Substance Use & Misuse
ISSN: 1082-6084 (Print) 1532-2491 (Online) Journal homepage: http://www.tandfonline.com/loi/isum20
Adverse Childhood Experiences and Early Initiation of Marijuana and Alcohol Use: The Potential Moderating Effects of Internal Assets Debanjana Chatterjee, Barbara McMorris, Amy L. Gower, Myriam Forster, Iris Wagman Borowsky & Marla E. Eisenberg To cite this article: Debanjana Chatterjee, Barbara McMorris, Amy L. Gower, Myriam Forster, Iris Wagman Borowsky & Marla E. Eisenberg (2018): Adverse Childhood Experiences and Early Initiation of Marijuana and Alcohol Use: The Potential Moderating Effects of Internal Assets, Substance Use & Misuse, DOI: 10.1080/10826084.2017.1421224 To link to this article: https://doi.org/10.1080/10826084.2017.1421224
Published online: 24 Jan 2018.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum20
SUBSTANCE USE & MISUSE , VOL. , NO. , – https://doi.org/./..
ORIGINAL ARTICLE
Adverse Childhood Experiences and Early Initiation of Marijuana and Alcohol Use: The Potential Moderating Effects of Internal Assets Debanjana Chatterjeea , Barbara McMorrisb , Amy L. Gowerc , Myriam Forsterd , Iris Wagman Borowskyc , and Marla E. Eisenbergc a U.S. Health Economics Outcomes Research, Eisai Inc., New Jersey, USA; b School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA; c Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA; d Department of Health Sciences, College of Health and Human Development, California State University, Northridge, Los Angeles, California, USA
ABSTRACT
KEYWORDS
Introduction: Early adolescence is a critical risk period for initiation of substance use. Internal assets (IAs), which are individual qualities guiding positive choices, and adverse childhood experiences (ACEs) are important protective and risk factors, respectively, against substance use. The purpose of this study is to investigate whether IAs modify associations between ACEs and early initiation of alcohol and marijuana use. Method: Data were from 9th and 11th graders who completed the 2013 Minnesota Student Survey (n = 79,339). Students reported on experiences of abuse, household dysfunction, and substance use. Multivariable logistic regressions examined associations between different types of ACEs and substance use. Interactions between IAs and ACEs were added to models to test effect modification. For significant interactions, main effects models were re-estimated at different percentiles of IAs. Result: IAs moderated associations of both abuse and household dysfunction with early initiation of marijuana (p < .003) and alcohol (p = .007) for females but not for males. For females with low IAs, odds of early initiation of marijuana were approximately twice as high as students without any ACEs. A similar pattern was detected for females’ initiation of alcohol use. No effect modification was detected for IAs and experiencing only abuse or household dysfunction on initiation. Conclusion: Special attention should be paid to improving IAs among girls who have already experienced ACEs. Future research should examine protective factors that buffer the effects of ACEs for boys.
Adolescence; adverse childhood events; alcohol; internal assets; marijuana
Introduction In the United States, marijuana and alcohol are two of the most commonly used substances by adolescents (Johnston, O’Malley, & Bachman, 2000; Kosterman, Hawkins, Guo, Catalano, & Abbott, 2000). Extant research has demonstrated that substance use initiation in adolescence increases risk for a range of serious health and behavioral problems (Bachman, 1978; Gruber, DiClemente, Anderson, & Lodico, 1996; Kandel & Logan, 1984), including subsequent misuse of substances (Hawkins et al., 1997), and that initiation during early adolescence (age 12– 14 years) is a strong predictor of later dependence (Dawson, Goldstein, Patricia Chou, June Ruan, & Grant, 2008; King & Chassin, 2007; Lopez-Quintero et al., 2011; Substance Abuse and Mental Health Services Administration, 2012). Among adults who tried marijuana by age 14 or younger, 13% were classified as illicit drug dependent or with abuse disorders, six times higher than that for adults who first used marijuana after age 18 (Substance Abuse and Mental Health Services Administration, 2012). Sim-
ilarly, adolescents who have their first drink at or before age 14 are six times more likely to develop alcohol problems in later years than those who do not try alcohol until the legal drinking age (Substance Abuse and Mental Health Services Administration, 2012). Early substance use initiation is more common among boys, with 64% of males reporting substance use initiation between 12 and 14, while only 36% of females reported doing the same (Substance Abuse and Mental Health Services Administration, 2012). Since the landmark ACEs study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente (Anda et al., 1999; Anda et al., 2006), a mounting body of evidence indicates that adverse childhood events (ACEs), a set of highly correlated negative and traumatic events experienced before age 18 that include childhood maltreatment and household dysfunction, are associated with early initiation of marijuana and alcohol use (Blum et al., 2000; DeWit, Adlaf, Offord, & Ogborne, 2000; Dick,
CONTACT Debanjana Chatterjee, PhD vard, Woodcliff Lake, NJ , USA.
