Predictors and outcomes of adolescent alcohol and drug use: a scoping review

These commentaries [1,2] as well as the Engberg & Morral [3] paper, raise important and thought-provoking questions concerning the role of adolescent substance use in academic outcomes. Godley [1] makes the point that, regardless of the nature of the relation between academic achievement and substance use, schools are an important potential intervention environment for adolescents who are at risk for substance use problems. Indeed, our own findings and those of Engberg & Morral [3] suggest that adolescent drug use is related to reductions in sustained engagement in academic pursuits, which implies that interventions outlined by Godley [1] could improve school engagement and attendance. Engberg & Morral's data are particularly compelling, as they demonstrate that reducing substance use through a treatment program increases school attendance among heavy drug-using adolescents. Taken together, the results of both empirical studies suggest that decreasing drug use will produce improvements in academic outcomes. Results of both studies [3,4] underscore the importance of clarifying the mechanisms by which substance use influences academic outcomes. Research suggests at least two potential mechanisms. First, substance use itself may impair cognitive development which, in turn, reduces academic achievement and disrupts academic progression. Recent studies have shown that heavy adolescent substance use can lead to problems with working memory and attention due to changes in adolescent brain activity [5]. In turn, these memory and attention problems may lead to decreases in academic performance and engagement in school, and ultimately increase risk for school problems and dropout. However, these findings have been reported with heavy drinking and drug-using adolescents (similar to the clinical sample used by Engberg & Morral), and it is unclear whether such effects would emerge at lower levels of use. Moreover, the magnitude and permanence of these effects are unclear in terms of whether they extend to impair academic functioning. For example, studies [6,7] suggest that withdrawal is an important predictor of the neurocognitive deficits associated with adolescent drinking, but it is not clear whether prolonged periods of abstinence rectifies these deficits or whether they are permanent. Alternatively, it could be that drug and alcohol use during adolescence leads to association with antisocial peer groups, which in turn diminishes school engagement and increases other behavioral and social problems. Indeed, as Godley and the current studies support, substance use is related to many school-related outcomes that have a strong behavioral and social component. That is, outcomes such as school grades, attendance, school completion and dropout are influenced not only by intellectual functioning, but also by motivation, organizational skills and social/behavioral skills. In other words, the effects of substance use on academic outcomes may have motivational, social and behavioral components in addition to any effects on cognition and cognitive development. Thus, negative academic outcomes may be due to both the direct effect of substance use on cognitive skills as well as the constellation of motivational, social and behavioral risk factors associated with substance use in adolescence. Interestingly, the findings from the current studies suggest that the mechanism by which substance use influences academic performance may differ depending on the nature of the adolescent sample (clinical versus community) and the developmental outcome that is studied (high school attendance versus academic achievement and college completion). Specifically, the substance use of heavy drug-using adolescents may directly impair academic (cognitive) abilities which limits academic performance in adolescence. For most adolescents who use drugs at a lower level, however, adolescent drug use may serve as a maturational ‘snare’ that keeps some adolescents engaged in deviant peer groups as others move on to more normative groups, thus having a long-term direct effect on educational attainment. Other studies [8–10] have discussed similar processes, in which differential pathways to problematic outcomes are determined, in part, by the level of multiple risk behaviors. If we believe that multiple mechanisms are operating, then it follows that preventive interventions aimed at improving academic engagement should broaden their focus beyond drug use in adolescence. We echo Godley's [1] suggestion that community and family risk factors should also be targets of intervention. Our findings showed that drug use in adolescence partially mediated the effect of adolescent externalizing behaviors on college completion; adolescent externalizing also had direct effects on both adolescent reading achievement and on degree completion [3]. This implies that a powerful target of intervention would be externalizing behaviors, especially for adolescents who have not yet developed heavy or problematic levels of alcohol and/or drug use. This commentary was supported by Grant AA16213 from the National Institute an Alcohol Abuse and Alcoholism to Laurie Chassin and a National Research Service Award from the National Institute on Drug Abuse to Kevin M. King, Grant DA019753.

This chapter reviews the literature on family, peer, and media influences on alcohol, tobacco, and other drug use among children and adolescents. Parental drinking and drug use are significant predictors of child and adolescent drinking, smoking, and marijuana use. Furthermore, parental substance use is associated with lower quality parenting and family management practices, which are, in turn, associated with greater offspring substance use. In addition, parental substance use and parenting practices are associated with adolescents’ affiliation with substance-using friends. Parental nonuse and effective parenting practices buffer the relation between friends’ modeling of substance use and adolescent offspring substance use. Sibling and friend substance use relate both concurrently and longitudinally to adolescent substance use. Lastly, child and adolescent exposure to alcohol and smoking on television and in films, and to alcohol and cigarette advertising, constitutes a third independent source of modeling and influence on child and adolescent substance use.

