Journal of Traumatic Stress April 2014, 27, 208–216
Negative Cognitions as a Moderator in the Relationship Between PTSD and Substance Use in a Psychiatrically Hospitalized Adolescent Sample Maureen A. Allwood,1 Christianne Esposito-Smythers,2 Lance P. Swenson,3 and Anthony Spirito4 1
Department of Psychology, John Jay College, City University of New York, New York, New York, USA 2 Department of Psychology, George Mason University, Fairfax, Virginia, USA 3 Department of Psychology, Suffolk University, Boston, Massachusetts, USA 4 Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island, USA
Adolescents exposed to trauma are more likely to engage in alcohol and marijuana use compared to their nontrauma-exposed counterparts; however, little is known about factors that may moderate these associations. This study examined the potential moderating effect of cognitions relevant to exposure to trauma (i.e., negative view of self, world, and future) in the association between posttraumatic stress disorder (PTSD) diagnosis and substance use among a psychiatric inpatient sample of 188 adolescents. Findings were that PTSD diagnosis was not significantly associated with substance-use diagnoses, but was associated with substance-use symptoms, accounting for 2.9% and 9.6% of the variance in alcohol and marijuana symptoms, respectively. The association between PTSD diagnosis and substance use symptoms, however, was moderated by negative cognitions, with PTSD and high negative cognitions (but not low negative cognitions) being significantly positively associated with substance use symptoms. The relevant cognitions differed for alcohol symptoms and marijuana symptoms. Children and adolescents who experience trauma and PTSD may benefit from early interventions that focus on cognitive processes as one potential moderator in the development of posttrauma substance use.
Adolescents exposed to trauma are more likely to engage in problematic alcohol and marijuana use compared to their nontrauma-exposed counterparts (Lipschitz et al., 2003; Vermeiren et al., 2003). Moreover, as many as 71% of youth in substance abuse treatment report experiencing a significant traumatic event at some time before their admission to treatment (Jaycox et al., 2004). In fact, high rates of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) comorbidity are found among adolescents in clinical settings (Deykin & Buka, 1997; Lipschitz, Grilo, Fehon, McGlashan, & Southwick, 2000) as well as among community youth (Giaconia et al., 2000; Kilpatrick et al., 2003; Lipschitz et al., 2003). Kilpatrick et al.’s study of more than 4,000 adolescents found that 24.6% of girls and 13.5% of boys with PTSD also met criteria for a SUD. As indicated by Kilpatrick et al. (2003) and others (Deykin & Buka, 1997; Lipschitz et al., 2000; Lopez, Turner, & Saavedra, 2005), the associations between PSTD and
substance use are particularly robust for girls and appear to be more strongly related to girls’ use of alcohol as compared to other substances (Lopez et al., 2005). Despite the well-documented linkages between trauma, PTSD, and SUD, most of what is known about these associations is derived from studies with adults. Adult studies, however, have yielded mixed findings, with some indicating that PTSD is strongly associated with substance use (Cougle, Bonn-Miller, Vujanovic, Zvolensky, & Hawkins, 2011; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), and others finding no significant association (Breslau, Davis, & Schultz, 2003; Fetzner, McMillan, Sareen, & Asmundson, 2011). Overall, little is known about the factors that might contribute to or moderate the development and progression of substance use problems among individuals with experiences of trauma and PTSD. This is particularly true during adolescence, when alcohol and drug behavior are likely to commence (Hien, Cohen, & Campbell, 2005; Lipschitz et al., 2003). Indeed, studies do show that problematic substance use among adolescents with PTSD generally follows trauma exposure and the onset of PTSD symptoms (Lipschitz et al., 2003; Lopez et al., 2005), suggesting that substance use might occur in response to the effects of trauma, albeit only for some individuals. In an epidemiologic study conducted with young adults, Chilcoat and Breslau (1998) found that those with a prior
Correspondence concerning this article should be addressed to Maureen A. Allwood, Department of Psychology, John Jay College, City University of New York, 524 West 59th Street, New York, NY 10019. E-mail: [email protected] C 2014 International Society for Traumatic Stress Studies. View Copyright this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21907
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diagnosis of PTSD were four times as likely to develop a SUD during a 5-year follow-up period as compared to those without a diagnosis of PTSD. Nonetheless, the emerging literature on PTSD and SUD in adolescents has yet to fully examine the potential moderators involved in the association between PTSD and problematic adolescent substance use. Possible moderators, such as cognitive and emotional processes that occur secondary to trauma exposure and PTSD symptoms, may help to explain the increased risk for later substance use among some traumaexposed youth. One conceptual model of trauma cognitions in the association between PTSD and SUD examined in the adult literature (Jayawickreme, Yasinski, Williams, & Foa, 2011), but applicable to adolescents, suggests that alcohol and other drugs may be used as a means to avoid trauma reminders and related cognitions (Giaconia et al., 2000). This conceptual model, referred to here as the trauma cognitive-avoidance model, postulates that cognitions associated with trauma exposure moderate the association between PTSD and SUD (i.e., the risk of SUD is greater in the context of PTSD when the diagnosis is coupled with negative trauma-related cognitions such as self-blame, distrust of others, and sense of a foreshortened future). In support of the trauma cognitive-avoidance model, research conducted with women indicates that trauma-related cognitions may serve as a vulnerability factor for SUDs (Hien et al., 2005; Najavits, Gotthardt, Weiss, & Epstein, 2004). Specifically, Najavits and colleagues (2004) found that women diagnosed with both PTSD and SUD reported more cognitions related to self-deprecation (i.e., negative view of self) and the need to escape negative affect as compared to women with PTSD alone. Similarly, Jayawickreme et al. (2011) found that trauma-related self-blame and negative view of self and the world were significantly positively related to alcohol craving. Building on the work of Najavits and colleagues (2004) and Jayawickreme et al. (2011), the present study examined negative views of self, the world, and the future as moderators of the PTSD–SUD association in a clinical sample of adolescents. The negative views of self, world, and future have been referred to as the “cognitive triad” in prior research and have been linked to depressive (Beck, 1967) as well as PTSD symptoms (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). Thus, youth with posttrauma symptoms who experience high levels of negative cognitions may use alcohol and other drugs to block out or dampen these destructive thought processes and the negative emotional state that the thoughts elicit. Accounting for the potential moderating effects of negative cognitions might be an important step in advancing the literature focused on the complexity of trauma exposure and response, and the likelihood of comorbid outcomes (Allwood, Dyl, Hunt, & Spirito, 2008), including comorbid SUDs. Utilizing a clinical sample of adolescents drawn from a psychiatric inpatient unit, the present study examined the relation between PTSD diagnosis and problematic substance use, as well as the potential moderating effects of negative views of self, world, and future. Two specific hypotheses were exam-
ined. First, we hypothesized that a diagnosis of PSTD would be significantly positively associated with alcohol and/or marijuana use among adolescents. Second, we hypothesized that the relation between PTSD diagnosis and substance use symptoms would be stronger in the presence of more negative cognitions.