Manager, U.S. Health Economics Outcomes Research, Eisai Inc., , Tice Boule-
© Taylor & Francis Group, LLC
[email protected]
2
D. CHATTERJEE ET AL.
Rose, Viken, & Kaprio, 2000; Dube et al., 2003; Dube et al., 2006; Forster, Gower, Borowsky, & McMorris, 2017; Gillmore et al., 1990; Kosterman et al., 2000; Ompad et al., 2005; Rothman, Edwards, Herren, & Hingson, 2008; Wang et al., 2009). The prolonged activation of the stress response, due to ACE exposure, can impair healthy development of brain structures thereby increasing vulnerability for stress-related health behaviors such as substance use (American Psychological Association, 2014; Brady & Sonne, 1999; Center on the Developing Child, 2015). Overwhelmingly, empirical studies investigating the association between ACEs and health have found that the likelihood of poor outcomes increases as the number of ACEs increases (Anda et al., 2006; Shonkoff & Garner, 2011), with even one additional ACE increasing the likelihood of early initiation of both illicit drug and alcohol use. As with early substance use initiation, differential prevalence of ACEs has been documented among boys and girls, with females reporting higher levels of exposure to sexual assault and interpersonal victimization while males report higher rates of witnessing violence (Cauffman, Feldman, Watherman, & Steiner, 1998; Ford, Chapman, Hawke, & Albert, 2007; Wood, Foy, Layne, Pynoos, & James, 2002). In contrast to deficit-based models of adolescent health behaviors, the healthy youth development framework, a strengths-based approach, has identified internal assets (IAs) as an important promotive factor for adolescent substance use (Leffert et al., 1998). Extensive research conducted by the Search Institute, a leader and partner for organizations dedicated to discovering resources needed by children and adolescents to succeed, conceptualized, and constructed the “IAs” scale. This composition of personal values, social competencies, commitment to learning, and positive identity are individual qualities that guide positive choices and the development of confidence, passion, and purpose (Search Institute, 2015). IAs are critical components of healthy development because they are central for effective self-regulation (Scales, Benson, Leffert, & Blyth, 2000) and are recognized as important areas of intervention to improve health and behavioral outcomes over the life course (Cheney, Oman, & Vesely, 2015; Oman et al., 2004). There are crucial gender differences in the importance of IAs that tend to vary across life stages and with the demands of each gender in the context of prevailing sex role expectations (Goldstein & Brooks, 2012). To address these, the Search Institute (2012) recommends that particular attention needs to be provided girls so that they can develop and express assertiveness skills, personal control, and skill mastery whereas for boys, development and expression of compassion and caring skills should be stressed (Search Institute, 2012).
Although research has extensively investigated the role of risk and protective factors on adolescent substance use patterns, no studies to our knowledge have investigated whether IAs moderate the association between childhood abuse or household dysfunction and early initiation of marijuana and alcohol using a population-based dataset. Understanding the potential buffering role of IAs could reveal important avenues for intervention with vulnerable, trauma exposed youth populations. Building upon the research demonstrating an association between ACEs and substance use, the purpose of this study was to investigate if, and to what extent, IAs moderate the relationship between ACEs and early initiation of alcohol and marijuana use. Specifically, we tested hypotheses that (1a) the associations between experiencing any maltreatment, (1b) any household dysfunction, or (1c) both and early initiation of marijuana and alcohol would be stronger for adolescents with lower IAs than for those who report higher IAs. Given the demonstrated gender differences in ACE-risk behavior relationship (Shilling et al., 2007) and IAs, we examined the role of gender in these associations as well.
Methods Study sample Data came from the 2013 Minnesota Student Survey (MSS), a statewide survey of 5th, 8th, 9th, and 11th graders attending Minnesota public schools. All publicschool districts were invited to take part; 280 out of 334 districts in the state participated (84%). Parents were notified of survey administration and could decline consent to participate. Data collection was anonymous. Students who were included in the MSS are generally representative of the demographic profile of the state (Minnesota State Epidemiological Outcomes Workgroup, 2014; United States Census, 2015). Additional details about the MSS survey are discussed elsewhere (Eisenberg, Gower, & McMorris, 2016; Eisenberg, Gower, McMorris, & Bucchianeri, 2015; Gower, McMorris, & Eisenberg, 2015). Fifth and 8th graders were not asked about experiences of abuse or household dysfunction and were excluded from analysis. The remaining sample included 79,339 students from 9th and 11th grades. The University of Minnesota’s Institutional Review Board determined that this analysis was exempt from review due to use of existing anonymous data. Measures Dichotomous variables for early initiation of alcohol and marijuana use were constructed based on the following
SUBSTANCE USE & MISUSE