The present study examined putative environmental predictors of adolescent substance use, using a prospective adoption design to distinguish between environmental mediation (i.e., parenting influencing adolescent substance use), passive gene-environment correlation (i.e., parental genetic predisposition influencing the association between parenting characteristics and adolescent substance use), and evocative gene-environment correlation (i.e., children's genetic predisposition influencing parenting). Longitudinal data from the Colorado Adoption Project (395 adoptees, 491 nonadoptees, 485 adoptive parents, and 490 biological parents) were examined. Children (48% girls) were assessed at ages 1 to 17 years. Over 90% of the sample were non-Hispanic White. Associations between parenting and adolescent substance use were compared between adoptive and nonadoptive families. Positive, negative, and inconsistent parenting measures in early childhood through adolescence were not consistently associated with adolescent substance use, with only 6% of correlations being statistically significant (r = -0.152 to .207). However, parent-child relationship quality assessed from childhood to adolescence and orientation to parents assessed during adolescence were significantly, negatively associated with adolescent substance use, with 71% of correlations being statistically significant (r = -0.88 to -0.11). There was little evidence of sex differences in the associations. Environmental mediation, rather than passive or evocative gene-environment correlation, explained most associations.

ADOLESCENT ESTIMATION OF PEER SUBSTANCE USE: WHY IT MATTERS

Poly drug use in adolescents represents a significant public health issue, heightening risk for abuse, dependency, and a variety of short- and long-term psychological, psychosocial, and health consequences. However, past studies have typically examined just one or two substances in isolation and there is a lack of research that has comprehensively examined possible predictors of poly drug use in adolescents. To inform the development of comprehensive prevention programs that can simultaneously target multiple substances, the present study sought to identify psychological, environmental, and demographic factors that are most strongly associated with alcohol, tobacco, and cannabis poly drug use. Adolescents aged 15 to 17years (n = 1661; 50.9% male) completed a survey on their use of alcohol, tobacco, and cannabis over the last 30days. Various psychological, environmental, and demographic factors were also assessed. Weighted multiple-level logistic regression was conducted to assess the factors associated with poly drug use. In total, 20.3% of respondents had used at least one substance, 6.7% reported using two substances, and 3.3% reported using all three substances. The most common combined pattern of use was alcohol and tobacco, followed by alcohol and cannabis. Several factors emerged as significant, with conduct problems, depression, and the school environment accounting for the most variance. Specific psychological and environmental factors appear to be particularly important domains to target in adolescent substance use prevention programs. Early identification of adolescent depression and conduct problems and the development of programs that address these symptoms in youth may be effective approaches to delaying or preventing poly drug use in this population.

Adverse childhood experiences (ACEs) are associated with an increased risk of substance use during adolescence. However, most prevention efforts target youth with known childhood adversities who are receiving services in clinical or service programs, not in public settings such as schools. Moreover, research on the relationship between ACEs and substance use, as well as on the effectiveness of prevention strategies to mitigate the impact of ACEs on substance use, remains limited in East Asian countries, including Taiwan. This study aimed to address existing research gaps by examining the effects of a universal, school-based intervention on substance use outcomes among adolescents. Specifically, the study sought to examine the moderating effects that a life-skills intervention program, the Positive Interpersonal and Life Skills Training (PILOT), had on Taiwanese middle school adolescents with ACEs, assessing the program’s impact on their level of substance use-related knowledge, attitudes, and skills. A total of 257 students from two middle schools in Taiwan participated in the study during the spring and fall of 2023. Of these, 139 students received the 8-module PILOT program integrated into their regular school curriculum, while 118 students received the standard curriculum. Participants completed pre-test and post-test questionnaires assessing ACEs and substance use prevention outcomes. The results indicate that ACEs were significantly associated with reduced substance-use-related knowledge among participants. The findings further confirmed the effectiveness of life skills-based interventions in enhancing substance use-related knowledge among Taiwanese middle school students. Notably, the PILOT program demonstrated a significant moderating effect, improving substance use-related knowledge among students with higher ACE exposure. In conclusion, life skills-based interventions can mitigate the negative impact of ACEs on adolescents’ substance use prevention knowledge, which highlights the potential of universal, school-based life skills programs to serve as protective buffers for adolescents facing adversity.