Method Participants Two hundred sixty-three adolescents, ages 13 to 18 years and their parents were approached for recruitment over the course of a 3-year period. All adolescents were hospitalized on an acute psychiatric adolescent inpatient unit, the majority due to suicidal thoughts or behavior. Of those families approached for participation, 201 were successfully recruited. Sixteen participants did not complete the full assessment battery after consent, resulting in a final sample size of 188 participants (M = 15.02 years, SD = 1.32). Consistent with the hospital population from which the sample was drawn, the majority of the participants were female (70.1%). The racial composition consisted of 84.0% Caucasian, 2.7% African American, 2.1% Asian, 3.7% Native American, and 7.5% other racial/ethnic background. Approximately 9.6% of the sample was of Hispanic/Latino ethnicity. Family income varied widely from $100,000 per year with a median income range of $50,000 to $60,000. Inclusion criteria for participation included (a) parent and adolescent fluency in spoken English, (b) adolescent assent and parental consent, and (c) an adolescent verbal intelligence quotient (IQ) estimate ࣙ70 as assessed via the Kaufman brief intelligence test (Kaufman & Kaufman, 1990) to ensure that adolescents could cognitively understand and answer the questions included in the assessment. Exclusion criteria included current psychosis or full legal placement in child-protective custody, as documented in the inpatient admission materials. Fifty-one participants (25.4%) met criteria for PTSD diagnosis. Examination of demographic variables indicated that adolescents with PTSD did not differ from their non-PTSD counterparts on age, ethnicity, or family income (ps > .220). Girls were significantly more likely to be diagnosed with PTSD than boys, χ2 (1, N = 188) = 11.69, p < .001, with 34.1% girls and 9.4% boys meeting criteria. As expected, adolescents with PTSD reported a higher number of adverse and traumatic life events, including abuse, assaults, death of a loved one, domestic violence and disasters, but not more neglect, accidents, or illness of a loved one (see Table 1). Measures The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADSPL; Kaufman et al., 1997) is a widely used semistructured diagnostic interview that provides a reliable and valid measurement of psychopathology in children and adolescents according to the
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Table 1 Frequency of Adverse and Traumatic Events by PTSD Diagnostic Status PTSD n = 51 Event Death of loved one Domestic violence Sexual assault Sexual abuse Physical abuse Physical assault Witnessed assault Accident Illness of loved one Neglect Disaster
No-PTSD n = 137
n
%
n
%
χ2
29 24 19 18 17 10 10 6 6 3 2
56.9 47.1 37.3 35.3 33.3 19.6 19.6 3.9 11.8 5.9 3.9
45 26 13 18 23 9 2 2 16 3 0
32.8 19.0 9.5 13.1 16.8 6.6 1.5 4.4 11.7 2.2 0.0
8.98** 15.01*** 20.29*** 11.78*** 6.07* 6.95** 20.48*** 0.02 0.00 1.64 5.43*
Note. PTSD = posttraumatic stress disorder. *p < .05. **p < .01. ***p < .001.
Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994). Interrater agreement for scoring screens and diagnoses is high (range = 93%–100%). Test-retest reliability and κ coefficients are in the excellent range for most diagnoses (.77–1.00; Kaufman et al., 1997). For the present study, all interviewers were extensively trained in the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL; Kaufman et al., 1997) through didactic training, rating of audiotapes, administering in-person interviews while being observed, and then audiotaping full interviews, which were rated for reliability. Upon completion of training, all interviews were audiotaped and 18 adolescent interviews and 18 parent interviews were randomly selected and rated for reliability. Kappa coefficients reflected strong agreement for all anxiety disorders including PTSD (κ = .92–1.0), all substance use disorders (κ = .79–1.0), and all depressive disorders (κ = .89–1.0), except dysthymia. In addition to conducting regular reliability ratings, all cases were staffed during weekly clinical consensus team meetings. During this meeting, all K-SADS-PL symptoms and assessment data were reviewed by doctoral-level child psychologists in addition to the interviewers. A best-estimate clinical consensus procedure (Klein, Ouimette, Kelly, Ferro, & Riso, 1994) was used to resolve discrepancies between symptoms reported by adolescent and parent as well as to confirm diagnoses. All diagnoses examined were based on the consensus procedures. The KSADS-PL modules pertaining to PTSD and SUDs were of interest in the present research. The PTSD module assesses for most potential traumas (e.g., accident, fire, disaster, crime victimization, abuse, and other self-specified traumas). In ad-
dition to experiencing an identified trauma, to meet criteria for PTSD, participants must have indicated that they experienced the requisite number of symptoms in all three PTSD symptom components (i.e., at least one reexperiencing, three avoidance/numbing, and two arousal symptoms). Alcohol abuse was indicated by the endorsement of at least one of four alcoholrelated symptoms and alcohol dependence was indicated by at least three of seven symptoms. These same criteria were used for each substance abuse and dependence disorders. To assess total alcohol symptoms and substance use symptoms, the respective abuse and dependence symptoms were added to establish a symptom count. The Cognitive Triad Inventory for Children (Kaslow & Stark, 1986) is a 36-item self-report questionnaire designed to assess self-perceived competencies and global self-worth in children and adolescents. Participants indicated how similar the stated thoughts or opinions were to those of their own by circling yes, no, or maybe. Three 12-item subscales are derived from the individual items, such as “I am a failure,” “The world is a very mean place,” and “My future is too bad to think about”: View of the Self, View of the World, and View of the Future. A total score is calculated by summing scores from each subscale after reverse scoring negative items on subscales. Higher scores on the Cognitive Triad Inventory for Children reflect fewer negative cognitions. Adequate internal consistency and convergent/discriminant validity have been demonstrated for this measure (Kaslow, Stark, Printz, Livingston, & Tsai, 1992). Internal consistency for the Cognitive Triad Inventory for Children in the present study was α = .96, and subscale alphas ranged from α = .82 (world) to α = .94 (future). Procedures Daily chart reviews were conducted by a bachelor-level research assistant employed by the participating hospital. All eligible adolescents and their parents/guardians were then approached for recruitment by the research assistant after family meetings or visits on the adolescent inpatient unit. Once written parental consent and adolescent assent were obtained, adolescents and their parent/guardian completed the assessments while the adolescent was hospitalized in the unit. The research assistant administered the assessment battery with the exception of the diagnostic interview, which was administered by trained masters- and doctoral- level clinicians. Parent and adolescent assessments were conducted separately. The parent version of the diagnostic interview and assessment measures was administered in a 2-hour session. The child version of the diagnostic interview and assessment measures were administered in two separate 1½- to 2-hour sessions. All adolescents received four movie tickets and their parent/guardian received a $50 money order for their participation. Substance-related information was not shared with parents because teens self-reported substance use has been shown to be accurate and reliable under conditions of confidentiality (Needle, McCubbin, Lorence, & Hochhauser, 1983). This study was
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Negative Cognitions and Adolescent Substance Use
Table 2 Frequency of Substance Use Disorders for Total Sample and by PTSD Diagnostic Status
Substance use disorder Alcohol Marijuana Both alcohol & marijuana
Total n = 188
PTSD n = 51
No PTSD n = 137
n
%
n
%
n
%
42 51 31
20.9 25.4 16.5
16 12 10
31.4 23.6 19.6
26 39 21
19.0 28.5 15.3
Note. PTSD = posttraumatic stress disorder.
approved by the Brown University and Lifespan Hospitals Institutional Review Boards. Data Analysis First, descriptive information regarding the rate of diagnosed PTSD and alcohol and other substance disorders were generated. Next, the rate of exposure to traumas among adolescents with and without PTSD was examined using χ2 analyses. Adolescent-reported substance use symptoms were then used as the dependent variable in a series of three hierarchical regressions. Demographic variables, diagnosis of PTSD, and a cognitive variable (i.e., View of the Self, World, or Future subscales) were entered in the first step and the interaction between diagnosis of PTSD and the cognitive variable was entered in the second step. The three negative cognitions subscales were mean-centered prior to all analyses. Significant interactions associated with substance use symptoms were explored following procedures outlined by Aiken and West (1991). To examine whether significant findings might be due to the presence of depressive symptoms among the sample, correlational analyses included a composite of depressive disorder diagnoses (i.e., major depression, dysthymia, depression not otherwise specified [NOS]) and regression analyses were reexamined adjusting for the composite of depressive disorders.
