Predictors of Substance Use Among Adolescent Psychiatric Inpatients: The Role of Adverse Childhood Experiences (ACEs)

doi:10.21203/rs.3.rs-5234186/v1

Background: Adverse childhood experiences (ACEs) have been associated with a number of detrimental outcomes in adolescence. The relationship between ACEs and substance use behaviors is poorly characterized among clinical inpatient samples, although this population may be at most need for effective intervention.

Objective: To address this gap in the literature, the present study comprehensively examined correlates of substance use behavior in a sample of adolescent inpatients undergoing psychiatric hospitalization, with emphasis on the role of ACEs.

Method: A retrospective review of medical records spanning from 2019 to 2023 included 551 participants (54.8% female, 67.3% non-Hispanic white) between the ages of 13 to 21, who underwent comprehensive neuropsychological evaluation while hospitalized in an inpatient psychiatric unit. Participants were classified as substance users and non-substance users and psychiatric diagnoses were assigned based on clinical interview. Regression models examined the relationship between overall ACE score, individual ACEs, and substance use, adjusting for covariates.

Results: Participants most commonly reported experiencing 7 ACEs. 40.3% of the sample were classified as substance users (n=222). Substance users were found to have a higher number of total ACEs. The odds of substance use increased by 10.4% with each additional ACE history (aOR=1.102, 95% CI [1.143-1.432], p<0.001). The significant association between ACEs and substance use remained when adjusting for a post-traumatic stress disorder diagnosis.

Conclusions: Results underscore the pervasive impact of ACEs on substance use behaviors among clinically acute adolescents undergoing hospitalization. Findings highlight the role of early-life stressors in shaping substance use behaviors among adolescents in psychiatric care.

Psychology

substance use

ACEs

adolescent mental health

inpatient populations

The prevalence of substance use behaviors among American adolescents is alarmingly high. In 2022, approximately 13.7 % of the US population aged 12 to 17 reported using substances (Substance Abuse and Mental Health Services Administration, 2023), with an estimated 2.2 million individuals among this cohort meeting criteria for a substance use disorder (SUD) (SAMSHA, 2023). Substance use is a major concern for parents, clinicians, educators, and policy makers alike, due to increased risk of behavioral problems, school dropout, overdose, and potential for problematic neurodevelopmental effects (Castellanos-Ryan et al., 2013; Gray and Squeglia, 2018). The urgency for addressing substance use rates is underscored by the fact that in 2020, drug overdoses and poisonings became the third leading cause of death for adolescents and children in the United States (US) (Goldstick et al., 2022). Numerous theoretical models propose neurological, attachment-based, and learning-based origins of substance use behaviors in adolescents, each with varying levels of support (Alvares-Monjaras et al., 2018; Lewis, 2018). While these theoretical models provide insight into the potential underlying mechanisms of substance use initiation, there continues to be a gap in our understanding of the specific predisposing factors which contribute to the onset of substance use during adolescence. Understanding potential origins of adolescent substance use could help individuals working with adolescents devise effective interventions and programs that improve life outcomes and reduce risk of overdose.

There has been a growing interest in the role of adverse childhood experiences (ACEs) and their association with the development of SUD (Leza et al., 2021). ACEs are defined as a wide range of potentially traumatic experiences that individuals may encounter between the ages of 0-18 years, including incidents such as experiencing physical or sexual abuse, witnessing domestic violence, or experiencing homelessness (Ports et al., 2020). Approximately 63.7% of adolescents aged 13 to 18 have experienced at least one ACE, with 19.4% experiencing 4 or more ACEs (Hertz et al., 2023). Higher rates of ACEs in childhood significantly increase risk for inpatient hospitalization, substance use treatment, post-traumatic stress disorder (PTSD), suicidality, and overall risk of developing mental health problems (Rytilä-Manninen et al., 2014; Isohookana et al., 2013; Goldenson et al., 2020; Fehon et al., 2001; Baldwin et al., 2023). ACEs have been used to examine risk for substance use initiation among adolescents and young adults, with findings suggesting a strong relationship between experiencing a high number of ACEs and initiation of substance use in the general population (Dube et al., 2003; Shin et al., 2018; Leza et al., 2021).

A diagnosis of PTSD and SUD are often comorbid, with those diagnosed with PTSD also being diagnosed with a SUD at 14 times a higher rate than those without PTSD (McCauley et al., 2012). Previous findings have shown that higher rates of nicotine, marijuana, and alcohol usage among those with PTSD symptoms (Lipschitz et al., 2003). Contemporary models of substance use and childhood trauma (i.e., self-medication theory) postulate that substance use is a method by which to suppress and cope with traumatic experiences (Schimmenti et al, 2022). Yet, other findings also suggest that potentially traumatic experiences in childhood, along with a diagnosis of PTSD, are more predictive of substance use than solely potentially traumatic experiences in childhood (Mergler et al., 2018); highlighting the need for studies that examine the combined presentation of ACEs history and PTSD symptoms.