questions: “How old were you when you had your first drink of an alcoholic beverage such as beer, wine, wine cooler and liquor, other than a few sips?” and “ …tried marijuana (pot, weed) or hashish (hash, hash oil) for the first time.” Answers ranged from “age 10 or younger” to “17 years or older” and included a “never tried” option. Informed by existing research (Syvertsen, Cleveland, Gayles, Tibbits, & Faulk, 2010), among those who ever tried marijuana or alcohol, students who reported first use at age 14 or younger were categorized as early initiators. Guided by the framework of the Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2014) and supported by original research (Duke, Pettingell, McMorris, & Borowsky, 2010), an affirmative response to any of four questions indicated abuse: (a) “Does a parent or other adult in your home regularly swear at you, insult you or put you down?,” (b) “Has a parent or other adult in your household ever hit, beat, kicked or physically hurt you in any way?,” (c) “Has any adult or other person outside of the family ever touched you sexually against your wishes or forced you to touch them sexually,” and (d) “Has any older or stronger member of your family ever touched you or had you touch them sexually?” Similarly, an affirmative response to any of three questions indicated household dysfunction: (a) “Do you live with anyone who drinks too much alcohol?,” (b) “Do you live with anyone who uses illegal drugs or abuses prescription drugs?,” (c) “Have your parents or other adults in your home ever slapped, hit, kicked, punched or beat each other up?” Students were categorized into four mutually exclusive categories based on their experiences of adverse events: (a) abuse, (b) household dysfunction, (c) both household dysfunction and abuse, and (d) neither. IAs were assessed with 14 items from the Developmental Assets Profile (Search Institute, 2012, 2012, 2015). Complete subscales for social competency (six items; α = .84; e.g., “I express my feelings in proper ways”) and positive identity (eight items; α = .82; e.g., “I feel in control of my life and future”) were included. Students responded on a four-point scale with response items ranging from “not at all or rarely” to “extremely or almost always.” These items were averaged to create a measure of IAs (range = 1–4; α = .90). Participants who provided data on fewer than 11 items (n = 4,429, 5.8%) were excluded from analysis. We adjusted for multiple sociodemographic variables in our analyses. Binary variables for gender (male or female) and grade (9th or 11th) were based on student report. Race/ethnicity groups were defined as Hispanic and non-Hispanic White; Black/African/African American; Asian/Pacific Islander; American Indian; and multiple races. Three items were used to determine poverty status, including receipt of free or reduced price
3
lunch, experiencing homelessness in the past year, and experiencing food insecurity in the last 30 days. Students reporting any of these were included in the poverty group. Family composition was defined as youth living with two biological parents versus any other family unit. School location was binary with the school in the seven-county metropolitan area versus other nonmetropolitan areas of Minnesota. A potential confounder, connections to parents, was measured using responses from two separate questions. Students were asked whether they can talk about their problems with their father and mother. Students who responded “yes, most of the time” or “yes, some of the time” to each of these questions were categorized as having high connectedness with their respective parents. Statistical analyses Analyses were conducted using SAS 9.4 (2014). In our sample (n = 79,339) of 9th and 11th graders, 6.3% had missing information on ACEs, 1.1% on race and ethnicity, 2.5% on the poverty measure, and less than 1% for parent communication and household composition. We did not have age of initiation information on 8.8% and 8.6% of the participants for alcohol and marijuana use, respectively. For IAs, we did not have information on 5.8% of the students in our sample because of nonresponse to at least 11 items in the questionnaire used to create the IAs score. Missing data on ACEs, age of substance use initiation, IAs and demographic variable ranged from 1.1% to 6.3%. To determine the representativeness of the analytic sample, we used chi-square tests to compare those who were and were not included in the analysis based on data availability of substance use initiation. Students with missing information on marijuana initiation were more likely to experience abuse and household dysfunction (12.6% vs. 9.8%, p < .001); however, among teens with missing information on alcohol use initiation, did not differ in their experiences of ACEs. There were no significant differences in the mean IAs among these groups. Given prior evidence of gender differences in both ACEs and IAs, all analyses were stratified by gender a priori (Cauffman et al., 1998; Duke et al., 2010; Ford et al., 2007; Wood et al., 2002). Chi-square tests were used to detect differences in prevalence of early initiation of marijuana and ACE, adjusting for other risk and protective factors by gender. Separate staged multivariable logistic regression models were used to generate odds of early initiation of marijuana use and alcohol use for youth who experienced any abuse, any household dysfunction or both, with students who experienced neither as the reference category, adjusting for IAs and all covariates (first stage).
4
D. CHATTERJEE ET AL.
Table . Descriptive statistics for the total student sample, stratified by gender.
Age Race/Ethnicity Hispanic White (non-Hisp) Black (non-Hisp) Asian/Pacific Islander (non-Hisp) American Indian (non-Hisp) Multiple races (non-Hisp) Other (non-Hisp) Poverty status Yes () No () Grade th th School location Metropolitan area () Nonmetro () Family composition Two parent household Other Connections to parents Talk about problems some or most of the time with mother Talk about problems some or most of the time with father Early initiation of: Marijuana Alcohol Experience of: Any abuse Any household dysfunction Both abuse and household dysfunction Neither abuse nor household dysfunction a Internal assets scores
Total n = , % or Mean (SD)
Boys n = , % or Mean (SD)
Girls n = , % or Mean (SD)
. (.)
. (.)
. (.)
. . . . . . .
. . . . . . .
. . . . . . .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. .
. . . . . (.)
. . . . . (.)
. . . . . (.)
p value, gender diffs