Results Forty-two participants met criteria for an alcohol use disorder (i.e., abuse or dependence), 51 met criteria for a marijuana use disorder, and 10 met criteria for all other SUDs (see Table 2). Of the 10 participants who met criteria for a nonalcohol or marijuana SUD (e.g., cocaine, prescription drugs), 5 were comorbid for marijuana abuse or dependence and 7 were comorbid for alcohol abuse or dependence. Given the low incidence of SUDs not related to alcohol or marijuana and the high comorbidity, only alcohol and marijuana disorders and symptoms were used in subsequent analyses. Notably, 31 adolescents met criteria for both alcohol and marijuana use disorders, therefore a total
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of 62 adolescents account for all alcohol- and marijuana-use diagnoses. Analyses of alcohol and marijuana use disorders with PTSD diagnosis using χ2 showed that adolescents with PTSD were not more likely to have an alcohol-use disorder, χ2 (1, N = 188) = 3.29, p = .070, or a marijuana-use disorder, χ2 (1, N = 188) = 0.46, p = .498, compared to adolescents without PTSD. Similarly, adolescents with PTSD were not more likely to meet criteria for comorbid alcohol and marijuana use disorders, χ2 (1, N = 188) = 0.49, p = .482. The onset of PTSD diagnosis occurred at an average of 10.65 years, (SD = 3.47); alcohol-use disorder was on average at 14.04 years, (SD = 1.11) and on average substance-use disorder at 14.67, years (SD = 1.43). The onset of drinking was on average 12.42 years (SD = 3.69). To further examine the relationship between PTSD diagnosis and alcohol and marijuana use, subsequent analyses focused on alcohol and marijuana symptoms (vs. the dichotomous substance-use diagnoses derived by consensus). Table 3 presents descriptive statistics and the correlations among PTSD diagnosis and symptom counts for alcohol use, marijuana use, and the three cognitive subscales. As shown in Table 3, adolescents reported more marijuana symptoms than alcohol symptoms. The differences in mean symptoms is largely because adolescents who reported no prior marijuana use (n = 132) provided no information regarding symptoms, whereas adolescents who reported alcohol use as little as one time, provided information regarding symptoms (i.e., zero symptoms), therefore deflating the overall alcohol-symptom mean. In the examination of the associations among PTSD diagnosis, substance-use symptoms, and negative cognitions, PTSD diagnosis was significantly positively related to both alcohol and marijuana symptoms. PTSD diagnosis was also significantly related to all negative cognitions in the expected direction. Negative cognitions were differentially associated with marijuana and alcohol symptoms. Negative views of the self and the world were significantly related to alcohol symptoms, whereas negative view of the future was significantly related to marijuana symptoms. In addition, alcohol symptoms were positively related to age (r = .17, p = .024), with older adolescents being more likely to report alcohol related symptoms. Marijuana symptoms were not significantly related to age (r = .19, ns) for the 53 who endorsed prior marijuana use, although age accounted for almost 4% of the variance (vs. almost 3% of the variance for alcohol symptoms). Neither alcohol nor marijuana symptoms were significantly related to gender, ethnicity, or family income (ps >.165; based on respective t tests or Pearson correlations). To examine whether the main effect of PTSD on alcohol and marijuana symptoms was moderated by negative cognitions, separate hierarchical regression analyses were conducted (see Tables 4 and 5). Because girls were more likely to be diagnosed with PTSD than boys, and because older adolescents were more likely to report substance use symptoms, gender and age were entered in the first step of each model. Table 4 shows the main effects of PTSD, View of the Self, World, and Future in relation
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Table 3 Intercorrelations, Means, and Standard Deviations of Key Measures Variable 1. PTSDa 2. Alcohol symptoms 3. Marijuana symptoms 4. View of Self 5. View of World 6. View of Future
M
SD
1
2
3
4
5
0.27 0.92 4.92 15.92 15.23 17.47
0.45 1.88 2.51 6.60 4.76 6.60
– .17* .31* −.35*** −.33*** −.25***
– .34* −.19* −.17* −.12
– −.20 −.17 −.29*
– .73*** .83***
– .73***
Note. Alcohol symptoms are reported for 185 individuals; marijuana symptoms are reported for 53 individuals. PTSD = posttraumatic stress disorder. a Point biserial correlations were conducted for dichotomous variable. *p < .05. **p < .01. ***p < .001.
to alcohol symptoms, as well as the interaction effects of PTSD and the negative cognitions. The main effect of PTSD diagnosis and View of Self were both only marginally related to alcohol symptoms, however, the interaction effect was significantly related to alcohol symptoms. To interpret this interaction, simple slope analyses examined relations between PTSD and alcohol symptoms at high (i.e., above the mean) and low (i.e., below the mean) View of Self (see Figure 1). At high negative View of Self, PTSD was significantly positively associated with alcohol symptoms (β = .37, p = .002). At low negative View of Self, PTSD was not significantly associated with alcohol symptoms
(β = −.05, ns). Neither the main effect nor interaction effect of View of the World or View of the Future was significantly related to alcohol symptoms after accounting for gender, age, and PTSD. In the examination of PTSD diagnosis and negative cognitions in relation to marijuana symptoms, PTSD remained significantly related to marijuana symptoms after accounting for demographics and negative cognitions (Table 5). None of the three negative cognitions was significantly associated with marijuana symptoms after accounting for demographics, however, the interaction effects differed by cognitive distortions. The
Table 4 Hierarchical Regression Analyses of Moderation by Negative Cognitions of Association Between PTSD and Alcohol Symptoms Step 1 Variable Gender Age PTSD View of Self PTSD × View of Self Gender Age PTSD View of World PTSD × View of World Gender Age PTSD View of Future PTSD × View of Future
Step 2 β
B
SE B
−.27 .22 .62 −.04
.31 .10 .33 .02
View of Self −.07 .15* .15 .14
.31 .10 .33 .03
View of World −.05 .15* .16* −.11
.31 .10 .33 .02
View of Future −.05 .17* .17* −.08
−.23 .22 .66 −.04 −.21 .24 .72 −.02
R2
B
SE B
β
R2
.08
−.24 .21 1.14 .00 −.12
.31 .10 .38 .03 .05
−.06 .15* .27** .00 −.25*
.11
.07
−.23 .22 .59 −.03 −.05
.31 .10 .34 .04 .06
−.06 .15* .14 −.07 −.08
.15
.07
−.22 .24 .66 .00 −.05
.31 .10 .33 .03 .04
−.05 .17* .16* −.01 −.11
.17
Note. n = 185. View of Self, World, and Future are mean-centered. The results are unchanged by the inclusion of diagnoses of depression. PTSD = posttraumatic stress disorder. *p < .05. **p < .01.
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Table 5 Hierarchical Regression Analyses of Moderation by Negative Cognitions of Association Between PTSD and Marijuana Symptoms Step 1 Variable
B
SE B
Gender Age PTSD View of Self PTSD × View of Self
−.81 .30 1.89 −.01
.72 .29 .95 .06
Gender Age PTSD View of World PTSD × View of World
−.82 .30 1.88 −.04 −.02
.71 .29 .90 .03 .08
Gender Age PTSD View of Future PTSD × View of Future
−.70 .27 1.62 −.06
.71 .29 .86 .05
Step 2 β
R2
View of Self −.16 .14 .32* −.03 .14 View of World −.16 .14 .32* −.11 −.04 .15 View of Future −.14 .12 .27 −.17 .17
B
SE B
β
R2
−.85 .27 2.22* .03 −.13
.72 .29 .99 .07 .12
−.17 .13 .37* .08 −.17
.17
−.95 .25 1.27 .11 .31
.70 .28 .92 .10 .16
−.16 .12 .21 −.21 −.41*
.21
−.90 .30 1.18 .01 −.21
.70 .28 .87 .06 .10
−.18 .14 .20 .02 −.34
.23
Note. n = 53. View of Self, World, and Future mean-centered. The results are unchanged by the inclusion of diagnoses of depression. PTSD = posttraumatic stress disorder. *p < .05.
interaction between PTSD and View of Self was not significantly related to marijuana symptoms, but the interaction with View of the World and the Future were either significantly or marginally related to marijuana symptoms (Table 5). Simple slope analyses indicated that at high negative View of the Future (+1 SD), PTSD was significantly positively associated with marijuana symptoms (β = .73, p < .001; see Figure 1), but at low negative View of the Future (−1 SD), PTSD was not associated with marijuana symptoms (β = .03, ns). Notably, the simple slope analysis for the interaction between PTSD diagnosis and negative View of the World was not interpreted because only two adolescents with PTSD diagnosis and high negative View of the World (+1 SD) reported having marijuana symptoms. Because negative views of self, world, and future are often related to depression, analyses were conducted to examine whether findings might be largely accounted for by depression versus PTSD diagnosis. First-order correlations indicated that a composite of depressive disorder diagnoses (i.e., major depression, dysthymia, depression NOS) was not significantly related to either alcohol (r = .04, ns) or marijuana symptoms (r = .13, ns). Additionally, all significant regression analyses were reexamined with depression diagnosis at Step 1, but there were no changes in the findings reported above.