While the current literature has elucidated a relationship between ACEs and substance use among the general adolescent population, little research has focused on the link between ACEs and substance use within acute clinical psychiatric populations. This is a major area of concern as pediatric psychiatric hospitalizations have increased by 25% from 2009 to 2019, resulting in pediatric stays accounting for 19.8% of mental health hospitalizations in 2019 (Arakaylen et al., 2023). Moreover, experiencing a higher number of potentially traumatic experiences in childhood can lead to severe psychopathology and worse health outcomes over time, especially when paired with a comorbid SUD (Sullivan et al., 2006; Boxer and Terranova, 2008; Wolitzky-Taylor et al., 2016). The lack of attention to ACEs and substance use behaviors in hospitalized adolescents may represent a potential oversight in the literature, as this vulnerable population may be most in need of comprehensive, effective interventions.

Taken together, ACEs are profoundly common and a potentially important factor in the development of SUDs and severe psychopathology, yet their impact remains understudied among psychiatrically acute adolescent populations. To address this gap in knowledge, the present study investigated the impact of ACEs on substance use behavior within a clinically diverse sample of adolescents undergoing inpatient psychiatric treatment (age 13-21). Specifically, we sought to: (Aim 1) characterize differences between substance users and non-users in addition to key correlates of substance use, including demographic traits, clinical diagnoses (including PTSD), neuropsychological characteristics, and history of ACEs; (Aim 2) examine the relationship between a prior history of ACEs and current substance use, controlling for sociodemographic covariates and PTSD diagnosis. We hypothesized that greater history of childhood adversity would predict an increased risk for substance use in this unique clinical sample. The findings of this study will inform diagnostic and treatment considerations related to risk factors for substance use in psychiatrically vulnerable adolescent populations.

Participants and Procedures

Data were extracted from a retrospective review of medical records spanning from August 2019 to October 2023. Participants were adolescents referred for neuropsychological and psychodiagnostics evaluation while hospitalized in an inpatient unit at a psychiatric hospital in the northeastern United States, which admits adolescents between the ages of 13 and 21. Referrals were made to characterize cognitive, functional, and behavioral characteristics, as well as to guide treatment planning. Out of 556 potential participants identified, five participants were excluded from the current analysis due to missing data of primary variables of interest (e.g., ACE scores). The collection of data from human subjects adhered to all relevant laws and ethical guidelines and received approval from the Butler Hospital Institutional Review Board.

Substance use

Substance use history over the last year was captured via the Mini International Neuropsychiatric Interview for children and adolescents (MINI-KID; Sheehan et al., 2010). This structured neuropsychiatric clinical interview tool aids clinicians in diagnosing psychiatric conditions in children and adolescents. It contains questions pertaining to use of alcohol, opioids, stimulants, cocaine, cannabis, sedatives, inhalants, hallucinogens, stimulants, and other drugs such as steroids. In the current analyses, participants were categorized as substance users if they reported using one or more substances in the past year. Participants who denied using any substances during this period were classified as non-users.

Diagnostic Classification

Psychiatric diagnoses were determined through responses to the MINI-KID, which utilizes diagnostic criteria of mood disorders, substance-related disorders, eating disorders, conduct disorders, neurodevelopmental disorders, PTSD, and psychotic disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Diagnoses were assigned if participants met criteria based on responses to the MINI-KID and symptoms reported during the clinical interview. For the purpose of this analysis, only the top three primary diagnoses were quantified even if participants met criteria for more than three psychiatric diagnoses. Primary diagnoses were determined via severity of symptoms reported on the MINI-KID.

Adverse Childhood Experiences (ACEs)

Childhood adversity was measured via the Center for Youth Wellness Adverse Childhood Experiences Questionnaire Teen Self-Report (CYW ACE-Q; Harris and Renschler, 2015). The CYW ACE-Q is composed of the 10 traditional ACEs used in the original CDC-Kaiser study (Felitti et al., 1998), as well as 9 additional ACEs identified by experts as contributing to developmental disruption (Harris and Renschler, 2015). The CYW ACE-Q captures distinct instances of stressors or potentially traumatic events that occur during childhood including abuse, neglect, household dysfunction, and community dysfunction (See Table 1 for ACE items). Participants self-report by indicating either “yes” or “no” to having a history of each adverse life experience. The total ACE score represents a sum of all individual ACEs endorsed, with possible scores ranging from 0-19, and higher scores indicating a more substantial history of childhood stress. We also examined individual ACEs in our analyses.

