Examining the internalizing pathway to substance use frequency in 10 cultural groups
Introduction
Frequent illicit substance use, along with mental disorders, account for the largest percentage of global health burden for 10–24-year-olds, according to the World Health Organization (Degenhardt, Stockings, Patton, Hall, & Lynskey, 2016). Therefore, international health organizations have prioritized adolescent substance use prevention (Degenhardt et al., 2016) by identifying and ameliorating preadolescent pathways to frequent adolescent substance use (Hussong, Jones, Stein, Baucom, & Boeding, 2011).
Currently, two such risk pathways have been hypothesized: the externalizing and internalizing pathways to substance use (Hussong, Rothenberg, Smith, & Haroon, 2018). The externalizing pathway is more widely studied and marked in childhood by the emergence of externalizing behaviors that persist into adolescence and predict substance use escalation (Zucker, Heitzeg, & Nigg, 2011). Strong evidence for this pathway emerges in longitudinal studies (Hussong et al., 2018).
The internalizing pathway to substance use is less studied, and hypothesized to be marked in infancy and childhood by behavioral inhibition (i.e., dispositional cautiousness/shyness/avoidance), which leads to the development of internalizing symptoms (i.e., anxiety, depression; Hussong et al., 2011). These symptoms persist throughout childhood and lead to interpersonal skill deficits. In adolescence, internalizing symptoms and interpersonal skill deficits predict the escalation of substance use, as adolescents turn to substance use to cope with these problems (Hussong et al., 2018). Questions remain about how the internalizing pathway operates.
One question is whether the entire internalizing pathway can be found in one sample over time. Specifically, behavioral inhibition in childhood predicts greater alcohol-related problems at age-21 (Caspi, Moffitt, Newman, & Silva, 1996). Additionally, child internalizing symptoms prospectively predict frequent substance use (Hussong, Ennett, Cox, & Haroon, 2017), and a lack of social ties exacerbates frequent substance use in adolescents experiencing depressive symptoms (Cole et al., 2019, Hussong et al., 2018). Yet, to our knowledge, no investigation has ever simultaneously investigated all of these primary predictor and outcome variables in a single sample. The present study does so, providing a strong test of the internalizing pathway’s validity.
A second question considers how the internalizing pathway functions alongside the externalizing pathway. Systematic reviews find that only symptoms of depression (not anxiety) predict frequent adolescent substance use after controlling for externalizing symptoms (Hussong et al., 2017). Therefore we only investigate depressive symptoms presently. Additionally, externalizing symptoms can be integrated into internalizing pathway conceptualizations (Eiden et al., 2016). Childhood internalizing symptoms might subsequently lead to the emergence of adolescent externalizing symptoms as youth high in internalizing symptoms turn to deviance to avoid rejection/loneliness and “fit in” with peers (Hussong et al., 2011). Elevated externalizing symptoms are then posited to lead to affiliations with deviant peers who support substance use, and greater substance use opportunities (Hussong et al., 2011).
Eiden and colleagues have evaluated aspects of this “externalizing branch” of the internalizing pathway longitudinally, demonstrating that early adolescent behavioral inhibition predicts mid-adolescent internalizing symptoms (Rhodes et al., 2013), and that mid-adolescent externalizing symptoms subsequently predict affiliation with peers who support substance use and eventual increased substance use (Eiden et al., 2016). However, the prospective link between internalizing and externalizing symptoms along this pathway has not been evaluated, nor has this “externalizing branch” been investigated alongside the typical internalizing pathway. We fill both gaps presently.
A third question is whether the internalizing pathway is cross-culturally generalizable. This pathway has only been studied in American/European samples due to a paucity of data worldwide (Degenhardt et al., 2016). Yet, scholars have identified markers of this pathway, including internalizing behaviors, peer support of use, and substance use availability as risk factors for frequent adolescent substance use that might be applicable in cultures worldwide (Degenhardt et al., 2016). Therefore, studies that investigate this pathway across cultures are needed (Degenhardt et al., 2016).
