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Longitudinal associations between childhood

and adolescent emotional problems,

behavioral problems and substance use

Jouko Miettunen, adjunct professor

University of Oulu, Finland

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Mental health and substance use Emotional and behavioral problems are commonly

associated with substance use in adolescence, but it is

unclear whether substance use causes or is a consequence of

mental health problems

Theories on associations between substance use and mental

health problems can be summarized to three pathways

a common pathway (same risk factors)

substance use causes psychopathology

psychopathology causes substance use (self-medication

hypothesis)

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Emotional and behavioral symptoms

Emotional problems include symptoms or traits

related to depression and anxiety

neurotic, internalising

Behavioral problems cover rule-breaking and

aggressive behavior

antisocial, externalising

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Emotional problems and substance use

Findings on cannabis use as risk factor for depressive and anxious

disorders and symptoms have been inconsistent (Moore et al)

Studies had methodological shortcomings e.g. regarding attempts to

take into account reverse causation and possible intoxication effects.

Emotional symptoms in childhood can even protect from substance use

(e.g., Maggs et al)

Early-onset depressive disorder have been associated with later tobacco

and alcohol use (e.g., Sihvola et al) and vice versa (e.g., Fergusson et al)

Moore et al. Lancet 2007;370:319-28; Maggs et al. Addiction Suppl 2008;103:7-22);Sihvola et al. Addiction 2008;103:2045-53; Fergusson et al. Arch Gen Psychiatry 2009;66:260-6.

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Behavioral problems and substance use

Childhood behavioral disorders have been linked to later alcohol use,

especially among males (e.g., McGue et al)

Substance use have been linked with later behavioural problems (e.g.,

Pernanen, White et al):

Pharmacological effects of intoxication reduce inhibitions which may lead people

to act more daringly and impulsively than they might do while sober.

Prolonged involvement in substance abuse may have developmental effects, such

as increased delinquent peer affiliations

Some drug related criminal activity may be purely utilitarian, for example, when

an unemployed drug addict turns to robbery and theft to support his habit

McGue et al. Alcohol Clin Exp Res 2001;25:1156-65; Pernanen. Alcohol in Human Violence, Guilford Press, 1991; White et al. J Stud Alcohol Suppl 1993;11:62-77.

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Northern Finland 1986 Birth Cohort Population based birth

cohort Individuals born in

Northern Finland July 1985 – June 1986

Original sample:

9,432 (4,865 males) Current sample:

6,348 (3,102 males)

Oulu

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AGE

Youth Self-Report (YSR)

(for previous six months)

-Emotional problems

-Behavioural problems

(covariate)

SELF REPORTS

8 years

REGISTERS

20-23 years15 to 16 years

(outcome, predictor and covariate)

- Regular smoker

- Heavy drinker

-Cannabis use

-Other intoxicant use

SELF REPORTS

TEACHERS AND PARENTS

Rutter scales

(for previous year)

-Emotional problems

-Behavioural problems

(predictor and covariate)

SUBSTANCE

USE

MENTAL

PROBLEMS

Hospital & Criminal Registers

(from age 15 to 16 )-Depressive and neurotic

disorders-Violent and property

offences(outcome)

YEAR1993 - 1994 2005-20082000 - 2001

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Northern Finland 1986 Birth Cohort

Emotional and behavioral data age 8y (Rutter scales)

Emotional subscale (teachers: 4 items / parents: 5 items)

Behavioral subscale (6/4) Items scored 0 to 2 High scorers:

in highest 25% both in parents’ and in teachers’ ratings

Emotional and behavioral data age 15-16y (YSR)

Self reports Emotional (internalising)

subscale (30 items) Behavioral (externalising)

subscale (29 items) Items scored: 0 to 2 High scorers:

highest 10%

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Northern Finland 1986 Birth Cohort

Emotional and behavioral data age 20-23y (registers)

Hospitalisations for emotional disorders (e.g. depression) until 23y

- number of events (n): M/F=40/32

Criminal convictions (property and violent crimes) until 20y

- n=80/40 No/Yes

Substance use data age 15-16y (YSR)

Self reports Regular smoking (ever)

[22/23%] Being drunk 10 times or more

during the past year [17/20%] Tried cannabis (ever) [5/6%] Other substance use (e.g.

medicines for intoxication, sniffing glues or solvents, ecstacy, …) [7/14%]

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Northern Finland 1986 Birth Cohort

Covariates (age 15 to 16)

1. Place of residence (urban vs. rural)

2. Family pattern (intact: no/yes)

3. Parental education (professional/other)

4. Parental psychiatric disorders (hospital registers until 2005)

Final models Logistic regressions (ORs) Predicting substance use with

childhood mental health Adjusted for covariates 1-4

Predicting hospitalisations and crimes with substance use

Adjusted for covariates 1-4 and previous emotional and behavioral problems (age 8 and age 15-16)

Summary of results Both among males and females, behavioral problems at age 8 were

associated (P<0.05) with later smoking and other substance use than

alcohol or cannabis (Adjusted Odds Ratios, OR, between 1.5 and 2.3).

Early emotional problems were not a risk for later substance use,

except being drunk among females (OR 1.4).

Cannabis (OR = 6.7; 95% CI: 2.3 to 19.6) use among females

predicted emotional disorders in the follow-up.

Substance use predicted later criminality in both genders; associations

were stronger among males.

Conclusions

Mental health problems and substance use are strongly

associated in adolescence and early adulthood.

Behavioral problems often both precede and follow substance

abuse, whereas emotional problems may follow adolescent

substance abuse, especially among females.

Males with substance use are at high risk for criminal offences.

These associations were robust even when taking into account

childhood and adolescence mental health problems.

Research group

University of Oulu, Finland

Jouko Miettunen, PhD

Juha Veijola, MD, PhD

Hanna Ebeling, MD, PhD

Irma Moilanen, MD, PhD

Pirjo Mäki, MD, PhD

Anja Taanila, PhD

Sari Törmänen, MD

University of Tampere, Finland

Matti Joukamaa, MD, PhD

University of Cambridge, UK

Peter Jones, FRCPsych

Graham Murray, MRCPsych

Imperial College London, UK

Marjo-Riitta Järvelin, MD, PhD

University of Nebraska, USA

Jukka Savolainen, PhD

www.joukomiettunen.net/presentations