Neuropsychological Assessment

Intellectual functioning (FSIQ) was measured via the Wechsler Abbreviated Scale of Intelligence, 2^nd Ed. (WASI-II). The WASI-II is a standardized measure of intelligence capturing perceptual reasoning and verbal comprehension skills (Groth-Marnat & Wright, 2016). Executive functioning was measured via the Stroop Color and Word Test (SCWT) and the Trail Making Test (TMT) A and B. The SCWT is a three-part test of processing speed (including trials reading words and naming colors) and inhibition (the color-word trial, which asks the participant to name the color of the ink a word is printed in which differs from what the word says). The TMT is a two-part test that examines processing speed (part A) and set shifting/mental flexibility (part B) (Wagner et al., 2011). We analyzed normed scores (age normed, percentiles) for neuropsychological outcomes to account for age variation within this sample.

Data Analysis

Descriptive statistics were conducted to characterize the sample in terms of demographic variables, clinical diagnoses, neuropsychological testing, ACEs, and substance use. To test Aim 1, independent samples t tests and chi-square tests of independence were used to characterize significant differences between substance users and non-users on all variables of interest. Point-biserial correlation coefficient and phi coefficient were used to determine correlates of substance use. To test aim 2, multivariate logistic regression models were conducted to evaluate the association between predictors of interest (i.e., total ACE score and individual ACEs,) and the odds of current substance use (in separate models). Model 1 adjusted for age and FSIQ. Model 2 adjusted for the covariates included in model 1 in addition to PTSD diagnosis. Covariates were selected based on significant association with independent and dependent variables of interest. All analyses were conducted using SPSS version 28.0.1.1 (IBM Corp., Armonk, NY, USA).

Overall Sample Descriptive Characteristics: Demographic traits, clinical diagnoses, neurocognitive features, and substance use patterns

Table 2 presents all demographic, neuropsychological, and clinical variables in the overall sample, as well as by substance use status. The sample consisted of 551 patients hospitalized within the inpatient psychiatric unit between August 2019 and October 2023. Ages of participants within the sample ranged from 13 to 21 years (M=15.58, SD=1.70). The most common current grade/education level at the time of testing was 9th grade (mode=9th grade, range=6th grade to senior in college [16 years education]). Over half of the sample self-identified as female (54.8%), while 35.4% identified as male, and 8.8% of the sample identified as transgender or non-binary. The sample ethno-racially self-identified as 67.3% non-Hispanic white, 12.7% Latinx, 10.5% biracial, 5.8% non-Hispanic black, 1.8% Asian, with the remaining participants identifying with “other” ethno-racial groups (1.1%).

In terms of clinical diagnoses, major depressive disorder was the most common diagnosis assigned (n=371, 67.3%) followed by PTSD (n=186, 33.7%). Other common diagnoses included generalized anxiety disorder (n=175, 31.7%), ADHD (n=46, 8.3%), and SUD (n=37, 6.7%). Clinical diagnoses were not mutually exclusive.

In terms of neurocognitive profiles, the overall sample showed average intellectual level (FSIQ=99.75, SD = 13.6). Performance on tests of processing speed (TMT part A %ile=38.6%, SD=31.3; Word%ile=28.8, SD=26.7; Color%ile=23.6, SD=22.8), inhibition (Color-Word%ile= 31.3, SD=29.1), and set-shifting (TMT part B %ile=24.6, SD = 27.1) were broadly in the average range, although relatively weaker skills when compared with the average level of general neuropsychological functioning.

The most frequent number of ACEs in this population was 7. In terms of specific adverse experiences (Table 1), 62.8% of the sample had divorced or separated parents (n=346), 62.8% had experienced bullying or harassment in school (n=346), 61.5% of the sample had lived with a household member with mental illness (n=339), 56.6% lived with a household member who perpetrated verbal abuse (n=312), 54.1% felt unsupported, unloved, or unprotected (n=298), 46.6% experienced or witnessed domestic abuse (n=257), 45.6% experienced physical abuse (n=251), 44.1% lived with someone with a SUD (n=243), 39.4% had experienced violence in the neighborhood or school (n=217), 32.7% had been discriminated against due to race, sexual orientation, place of birth, disability, or religion (n=180), 31.4% were victims of sexual abuse (n=173), 29.6 % of the sample had lived with a household member who served jail time (n=163), 24.7% had experienced verbal or physical abuse or threats from a romantic partner (n=136), 16.2% went without basic necessities (food, clothes, shelter) (n=89), 14% had been detained, arrested, or incarcerated (n=71), 12.3% had been in foster care (n=68), 11.1% had a parent who died (n=61), 9.3% have had a serious medical procedure or life threatening illness (n=51), and 2.4% has been separated from a caregiver due to deportation/immigration (n=13).