Discussion The present study examined the potential moderating effect of trauma-relevant cognitions in the association between PTSD diagnosis and substance use. Among this primarily female adolescent inpatient sample, PTSD was not significantly related to substance use diagnoses, but was associated with substance use symptoms. Nonetheless, negative cognitions moderated the associations, indicating that cognitions that often occur in the aftermath of trauma exposure might play an important role in the development of posttrauma substance use. Consistent with previous studies of adult women with histories of trauma (Jayawickreme et al., 2011; Najavits et al., 2004), we found that self-deprecating cognitions moderated the relationship between PTSD and alcohol symptoms. Moreover, we found that pessimistic views about the world and one’s future might moderate the relationship between PTSD diagnosis and marijuana symptoms. Specifically, PTSD was associated with marijuana use symptoms only among youth with more (but not less) pessimistic views of the future. Together, these findings offer preliminary support for the trauma cognitive-avoidance model, wherein PTSD in the context of high levels of negative cognitions is presumed to be associated with higher rates of alcohol and marijuana use. Conceptually, the context of high negative cognitions is associated with a greater desire to escape
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Figure 1. Posttraumatic stress disorder (PTSD) by View of Self in relation to alcohol symptoms (n = 185) and PTSD by View of Future in relation to marijuana symptoms (n = 53), both adjusted for age and gender. High and low groups formed by a mean split.
such cognitions and the associated affect through the use of substances. These findings have several important implications. First, this is the only study to replicate the moderating effects of self-deprecation (e.g., negative view of self) on the relation between PTSD and alcohol use in a sample of adolescents of which we are aware. The emergence of such negative cognitions and cognitive avoidance early in development (adolescence) might interact with other psychological symptoms, such as PTSD symptoms, to partly account for the increased risk of negative outcomes observed among youth exposed to trauma and victimization. In fact, PTSD symptoms (clinical or subclinical) that include negative thoughts about self, the world, or one’s future might better account for the higher rates of delinquent behaviors (Allwood & Bell, 2008; Becker & Kerig, 2011), derailed academic progress (Allwood & Widom, 2013; Duncan, 2000), revictimization (Widom, Czaja, & Dutton, 2008), and other negative outcomes (Ford, Elhai, Connor, & Frueh,
2010) found among trauma exposed youth, than PTSD diagnosis alone. Second, this study extends the relevance of negative cognitions to marijuana use among adolescents, with findings indicating that there are likely to be many individual differences that affect adolescent’s response to trauma and their decision to use substances. Negative views of oneself were not related to marijuana symptoms, and negative views of the world and future were not related to alcohol symptoms. These findings suggest that the choice of substance might be influenced by specific cognitive and affective states and expectancies (Simons, Gaher, Correia, Hansen, & Christopher, 2005), but speculation on the specific pattern found here seems premature and should await confirmation by additional studies. There are several important limitations to consider when interpreting these findings, primarily related to the fact that the sample was the largely female and psychiatrically hospitalized for severe mental health problems. First, the adolescents in this study have relatively high levels of psychopathology and general psychopathology is a predictor of early-onset substance use (Costello, Copeland, & Angold, 2011). Second, the patients in this study were admitted to the hospital primarily for suicidal thoughts and behavior; their cognitions might be more strongly influenced by their emotional state at the time of the assessment than might be found in other samples. Thus, our findings might not generalize to a healthier sample of adolescents. Third, this relatively young (average age = 15 years), primarily female sample might be less likely to use substances than older adolescents (Chen & Jacobson, 2012) and/or their male counterparts (Kaplow, Curran, & Dodge, 2002). Indeed, the number of adolescents using alcohol, marijuana, or both was relatively small and varied across substances which in turn affected the strength of the statistical analyses across substances. Thus, findings might not generalize to community youth or to outpatient clinical settings. Likewise, the findings might not generalize to males with or without PTSD. Future research in this area should include samples that are more representative of the general population of adolescents. Samples should be more racially, ethnically, and linguistically diverse and include comparable numbers of males and females drawn from a variety of settings, including nonclinical settings. In summary, among this psychiatrically hospitalized sample, adolescents with PTSD report significantly more negative cognitions about themselves, the world, and the future than their peers without PTSD, and these cognitions differentially moderated the associations between PTSD diagnosis and alcoholand marijuana-use symptoms. These preliminary findings suggest that adolescents exposed to traumatic experiences may benefit from early clinical interventions that focus on cognitive processes. Clinical interventions for adolescent posttrauma substance use should specifically attend to adolescent views of self (e.g., self-identity), the world, and the future (e.g., future orientation), as well as substance-use expectancies and motivations.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Negative Cognitions and Adolescent Substance Use
References Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA: Sage. Allwood, M. A., & Bell, D. J. (2008). A preliminary examination of emotional and cognitive mediators in the relations between violence exposure and violent behaviors in youth. Journal of Community Psychology, 36, 989– 1007. doi:10.1002/jcop.20277 Allwood, M. A., Dyl, J., Hunt, J., & Spirito, A. (2008). Comorbidity and service utilization among psychiatrically hospitalized adolescents with PTSD. Journal of Psychological Trauma, 7, 104–121. doi:10.1080/19322880802231791 Allwood, M. A., & Widom, C. S. (2013). Child abuse and neglect, developmental role attainment, and adult arrests. Journal of Research on Crime and Delinquency, 50, 551–578. doi:10.1177/0022427812471177 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A. T. (1967). Depression: Clinical, Experimental, and Theoretical Aspects. New York, NY: Harper & Row. Becker, S. P., & Kerig, P. K. (2011). Posttraumatic stress symptoms are associated with the frequency and severity of delinquency among detained boys. Journal of Clinical Child and Adolescent Psychology, 40, 765–771. doi:10.1080/15374416.2011.597091 Breslau, N., Davis, G. C., & Schultz, L. R. (2003). Posttraumatic stress disorder and the incidence of nicotine, alcohol, and other drug disorders in persons who have experienced trauma. Archives of General Psychiatry, 60, 289–294. doi:10.1001/archpsyc.60.3.289 Chen, P., & Jacobson, K. C. (2012). Developmental trajectories of substance use from early adolescence to young adulthood: Gender and racial/ethnic differences. Journal of Adolescent Health, 50, 154–163. doi:10.1016/j.jadohealth.2011.05.013 Chilcoat, H. D., & Breslau, N. (1998). Posttraumatic stress disorder and drug disorders: Testing causal pathways. Archives of General Psychiatry, 55, 913–917. doi:10.1001/archpsyc.55.10.913
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Kilpatrick, D. G., Ruggiero, K. J., Acierno, R., Saunders, B. E., Resnick, H. S., & Best, C. L. (2003). Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology, 71, 692–700. doi:10.1037/0022-006X.71.4.692
Deykin, E. Y., & Buka, S. L. (1997). Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. American Journal of Psychiatry, 154, 752–757. Duncan, D. R. (2000). Childhood maltreatment and college drop-out rates implications for child abuse and researchers. Journal of Interpersonal Violence, 15, 987–995. doi:10.1177/088626000015009005 Fetzner, M. G., McMillan, K. A., Sareen, J., & Asmundson, G. J. G. (2011). What is the association between traumatic life events and alcohol abuse/dependence in people with and without PTSD? Findings from a nationally representative sample. Depression and Anxiety, 28, 632–638. doi:10.1002/da.20852 Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The Posttraumatic Cognitions Inventory (PTCI): Development and validation. Psychological Assessment, 11, 303–314. doi:10.1037/1040-3590.11.3.303 Ford, J. D., Elhai, J. D., Connor, D. F., & Frueh, B. C. (2010). Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and in-
Klein, D. N., Ouimette, P. C., Kelly, H. S., Ferro, T., & Riso, L. P. (1994). Test-retest reliability team consensus best-estimate diagnoses of Axis I and II disorders in a family study. American Journal of Psychiatry, 151, 1043– 1047. Lipschitz, D. S., Grilo, C. M., Fehon, D., McGlashan, T. M., & Southwick, S. M. (2000). Gender differences in the associations between posttraumatic stress symptoms and problematic substance use in psychiatric inpatient adolescents. Journal of Nervous and Mental Disease, 188, 349–356. doi:10.1097/00005053-200006000-00005 Lipschitz, D. S., Rasmusson, A. M., Anyan, W., Gueorguieva, R., Billingslea, E. M., Cromwell, P. F., & Southwick, S. M. (2003). Posttraumatic stress disorder and substance use in inner-city adolescent girls. Journal of Nervous and Mental Disease, 191, 714–721. doi:10.1097/01.nmd.0000095123.68088.da Lopez, B., Turner, R. J., & Saavedra, L. M. (2005). Anxiety and risk for substance dependence among late adolescents/young adults. Journal of Anxiety Disorders, 19, 275–294. doi:10.1016/j.janxdis.2004.03.001