1. Kirstin A. M. Nackers, MD* 2. Patricia Kokotailo, MD, MPH* 3. Sharon J. L. Levy, MD† 1. *Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI. 2. †Division of Developmental Medicine, Boston Children’s Hospital, Boston, MA. The American Academy of Pediatrics recommends screening for alcohol and other drug use at adolescent health supervision visits and appropriate acute-care visits, (1) yet many clinicians find addressing substance use with youth to be a challenge. After completing this article, the reader should be able to: 1. Describe the use trends for alcohol and common other drugs by youth in the United States. 2. Explain the primary care clinician’s role in screening and management of alcohol and substance use. 3. Using motivational interviewing techniques, adopt an in-office brief intervention across the spectrum of adolescent substance use. 4. Analyze the utility of urine drug testing in various clinical situations, such as random screening in a low-risk patient/population, testing an adolescent who self-reports ongoing substance use, monitoring adherence to treatment for a substance use disorder, and evaluating a patient with signs/symptoms of acute toxicity. Adolescent drug and alcohol use remains a major issue in the United States. The American Academy of Pediatrics (AAP) recommends screening for use of these substances at adolescent health supervision visits and appropriate acute-care visits. (1) Primary care clinicians (PCCs) serve an important role in both the identification and management of alcohol and substance use disorders (SUDs). This role comes with many challenges, including managing the dynamics of families that may be in crisis, issues of adolescent confidentiality, and high variability of local resources to support patients in need of treatment for SUDs. In this article, we review the epidemiology of alcohol and substance use, the approach to screening and treatment, the issue of adolescent confidentiality, and the role of urine drug testing. ### Epidemiology The epidemiology of adolescent substance use must be …

The peer context is perhaps the most salient, robust predictor of an adolescent's substance use. However, in previous studies, the peer context is often poorly defined. The current study examined 3 models to understand how substance use within best friendships, peer cliques, and social crowds predicts adolescents' substance involvement. A sample of 377 high school juniors and seniors completed surveys assessing substance use and peer relationships. Results suggest that each of these 3 dimensions of the peer context uniquely predict adolescent substance use. Moreover, these peer contexts interacted in the prediction of adolescents' substance use such that adolescents who were more highly embedded in substance-using peer contexts showed greater risk for substance use whereas adolescents with substance-using best friends showed a reduced risk for substance use if they had other close friends who were less involved with substances.

Childhood sexual abuse and adolescent substance use: A latent class analysis

Parental illicit substance use is associated with increases in both interparental conflict frequency and children’s externalizing behaviors. There is a paucity of research examining the pathways linking these constructs. Assessing parental illicit substance use and interparental conflict frequency simultaneously can illustrate a process that potentially undermines children’s behavioral adjustment. Using a sample of stable, long-term couples and their children from the Future of Families and Child Wellbeing Study ( n = 1,011), the current study used path modeling and a multi-informant approach to examine the link between parental substance use and children’s later externalizing behaviors and if interparental conflict frequency mediated this association. Results indicated that parental substance use, assessed at the couple-level, was not associated with children’s later externalizing behavior, nor did interparental conflict frequency mediate this association. Post-hoc exploratory analyses found that mothers’ substance use was associated with children’s later externalizing behaviors, and this effect was stronger than fathers’ substance use, which was not associated with children’s later functioning. These results highlight the importance of examining how various aspects of substance use and different dimensions of interparental conflict might differentially impact children’s outcomes.

Adaptation of the Drug and Drug Problems Perception Questionnaire to assess healthcare provider attitudes toward adolescent substance use.

states that have legalized medical marijuana also have a greater percentage of adolescents who consider the drug to be less risky (3). The exact nature of this association is to be determined but should impact on the policy decisions related to substance abuse by groups like CARIAD. The evaluation by Reid et al of the effectiveness of CARIAD in meeting its training objectives to educate health and allied professionals about alcohol and drug use, and increase awareness of addiction issues in the Caribbean is included among the articles presented in this special edition of the Journal (4). As the cultural norms of the society change, it will continue to influence drug usage. This will not only be for adolescents but also young adults, particularly those engaged in academic pursuits. Undergraduate students and their substance use are also featured in this issue, where WhitehorneSmith et al investigated the drug use practices of medical/ health students (5). This has added to the empirically based research on drug use in this particular group across the Caribbean and Latin America and indicates that the trend in adolescent substance use continues into adulthood, with alcohol being the most commonly abused substance. The relatively high prevalence of alcohol use among Caribbean adolescents and adults, along with its relationship with emotional anguish, will continue to present a significant public health challenge for lowand middle-income countries. Through organizations such as CARIAD and the National Council on Drug Abuse (NCDA) in Jamaica, contextand culture-specific strategies to decrease the physical availability of alcohol and other drugs need to be implemented to reduce adolescent and young adult drug use (6). Substance abuse has become associated with a myriad of medical, psychiatric, social/family, employment, and legal problems internationally and similarly in Jamaica and the wider Caribbean. In terms of the relationship between substance abuse and violence and offending behaviour, substances not only impact on community violence but also violence in the home and in institutions. Substance use contributes more to the public health burden of the cycle of domestic violence more than any other risk factor (7). Longman-Mills et al have studied the relationship between physical abuse during childhood and experiencing psychological distress and substance abuse among university students (8). The authors were able to identify that experiencing physical abuse increases the likelihood of having higher levels of psychological distress and becoming a From: Department of Community Health and Psychiatry, The University of the West Indies, Kingston 7, Jamaica.

