institute—a private, not-for-profit, teaching hospital in New Haven, Connecticut. They ranged in age from 12 to 19 years (M=15.8; SD=1.5); 194 (42%) were male and 268 (58%) were female. The majority (79%) were Caucasian (10% were Hispanic American, 10% were African American, and 1% were of other backgrounds). Patients were hospitalized
Results
Table 1 compares the male and female subgroups with respect to the substance abuse variables and the psychosocial predictor variables. Females have significantly higher levels of alcohol abuse, depression, and childhood abuse, while males score higher on self-esteem and have greater tendencies toward delinquency. These significant group differences suggest that separate analyses for males and females are appropriate.
Table 2 shows the intercorrelations for all of these variables in the overall
Discussion
This study examined psychosocial correlates of substance abuse in a high-risk adolescent population. Our analyses revealed distinct patterns with respect to the independent predictors of drug and alcohol abuse, as well as distinct patterns for males and females. These differences may reflect differing risk factors, in adolescent psychiatric patients, for drug abuse and alcohol abuse—and differing risk factors for males and females.
Our overall predictive model was statistically significant for
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