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Najavits, L. M., Gotthardt, S., Weiss, R. D., & Epstein, M. (2004). Cognitive distortions in the dual diagnosis of PTSD and substance use disorder. Cognitive Therapy and Research, 28, 159–172. doi:10.1023/B:COTR.0000021537.18501.66 Needle, R., McCubbin, H., Lorence, J., & Hochhauser, M. (1983). Reliability and validity of adolescent self-reported drug use in a family based study: A methodological report. International Journal on Addictions, 18, 901–912. Simons, J. S., Gaher, R. M., Correia, C. J., Hansen, C. L., & Christopher, M. S. (2005). An affective-motivational model of marijuana and alcohol problems
among college students. Psychology of Addictive Behaviors, 19, 326–334. doi:10.1037/0893-164X.19.3.326 Vermeiren, R., Schwab-Stone, M., Ruchkin, V. V., King, R. A., Van Heeringen, C., & Deboutte, D. (2003). Suicidal behavior and violence in male adolescents: A school-based study. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 41–48. doi:10.1097/00004583-20030100000009 Widom, C. S., Czaja, S. J., & Dutton, M. A. (2008). Childhood victimization and lifetime revictimization. Child Abuse & Neglect, 32, 785–796. doi:10.1016/j.chiabu.2007.12.006
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Negative Cognitions as a Moderator in the Relationship Between PTSD and Substance Use in a Psychiatrically Hospitalized Adolescent Sample Maureen A. Allwood,1 Christianne Esposito-Smythers,2 Lance P. Swenson,3 and Anthony Spirito4 1
Department of Psychology, John Jay College, City University of New York, New York, New York, USA 2 Department of Psychology, George Mason University, Fairfax, Virginia, USA 3 Department of Psychology, Suffolk University, Boston, Massachusetts, USA 4 Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island, USA
Adolescents exposed to trauma are more likely to engage in alcohol and marijuana use compared to their nontrauma-exposed counterparts; however, little is known about factors that may moderate these associations. This study examined the potential moderating effect of cognitions relevant to exposure to trauma (i.e., negative view of self, world, and future) in the association between posttraumatic stress disorder (PTSD) diagnosis and substance use among a psychiatric inpatient sample of 188 adolescents. Findings were that PTSD diagnosis was not significantly associated with substance-use diagnoses, but was associated with substance-use symptoms, accounting for 2.9% and 9.6% of the variance in alcohol and marijuana symptoms, respectively. The association between PTSD diagnosis and substance use symptoms, however, was moderated by negative cognitions, with PTSD and high negative cognitions (but not low negative cognitions) being significantly positively associated with substance use symptoms. The relevant cognitions differed for alcohol symptoms and marijuana symptoms. Children and adolescents who experience trauma and PTSD may benefit from early interventions that focus on cognitive processes as one potential moderator in the development of posttrauma substance use.
Adolescents exposed to trauma are more likely to engage in problematic alcohol and marijuana use compared to their nontrauma-exposed counterparts (Lipschitz et al., 2003; Vermeiren et al., 2003). Moreover, as many as 71% of youth in substance abuse treatment report experiencing a significant traumatic event at some time before their admission to treatment (Jaycox et al., 2004). In fact, high rates of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) comorbidity are found among adolescents in clinical settings (Deykin & Buka, 1997; Lipschitz, Grilo, Fehon, McGlashan, & Southwick, 2000) as well as among community youth (Giaconia et al., 2000; Kilpatrick et al., 2003; Lipschitz et al., 2003). Kilpatrick et al.’s study of more than 4,000 adolescents found that 24.6% of girls and 13.5% of boys with PTSD also met criteria for a SUD. As indicated by Kilpatrick et al. (2003) and others (Deykin & Buka, 1997; Lipschitz et al., 2000; Lopez, Turner, & Saavedra, 2005), the associations between PSTD and
substance use are particularly robust for girls and appear to be more strongly related to girls’ use of alcohol as compared to other substances (Lopez et al., 2005). Despite the well-documented linkages between trauma, PTSD, and SUD, most of what is known about these associations is derived from studies with adults. Adult studies, however, have yielded mixed findings, with some indicating that PTSD is strongly associated with substance use (Cougle, Bonn-Miller, Vujanovic, Zvolensky, & Hawkins, 2011; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), and others finding no significant association (Breslau, Davis, & Schultz, 2003; Fetzner, McMillan, Sareen, & Asmundson, 2011). Overall, little is known about the factors that might contribute to or moderate the development and progression of substance use problems among individuals with experiences of trauma and PTSD. This is particularly true during adolescence, when alcohol and drug behavior are likely to commence (Hien, Cohen, & Campbell, 2005; Lipschitz et al., 2003). Indeed, studies do show that problematic substance use among adolescents with PTSD generally follows trauma exposure and the onset of PTSD symptoms (Lipschitz et al., 2003; Lopez et al., 2005), suggesting that substance use might occur in response to the effects of trauma, albeit only for some individuals. In an epidemiologic study conducted with young adults, Chilcoat and Breslau (1998) found that those with a prior
Correspondence concerning this article should be addressed to Maureen A. Allwood, Department of Psychology, John Jay College, City University of New York, 524 West 59th Street, New York, NY 10019. E-mail: [email protected] C 2014 International Society for Traumatic Stress Studies. View Copyright this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21907
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diagnosis of PTSD were four times as likely to develop a SUD during a 5-year follow-up period as compared to those without a diagnosis of PTSD. Nonetheless, the emerging literature on PTSD and SUD in adolescents has yet to fully examine the potential moderators involved in the association between PTSD and problematic adolescent substance use. Possible moderators, such as cognitive and emotional processes that occur secondary to trauma exposure and PTSD symptoms, may help to explain the increased risk for later substance use among some traumaexposed youth. One conceptual model of trauma cognitions in the association between PTSD and SUD examined in the adult literature (Jayawickreme, Yasinski, Williams, & Foa, 2011), but applicable to adolescents, suggests that alcohol and other drugs may be used as a means to avoid trauma reminders and related cognitions (Giaconia et al., 2000). This conceptual model, referred to here as the trauma cognitive-avoidance model, postulates that cognitions associated with trauma exposure moderate the association between PTSD and SUD (i.e., the risk of SUD is greater in the context of PTSD when the diagnosis is coupled with negative trauma-related cognitions such as self-blame, distrust of others, and sense of a foreshortened future). In support of the trauma cognitive-avoidance model, research conducted with women indicates that trauma-related cognitions may serve as a vulnerability factor for SUDs (Hien et al., 2005; Najavits, Gotthardt, Weiss, & Epstein, 2004). Specifically, Najavits and colleagues (2004) found that women diagnosed with both PTSD and SUD reported more cognitions related to self-deprecation (i.e., negative view of self) and the need to escape negative affect as compared to women with PTSD alone. Similarly, Jayawickreme et al. (2011) found that trauma-related self-blame and negative view of self and the world were significantly positively related to alcohol craving. Building on the work of Najavits and colleagues (2004) and Jayawickreme et al. (2011), the present study examined negative views of self, the world, and the future as moderators of the PTSD–SUD association in a clinical sample of adolescents. The negative views of self, world, and future have been referred to as the “cognitive triad” in prior research and have been linked to depressive (Beck, 1967) as well as PTSD symptoms (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). Thus, youth with posttrauma symptoms who experience high levels of negative cognitions may use alcohol and other drugs to block out or dampen these destructive thought processes and the negative emotional state that the thoughts elicit. Accounting for the potential moderating effects of negative cognitions might be an important step in advancing the literature focused on the complexity of trauma exposure and response, and the likelihood of comorbid outcomes (Allwood, Dyl, Hunt, & Spirito, 2008), including comorbid SUDs. Utilizing a clinical sample of adolescents drawn from a psychiatric inpatient unit, the present study examined the relation between PTSD diagnosis and problematic substance use, as well as the potential moderating effects of negative views of self, world, and future. Two specific hypotheses were exam-
ined. First, we hypothesized that a diagnosis of PSTD would be significantly positively associated with alcohol and/or marijuana use among adolescents. Second, we hypothesized that the relation between PTSD diagnosis and substance use symptoms would be stronger in the presence of more negative cognitions.