An important cross-cultural starting point is to determine the extent to which adolescent substance use frequency is explained by differences between cultures, versus differences within cultures (Deater-Deckard et al., 2018). This knowledge would be beneficial for two reasons. First, it would be useful to know whether the internalizing pathway predicts substance use frequency within cultures even after accounting for variations in adolescent substance use frequency across cultures. Answering this question evaluates the cross-cultural generalizability of the internalizing pathway. Second, it would be useful to know whether between-culture differences in internalizing pathway variables predict between-culture variation in adolescent substance use frequency. Answering this question identifies prospective risk factors in countries at highest risk for frequent adolescent substance use (Degenhardt et al., 2016).
We answer both questions by investigating the internalizing pathway in a sample of children followed from ages 8–14 in 10 cultural groups from countries ranging from 8th to 145th in the 2015 Human Development Index (United Nations Development Programme, 2015).
We have three objectives. First, we examine each of the links in the internalizing pathway across childhood and adolescence (Fig. 1 solid paths). We expect the internalizing pathway to emerge even after accounting for between-culture variations in substance use frequency, and the powerful direct effects of earlier externalizing symptoms on later substance use frequency. Second, we seek to understand how externalizing symptoms inform internalizing pathway development by testing Hussong’s “externalizing branch” of the internalizing pathway (Fig. 1 dashed paths). Third, we investigate whether the internalizing pathway is associated with variability in substance use frequency both between- and within-cultures (Fig. 1; part of the model labeled 3).
Importantly, we employ the recommended multi-reporter, multimethod longitudinal design to study adolescent substance use frequency (Eiden et al., 2016). Specifically, we evaluate objectives with two models: one using adolescent self-reports of depressive and externalizing symptoms, and age-14 substance use frequency, and a second where depressive and externalizing symptoms combine all available reports (mother/father/adolescent), and age-13 substance use frequency is mother-reported.
Section snippets
Participants
Participants included 1,083 children (M = 8.29 years, SD = 0.66, 51% girls) followed from ages 8–14, their mothers (M = 36.93 years, SD = 6.27), and their fathers (M = 39.96 years, SD = 6.52). Families were recruited from 10 ethnic/cultural groups including: Shanghai, China (n = 121); Medellín, Colombia (n = 108); Naples (n = 100) and Rome (n = 103), Italy; Kisumu, Kenya (n = 100); Manila, Philippines (n = 120); Chiang Mai, Thailand (n = 120); and Durham, NC, USA (n = 111 White, n = 103 Black, n
Results
Descriptive statistics (Table 1; Table 2) revealed that 15.7% of mothers reported their 13-year-olds had used at least one substance in the past year, and 12.0% of 14-year-olds self-reported use of substances in the past 6 months.
Significant Intraclass Correlations revealed that 93% of age-13 and 99% of variance in age-14 adolescent substance use frequency in each respective model was attributable to within-culture differences. Therefore, we grand-mean centered predictor variables to capture
Finding an internalizing pathway
This study contributes to existing literature by providing evidence that a depressive pathway to adolescent substance use frequency persists from ages 8–14 in a variety of cultural groups, even after controlling for between-culture differences. Perhaps as impressively, this within-culture depressive pathway prospectively predicts adolescent substance use frequency above-and-beyond adolescent opportunities for substance use, and earlier externalizing symptoms (two powerful use predictors;
Conclusion
Results indicate depressive and externalizing symptoms each uniquely predicted more frequent adolescent substance use. Results also indicate that mediating depressive and externalizing branch pathways predicted frequent substance use within many cultures. Additionally, cultures with greater age-12 substance use opportunities had more frequent age-14 adolescent substance use. Findings suggest that frequent adolescent substance use could be prevented at multiple developmental stages through the
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
This research has been funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development grant RO1-HD054805 and Fogarty International Center grant RO3-TW008141. This research also was supported by the Intramural Research Program of the NIH/NICHD, USA, and an International Research Fellowship in collaboration with the Centre for the Evaluation of Development Policies (EDePO) at the Institute for Fiscal Studies (IFS), London, UK, funded by the European Research Council
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