1 Longitudinal associations between childhood and adolescent emotional problems, behavioral problems and substance use Jouko Miettunen, adjunct professor University of Oulu, Finland

2 Mental health and substance use n 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 n Theories on associations between substance use and mental health problems can be summarized to three pathways u a common pathway (same risk factors) u substance use causes psychopathology u psychopathology causes substance use (self-medication hypothesis)

3 Emotional and behavioral symptoms n Emotional problems include symptoms or traits related to depression and anxiety u neurotic, internalising n Behavioral problems cover rule-breaking and aggressive behavior u antisocial, externalising

4 Emotional problems and substance use n Findings on cannabis use as risk factor for depressive and anxious disorders and symptoms have been inconsistent (Moore et al) u Studies had methodological shortcomings e.g. regarding attempts to take into account reverse causation and possible intoxication effects. n Emotional symptoms in childhood can even protect from substance use (e.g., Maggs et al) n 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: ; Fergusson et al. Arch Gen Psychiatry 2009;66:260-6.

5 Behavioral problems and substance use n Childhood behavioral disorders have been linked to later alcohol use, especially among males (e.g., McGue et al) n Substance use have been linked with later behavioural problems (e.g., Pernanen, White et al): u Pharmacological effects of intoxication reduce inhibitions which may lead people to act more daringly and impulsively than they might do while sober. u Prolonged involvement in substance abuse may have developmental effects, such as increased delinquent peer affiliations u 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: ; Pernanen. Alcohol in Human Violence, Guilford Press, 1991; White et al. J Stud Alcohol Suppl 1993;11:62-77.

6 Northern Finland 1986 Birth Cohort n Population based birth cohort n Individuals born in Northern Finland July 1985 – June 1986 n Original sample: 9,432 (4,865 males) n Current sample: 6,348 (3,102 males) Oulu

7 AGE Youth Self-Report (YSR) (for previous six months) -Emotional problems -Behavioural problems (covariate) SELF REPORTS 8 years REGISTERS years 15 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 USESUBSTANCE USE MENTAL PROBLEMSMENTAL PROBLEMS Hospital & Criminal Registers (from age 15 to 16 ) -Depressive and neurotic disorders -Violent and property offences (outcome) YEAR

8 Northern Finland 1986 Birth Cohort Emotional and behavioral data age 8y (Rutter scales) n Emotional subscale (teachers: 4 items / parents: 5 items) n Behavioral subscale (6/4) n Items scored 0 to 2 n High scorers: u in highest 25% both in parents’ and in teachers’ ratings Emotional and behavioral data age 15-16y (YSR) n Self reports n Emotional (internalising) subscale (30 items) n Behavioral (externalising) subscale (29 items) n Items scored: 0 to 2 n High scorers: u highest 10%

9 Northern Finland 1986 Birth Cohort Emotional and behavioral data age 20-23y (registers) n Hospitalisations for emotional disorders (e.g. depression) until 23y - number of events (n): M/F=40/32 n Criminal convictions (property and violent crimes) until 20y - n=80/40 n No/Yes Substance use data age 15-16y (YSR) n Self reports n Regular smoking (ever) [22/23%] n Being drunk 10 times or more during the past year [17/20%] n Tried cannabis (ever) [5/6%] n Other substance use (e.g. medicines for intoxication, sniffing glues or solvents, ecstacy, …) [7/14%]

10 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 n Logistic regressions (ORs) n Predicting substance use with childhood mental health n Adjusted for covariates 1-4 n Predicting hospitalisations and crimes with substance use n Adjusted for covariates 1-4 and previous emotional and behavioral problems (age 8 and age 15-16)

Summary of results n 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). n Early emotional problems were not a risk for later substance use, except being drunk among females (OR 1.4). n Cannabis (OR = 6.7; 95% CI: 2.3 to 19.6) use among females predicted emotional disorders in the follow-up. n Substance use predicted later criminality in both genders; associations were stronger among males.

Conclusions n Mental health problems and substance use are strongly associated in adolescence and early adulthood. n Behavioral problems often both precede and follow substance abuse, whereas emotional problems may follow adolescent substance abuse, especially among females. n Males with substance use are at high risk for criminal offences. n 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