Method Participants Two hundred sixty-three adolescents, ages 13 to 18 years and their parents were approached for recruitment over the course of a 3-year period. All adolescents were hospitalized on an acute psychiatric adolescent inpatient unit, the majority due to suicidal thoughts or behavior. Of those families approached for participation, 201 were successfully recruited. Sixteen participants did not complete the full assessment battery after consent, resulting in a final sample size of 188 participants (M = 15.02 years, SD = 1.32). Consistent with the hospital population from which the sample was drawn, the majority of the participants were female (70.1%). The racial composition consisted of 84.0% Caucasian, 2.7% African American, 2.1% Asian, 3.7% Native American, and 7.5% other racial/ethnic background. Approximately 9.6% of the sample was of Hispanic/Latino ethnicity. Family income varied widely from $100,000 per year with a median income range of $50,000 to $60,000. Inclusion criteria for participation included (a) parent and adolescent fluency in spoken English, (b) adolescent assent and parental consent, and (c) an adolescent verbal intelligence quotient (IQ) estimate ࣙ70 as assessed via the Kaufman brief intelligence test (Kaufman & Kaufman, 1990) to ensure that adolescents could cognitively understand and answer the questions included in the assessment. Exclusion criteria included current psychosis or full legal placement in child-protective custody, as documented in the inpatient admission materials. Fifty-one participants (25.4%) met criteria for PTSD diagnosis. Examination of demographic variables indicated that adolescents with PTSD did not differ from their non-PTSD counterparts on age, ethnicity, or family income (ps > .220). Girls were significantly more likely to be diagnosed with PTSD than boys, χ2 (1, N = 188) = 11.69, p < .001, with 34.1% girls and 9.4% boys meeting criteria. As expected, adolescents with PTSD reported a higher number of adverse and traumatic life events, including abuse, assaults, death of a loved one, domestic violence and disasters, but not more neglect, accidents, or illness of a loved one (see Table 1). Measures The Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADSPL; Kaufman et al., 1997) is a widely used semistructured diagnostic interview that provides a reliable and valid measurement of psychopathology in children and adolescents according to the
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Table 1 Frequency of Adverse and Traumatic Events by PTSD Diagnostic Status PTSD n = 51 Event Death of loved one Domestic violence Sexual assault Sexual abuse Physical abuse Physical assault Witnessed assault Accident Illness of loved one Neglect Disaster
No-PTSD n = 137
n
%
n
%
χ2
29 24 19 18 17 10 10 6 6 3 2
56.9 47.1 37.3 35.3 33.3 19.6 19.6 3.9 11.8 5.9 3.9
45 26 13 18 23 9 2 2 16 3 0
32.8 19.0 9.5 13.1 16.8 6.6 1.5 4.4 11.7 2.2 0.0
8.98** 15.01*** 20.29*** 11.78*** 6.07* 6.95** 20.48*** 0.02 0.00 1.64 5.43*
Note. PTSD = posttraumatic stress disorder. *p < .05. **p < .01. ***p < .001.
Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994). Interrater agreement for scoring screens and diagnoses is high (range = 93%–100%). Test-retest reliability and κ coefficients are in the excellent range for most diagnoses (.77–1.00; Kaufman et al., 1997). For the present study, all interviewers were extensively trained in the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL; Kaufman et al., 1997) through didactic training, rating of audiotapes, administering in-person interviews while being observed, and then audiotaping full interviews, which were rated for reliability. Upon completion of training, all interviews were audiotaped and 18 adolescent interviews and 18 parent interviews were randomly selected and rated for reliability. Kappa coefficients reflected strong agreement for all anxiety disorders including PTSD (κ = .92–1.0), all substance use disorders (κ = .79–1.0), and all depressive disorders (κ = .89–1.0), except dysthymia. In addition to conducting regular reliability ratings, all cases were staffed during weekly clinical consensus team meetings. During this meeting, all K-SADS-PL symptoms and assessment data were reviewed by doctoral-level child psychologists in addition to the interviewers. A best-estimate clinical consensus procedure (Klein, Ouimette, Kelly, Ferro, & Riso, 1994) was used to resolve discrepancies between symptoms reported by adolescent and parent as well as to confirm diagnoses. All diagnoses examined were based on the consensus procedures. The KSADS-PL modules pertaining to PTSD and SUDs were of interest in the present research. The PTSD module assesses for most potential traumas (e.g., accident, fire, disaster, crime victimization, abuse, and other self-specified traumas). In ad-
dition to experiencing an identified trauma, to meet criteria for PTSD, participants must have indicated that they experienced the requisite number of symptoms in all three PTSD symptom components (i.e., at least one reexperiencing, three avoidance/numbing, and two arousal symptoms). Alcohol abuse was indicated by the endorsement of at least one of four alcoholrelated symptoms and alcohol dependence was indicated by at least three of seven symptoms. These same criteria were used for each substance abuse and dependence disorders. To assess total alcohol symptoms and substance use symptoms, the respective abuse and dependence symptoms were added to establish a symptom count. The Cognitive Triad Inventory for Children (Kaslow & Stark, 1986) is a 36-item self-report questionnaire designed to assess self-perceived competencies and global self-worth in children and adolescents. Participants indicated how similar the stated thoughts or opinions were to those of their own by circling yes, no, or maybe. Three 12-item subscales are derived from the individual items, such as “I am a failure,” “The world is a very mean place,” and “My future is too bad to think about”: View of the Self, View of the World, and View of the Future. A total score is calculated by summing scores from each subscale after reverse scoring negative items on subscales. Higher scores on the Cognitive Triad Inventory for Children reflect fewer negative cognitions. Adequate internal consistency and convergent/discriminant validity have been demonstrated for this measure (Kaslow, Stark, Printz, Livingston, & Tsai, 1992). Internal consistency for the Cognitive Triad Inventory for Children in the present study was α = .96, and subscale alphas ranged from α = .82 (world) to α = .94 (future). Procedures Daily chart reviews were conducted by a bachelor-level research assistant employed by the participating hospital. All eligible adolescents and their parents/guardians were then approached for recruitment by the research assistant after family meetings or visits on the adolescent inpatient unit. Once written parental consent and adolescent assent were obtained, adolescents and their parent/guardian completed the assessments while the adolescent was hospitalized in the unit. The research assistant administered the assessment battery with the exception of the diagnostic interview, which was administered by trained masters- and doctoral- level clinicians. Parent and adolescent assessments were conducted separately. The parent version of the diagnostic interview and assessment measures was administered in a 2-hour session. The child version of the diagnostic interview and assessment measures were administered in two separate 1½- to 2-hour sessions. All adolescents received four movie tickets and their parent/guardian received a $50 money order for their participation. Substance-related information was not shared with parents because teens self-reported substance use has been shown to be accurate and reliable under conditions of confidentiality (Needle, McCubbin, Lorence, & Hochhauser, 1983). This study was
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Table 2 Frequency of Substance Use Disorders for Total Sample and by PTSD Diagnostic Status
Substance use disorder Alcohol Marijuana Both alcohol & marijuana
Total n = 188
PTSD n = 51
No PTSD n = 137
n
%
n
%
n
%
42 51 31
20.9 25.4 16.5
16 12 10
31.4 23.6 19.6
26 39 21
19.0 28.5 15.3
Note. PTSD = posttraumatic stress disorder.