Background: Adolescence is a common time for experimentation with substance use and the emergence of sex differences in substance use patterns. Although similar in early adolescence, male and female substance use patterns historically diverge by young adulthood, with males using more substances than females. We aim to add to current literature by utilizing a nationally representative sample, assessing a broad range of substances used, and focusing on a sentinel period during which sex differences emerge. We hypothesized that certain sex-specific substance use patterns emerge in adolescence. Methods: Data are from the 2019 Youth Risk Behavior Survey (n = 13,677), a nationally representative sample of high school students. Weighted logistic analyses of covariance adjusting for race/ethnicity evaluated males’ and females’ substance use (14 outcomes) by age category. Results: Among all adolescents, more males reported illicit substance use and cigarette smoking than females, whereas more females reported prescription opioid misuse, synthetic cannabis use, recent alcohol use, and binge drinking. Divergence between male and female use usually occurred at 18+ years. Odds of using most illicit substances were significantly greater among males than females at age 18+ years (aORs 1.7–4.47). Among 18+ year-olds, males and females did not differ in electronic vapor product use, alcohol use, binge drinking, cannabis use, synthetic cannabis use, cigarette smoking, or prescription opioid misuse. Conclusions: Sex differences in adolescent use of most but not all substances emerge by age 18+ years. Sex-specific patterns of adolescent substance use may inform specific prevention efforts and identify peak ages for intervention.

The purpose of this study was to evaluate the relationship between use of tobacco, alcohol, marijuana, and hard drugs (substance use) and psychiatric disorder in early adolescence and substance use in late adolescence. Adolescents included in the study were identified by means of a household sampling frame and participated in the Ontario Child Health Study in 1983 and the follow-up in 1987. There were 726 12-16-year-olds (369 boys and 357 girls) in 1983 who had complete information in 1987. Data on substance use were collected from adolescents by using a structured, self-administered questionnaire. Data on psychiatric disorder were collected in 1983 from both adolescents and their parents by using problem checklists to assess conduct disorder, attention deficit disorder, and emotional disorder. Prior substance use in 1983 was associated strongly with subsequent use in 1987. Among the psychiatric disorders assessed in 1983, only conduct disorder made an independent contribution to predicting use of marijuana (relative odds = 3.46) and other hard drugs (relative odds = 6.82) in 1987, after prior use of these substances and coexisting attention deficit and emotional disorders were controlled. Corresponding estimates of attributable risk (the expected contribution of exposure to conduct disorder to the development of substance use) were 5.7% and 11.1%, respectively. Although a statistically significant relationship existed between conduct disorder in early adolescence and use of marijuana and hard drugs in late adolescence, the potential is limited for preventing substance use in the general population by treating conduct disorder early on.

Parents play a role in shaping their children's beliefs and behaviors around substance use. When faced with unfamiliar or challenging situations, many parents turn to peers for advice. This study characterized the substance use-related advice parents sought from peers in an online parenting forum. We conducted a content analysis of substance use-related posts from the r/parenting subreddit. Among the advice-seeking posts included in this study (n=156), thematic coding assessed the presence (yes/no) of seven themes: (1) general communication with children about alcohol and drugs, (2) parental substance use, (3) responding to a child's substance use, (4) permissiveness of a child's substance use under adult supervision, (5) pregnancy or breastfeeding and substance use, (6) nicotine and tobacco use around children, and (7) dealing with an adult family member who is using substances or getting help for substance use problems. Posts could be coded into multiple themes. Two coders independently annotated posts (κ = 0.75). Parents asked about responding to a child's substance use (67/156; 42.9%), parental substance use in parenting contexts (54/156; 34.6%) and navigating other adult family members' substance use (54/156; 34.6%). Parents sought advice about general communication with children about alcohol and drugs (21/156; 13.5%), nicotine and tobacco use around children (19/156; 12.2%), permissiveness of adolescent substance use under adult supervision (18/156; 11.5%), and substance use during pregnancy or breastfeeding (4/156; 2.6%). Findings may inform the development of targeted resources, guide public health messaging, and support the use of social media data in ongoing research relevant to family development. This study shows that parents turn to online forums like Reddit for advice related to substance use and their children. Understanding the kinds of questions parents have can help shape educational resources and public health messaging that directly addresses these concerns.