approved by the Brown University and Lifespan Hospitals Institutional Review Boards. Data Analysis First, descriptive information regarding the rate of diagnosed PTSD and alcohol and other substance disorders were generated. Next, the rate of exposure to traumas among adolescents with and without PTSD was examined using χ2 analyses. Adolescent-reported substance use symptoms were then used as the dependent variable in a series of three hierarchical regressions. Demographic variables, diagnosis of PTSD, and a cognitive variable (i.e., View of the Self, World, or Future subscales) were entered in the first step and the interaction between diagnosis of PTSD and the cognitive variable was entered in the second step. The three negative cognitions subscales were mean-centered prior to all analyses. Significant interactions associated with substance use symptoms were explored following procedures outlined by Aiken and West (1991). To examine whether significant findings might be due to the presence of depressive symptoms among the sample, correlational analyses included a composite of depressive disorder diagnoses (i.e., major depression, dysthymia, depression not otherwise specified [NOS]) and regression analyses were reexamined adjusting for the composite of depressive disorders.
Results Forty-two participants met criteria for an alcohol use disorder (i.e., abuse or dependence), 51 met criteria for a marijuana use disorder, and 10 met criteria for all other SUDs (see Table 2). Of the 10 participants who met criteria for a nonalcohol or marijuana SUD (e.g., cocaine, prescription drugs), 5 were comorbid for marijuana abuse or dependence and 7 were comorbid for alcohol abuse or dependence. Given the low incidence of SUDs not related to alcohol or marijuana and the high comorbidity, only alcohol and marijuana disorders and symptoms were used in subsequent analyses. Notably, 31 adolescents met criteria for both alcohol and marijuana use disorders, therefore a total
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of 62 adolescents account for all alcohol- and marijuana-use diagnoses. Analyses of alcohol and marijuana use disorders with PTSD diagnosis using χ2 showed that adolescents with PTSD were not more likely to have an alcohol-use disorder, χ2 (1, N = 188) = 3.29, p = .070, or a marijuana-use disorder, χ2 (1, N = 188) = 0.46, p = .498, compared to adolescents without PTSD. Similarly, adolescents with PTSD were not more likely to meet criteria for comorbid alcohol and marijuana use disorders, χ2 (1, N = 188) = 0.49, p = .482. The onset of PTSD diagnosis occurred at an average of 10.65 years, (SD = 3.47); alcohol-use disorder was on average at 14.04 years, (SD = 1.11) and on average substance-use disorder at 14.67, years (SD = 1.43). The onset of drinking was on average 12.42 years (SD = 3.69). To further examine the relationship between PTSD diagnosis and alcohol and marijuana use, subsequent analyses focused on alcohol and marijuana symptoms (vs. the dichotomous substance-use diagnoses derived by consensus). Table 3 presents descriptive statistics and the correlations among PTSD diagnosis and symptom counts for alcohol use, marijuana use, and the three cognitive subscales. As shown in Table 3, adolescents reported more marijuana symptoms than alcohol symptoms. The differences in mean symptoms is largely because adolescents who reported no prior marijuana use (n = 132) provided no information regarding symptoms, whereas adolescents who reported alcohol use as little as one time, provided information regarding symptoms (i.e., zero symptoms), therefore deflating the overall alcohol-symptom mean. In the examination of the associations among PTSD diagnosis, substance-use symptoms, and negative cognitions, PTSD diagnosis was significantly positively related to both alcohol and marijuana symptoms. PTSD diagnosis was also significantly related to all negative cognitions in the expected direction. Negative cognitions were differentially associated with marijuana and alcohol symptoms. Negative views of the self and the world were significantly related to alcohol symptoms, whereas negative view of the future was significantly related to marijuana symptoms. In addition, alcohol symptoms were positively related to age (r = .17, p = .024), with older adolescents being more likely to report alcohol related symptoms. Marijuana symptoms were not significantly related to age (r = .19, ns) for the 53 who endorsed prior marijuana use, although age accounted for almost 4% of the variance (vs. almost 3% of the variance for alcohol symptoms). Neither alcohol nor marijuana symptoms were significantly related to gender, ethnicity, or family income (ps >.165; based on respective t tests or Pearson correlations). To examine whether the main effect of PTSD on alcohol and marijuana symptoms was moderated by negative cognitions, separate hierarchical regression analyses were conducted (see Tables 4 and 5). Because girls were more likely to be diagnosed with PTSD than boys, and because older adolescents were more likely to report substance use symptoms, gender and age were entered in the first step of each model. Table 4 shows the main effects of PTSD, View of the Self, World, and Future in relation
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Table 3 Intercorrelations, Means, and Standard Deviations of Key Measures Variable 1. PTSDa 2. Alcohol symptoms 3. Marijuana symptoms 4. View of Self 5. View of World 6. View of Future
M
SD
1
2
3
4
5
0.27 0.92 4.92 15.92 15.23 17.47
0.45 1.88 2.51 6.60 4.76 6.60
– .17* .31* −.35*** −.33*** −.25***
– .34* −.19* −.17* −.12
– −.20 −.17 −.29*
– .73*** .83***
– .73***
Note. Alcohol symptoms are reported for 185 individuals; marijuana symptoms are reported for 53 individuals. PTSD = posttraumatic stress disorder. a Point biserial correlations were conducted for dichotomous variable. *p < .05. **p < .01. ***p < .001.
to alcohol symptoms, as well as the interaction effects of PTSD and the negative cognitions. The main effect of PTSD diagnosis and View of Self were both only marginally related to alcohol symptoms, however, the interaction effect was significantly related to alcohol symptoms. To interpret this interaction, simple slope analyses examined relations between PTSD and alcohol symptoms at high (i.e., above the mean) and low (i.e., below the mean) View of Self (see Figure 1). At high negative View of Self, PTSD was significantly positively associated with alcohol symptoms (β = .37, p = .002). At low negative View of Self, PTSD was not significantly associated with alcohol symptoms
(β = −.05, ns). Neither the main effect nor interaction effect of View of the World or View of the Future was significantly related to alcohol symptoms after accounting for gender, age, and PTSD. In the examination of PTSD diagnosis and negative cognitions in relation to marijuana symptoms, PTSD remained significantly related to marijuana symptoms after accounting for demographics and negative cognitions (Table 5). None of the three negative cognitions was significantly associated with marijuana symptoms after accounting for demographics, however, the interaction effects differed by cognitive distortions. The
Table 4 Hierarchical Regression Analyses of Moderation by Negative Cognitions of Association Between PTSD and Alcohol Symptoms Step 1 Variable Gender Age PTSD View of Self PTSD × View of Self Gender Age PTSD View of World PTSD × View of World Gender Age PTSD View of Future PTSD × View of Future
Step 2 β
B
SE B
−.27 .22 .62 −.04
.31 .10 .33 .02
View of Self −.07 .15* .15 .14
.31 .10 .33 .03
View of World −.05 .15* .16* −.11
.31 .10 .33 .02
View of Future −.05 .17* .17* −.08
−.23 .22 .66 −.04 −.21 .24 .72 −.02
R2
B
SE B
β
R2
.08
−.24 .21 1.14 .00 −.12
.31 .10 .38 .03 .05
−.06 .15* .27** .00 −.25*
.11
.07
−.23 .22 .59 −.03 −.05
.31 .10 .34 .04 .06
−.06 .15* .14 −.07 −.08
.15
.07
−.22 .24 .66 .00 −.05
.31 .10 .33 .03 .04
−.05 .17* .16* −.01 −.11
.17
Note. n = 185. View of Self, World, and Future are mean-centered. The results are unchanged by the inclusion of diagnoses of depression. PTSD = posttraumatic stress disorder. *p < .05. **p < .01.
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Negative Cognitions and Adolescent Substance Use
Table 5 Hierarchical Regression Analyses of Moderation by Negative Cognitions of Association Between PTSD and Marijuana Symptoms Step 1 Variable
B
SE B
Gender Age PTSD View of Self PTSD × View of Self
−.81 .30 1.89 −.01
.72 .29 .95 .06
Gender Age PTSD View of World PTSD × View of World
−.82 .30 1.88 −.04 −.02
.71 .29 .90 .03 .08
Gender Age PTSD View of Future PTSD × View of Future
−.70 .27 1.62 −.06
.71 .29 .86 .05
Step 2 β
R2
View of Self −.16 .14 .32* −.03 .14 View of World −.16 .14 .32* −.11 −.04 .15 View of Future −.14 .12 .27 −.17 .17
B
SE B
β
R2
−.85 .27 2.22* .03 −.13
.72 .29 .99 .07 .12
−.17 .13 .37* .08 −.17
.17
−.95 .25 1.27 .11 .31
.70 .28 .92 .10 .16
−.16 .12 .21 −.21 −.41*
.21
−.90 .30 1.18 .01 −.21
.70 .28 .87 .06 .10
−.18 .14 .20 .02 −.34
.23
Note. n = 53. View of Self, World, and Future mean-centered. The results are unchanged by the inclusion of diagnoses of depression. PTSD = posttraumatic stress disorder. *p < .05.
interaction between PTSD and View of Self was not significantly related to marijuana symptoms, but the interaction with View of the World and the Future were either significantly or marginally related to marijuana symptoms (Table 5). Simple slope analyses indicated that at high negative View of the Future (+1 SD), PTSD was significantly positively associated with marijuana symptoms (β = .73, p < .001; see Figure 1), but at low negative View of the Future (−1 SD), PTSD was not associated with marijuana symptoms (β = .03, ns). Notably, the simple slope analysis for the interaction between PTSD diagnosis and negative View of the World was not interpreted because only two adolescents with PTSD diagnosis and high negative View of the World (+1 SD) reported having marijuana symptoms. Because negative views of self, world, and future are often related to depression, analyses were conducted to examine whether findings might be largely accounted for by depression versus PTSD diagnosis. First-order correlations indicated that a composite of depressive disorder diagnoses (i.e., major depression, dysthymia, depression NOS) was not significantly related to either alcohol (r = .04, ns) or marijuana symptoms (r = .13, ns). Additionally, all significant regression analyses were reexamined with depression diagnosis at Step 1, but there were no changes in the findings reported above.
Discussion The present study examined the potential moderating effect of trauma-relevant cognitions in the association between PTSD diagnosis and substance use. Among this primarily female adolescent inpatient sample, PTSD was not significantly related to substance use diagnoses, but was associated with substance use symptoms. Nonetheless, negative cognitions moderated the associations, indicating that cognitions that often occur in the aftermath of trauma exposure might play an important role in the development of posttrauma substance use. Consistent with previous studies of adult women with histories of trauma (Jayawickreme et al., 2011; Najavits et al., 2004), we found that self-deprecating cognitions moderated the relationship between PTSD and alcohol symptoms. Moreover, we found that pessimistic views about the world and one’s future might moderate the relationship between PTSD diagnosis and marijuana symptoms. Specifically, PTSD was associated with marijuana use symptoms only among youth with more (but not less) pessimistic views of the future. Together, these findings offer preliminary support for the trauma cognitive-avoidance model, wherein PTSD in the context of high levels of negative cognitions is presumed to be associated with higher rates of alcohol and marijuana use. Conceptually, the context of high negative cognitions is associated with a greater desire to escape
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Figure 1. Posttraumatic stress disorder (PTSD) by View of Self in relation to alcohol symptoms (n = 185) and PTSD by View of Future in relation to marijuana symptoms (n = 53), both adjusted for age and gender. High and low groups formed by a mean split.
such cognitions and the associated affect through the use of substances. These findings have several important implications. First, this is the only study to replicate the moderating effects of self-deprecation (e.g., negative view of self) on the relation between PTSD and alcohol use in a sample of adolescents of which we are aware. The emergence of such negative cognitions and cognitive avoidance early in development (adolescence) might interact with other psychological symptoms, such as PTSD symptoms, to partly account for the increased risk of negative outcomes observed among youth exposed to trauma and victimization. In fact, PTSD symptoms (clinical or subclinical) that include negative thoughts about self, the world, or one’s future might better account for the higher rates of delinquent behaviors (Allwood & Bell, 2008; Becker & Kerig, 2011), derailed academic progress (Allwood & Widom, 2013; Duncan, 2000), revictimization (Widom, Czaja, & Dutton, 2008), and other negative outcomes (Ford, Elhai, Connor, & Frueh,
2010) found among trauma exposed youth, than PTSD diagnosis alone. Second, this study extends the relevance of negative cognitions to marijuana use among adolescents, with findings indicating that there are likely to be many individual differences that affect adolescent’s response to trauma and their decision to use substances. Negative views of oneself were not related to marijuana symptoms, and negative views of the world and future were not related to alcohol symptoms. These findings suggest that the choice of substance might be influenced by specific cognitive and affective states and expectancies (Simons, Gaher, Correia, Hansen, & Christopher, 2005), but speculation on the specific pattern found here seems premature and should await confirmation by additional studies. There are several important limitations to consider when interpreting these findings, primarily related to the fact that the sample was the largely female and psychiatrically hospitalized for severe mental health problems. First, the adolescents in this study have relatively high levels of psychopathology and general psychopathology is a predictor of early-onset substance use (Costello, Copeland, & Angold, 2011). Second, the patients in this study were admitted to the hospital primarily for suicidal thoughts and behavior; their cognitions might be more strongly influenced by their emotional state at the time of the assessment than might be found in other samples. Thus, our findings might not generalize to a healthier sample of adolescents. Third, this relatively young (average age = 15 years), primarily female sample might be less likely to use substances than older adolescents (Chen & Jacobson, 2012) and/or their male counterparts (Kaplow, Curran, & Dodge, 2002). Indeed, the number of adolescents using alcohol, marijuana, or both was relatively small and varied across substances which in turn affected the strength of the statistical analyses across substances. Thus, findings might not generalize to community youth or to outpatient clinical settings. Likewise, the findings might not generalize to males with or without PTSD. Future research in this area should include samples that are more representative of the general population of adolescents. Samples should be more racially, ethnically, and linguistically diverse and include comparable numbers of males and females drawn from a variety of settings, including nonclinical settings. In summary, among this psychiatrically hospitalized sample, adolescents with PTSD report significantly more negative cognitions about themselves, the world, and the future than their peers without PTSD, and these cognitions differentially moderated the associations between PTSD diagnosis and alcoholand marijuana-use symptoms. These preliminary findings suggest that adolescents exposed to traumatic experiences may benefit from early clinical interventions that focus on cognitive processes. Clinical interventions for adolescent posttrauma substance use should specifically attend to adolescent views of self (e.g., self-identity), the world, and the future (e.g., future orientation), as well as substance-use expectancies and motivations.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Negative Cognitions and Adolescent Substance Use
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