40.3% of the sample endorsed using substances over the past year (n=222). In the entire clinical sample, 35.6% used marijuana/cannabis (n=196), 14.5% used alcohol (n=80), 10.2% used nicotine (n=56), 2.9% used hallucinogens (n=16), 1.6% used cocaine/stimulants (n=9), 1.3% used benzodiazepines (n=7), and 0.9% used opiates (n=5). About half of those who used any substance, used two or more substances over the past year (49.5% of the substance user sample, n=110). Among those who used a substance(s), primary substances were marijuana/cannabis (30.1%), alcohol (6.4%), and nicotine (2.9%), with a small minority primarily using hallucinogens (0.2%) or cocaine/stimulants (0.7%).

Aim 1. Differences between substance users and non-users and correlates of substance use

Significant differences between substance users and non-users are presented in Table 2. Exploratory analyses were conducted to examine differences among single substance users, multiple substance users, and non-users. No significant differences emerged between these three groups that were not captured by comparing users and non-users (e.g., there were no meaningful differences between multiple and single substance users). As such, we present only significant differences between substance users and non-users. Substance users were significantly older than non-users (user M=16.03 vs. non-user M=15.28; t(549)=5.176, p<0.001). Substance use status did not significantly differ by gender or race/ethnicity. Individuals who endorsed substance use over the past year demonstrated significantly lower FSIQ (user M=97.76 vs. non-user M=101.14; t(493)=2.731, p=0.003); however, both user and non-user FSIQs were solidly in the average range. No significant differences emerged on measures of processing speed or executive functioning.

In terms of clinical diagnosis, substance users were more likely to meet criteria for PTSD (𝛘²=16.9, p<0.001). Substance users did not differ from non-users in rates of MDD, GAD, or ADHD.

Substance users had a significantly higher number of total ACEs in their history than non-users (user M=7.47 vs. non-user M=6.03; t(544)=4.354, p<0.001). Specific ACEs by substance use status are presented in Table 3. Individuals who engaged in substance use over the past year were significantly more likely to have a history of sexual abuse (𝛘²=13.5, p<0.001), justice system involvement (𝛘²=4.8, p=0.027), and history of intimate partner violence/abuse (𝛘²=8.96, p=0.003).

Correlational analyses were also conducted. A weak but statistically significant association was observed between participant age (r=.216, p<0.001) and substance use. From a neurocognitive perspective, overall intellectual functioning (FSIQ, r=-1.22, p=0.007), but not executive functioning-related skills, were associated with substance use. The presence of an active PTSD diagnosis showed a weak but significant association with substance use (Φ=0.176, p<0.001). The presence of MDD, GAD, or ADHD were not correlated with substance use. PTSD diagnosis and total ACEs were significantly correlated (r=.452, p<0.001).

Aim 2. Association between history of Adverse Childhood Experiences and current substance use

Multivariate logistic regression models were used to analyze the relationship between ACE total score and substance use (table 4), controlling for participant age and FSIQ (model 1). Results demonstrated that for each additional ACE score, the odds of substance use increased by 10.4% (aOR=1.104, 95% CI [1.051-1.160], p<0.001). The significant association between total number of ACEs and substance use remained when controlling for current PTSD diagnosis (model 2) (aOR=1.171, 95% CI [1.014-1.132], p=0.015)

Analyses were conducted to examine the relationship between individual ACEs (identified above to be more prevalent in substance users) and current substance use. The odds of substance use were increased by 102% in the presence of sexual abuse history (model 1) (aOR=2.020, 95% CI [1.353-3.016], p<0.001) and remained when controlling for current PTSD diagnosis (model 2) (aOR=1.669, 95% CI [1.097-2.540], p=0.017). The odds of substance use were increased by 74% in the presence of intimate partner abuse history (model 1) (aOR=1.747, 95% CI [1.142-2.672], p=0.010) and remained when controlling for current PTSD diagnosis (model 2) (aOR=1.627, 95% CI [1.055-2.509], p=0.028). The odds of substance use were increased by 52% in the presence of physical abuse history (model 1) (aOR=1.526, 95%CI [1.049-2.221], p=0.027), but this association was no longer significant when controlling for PTSD diagnosis (model 2). All other ACEs were not significant predictors of substance use in this sample.

This study examined the association between history of ACEs and substance use behaviors among a sample of adolescent psychiatric inpatients. Specifically, we sought to: (Aim 1) characterize differences between substance users and non-users, including demographic traits, clinical diagnoses, neuropsychological characteristics, and history of ACEs; and (Aim 2) examine the relationship between a prior history of ACEs and current substance use.

Overall, we showed that substance users in our sample were significantly older than non-users, were more likely to meet diagnostic criteria for PTSD, and had higher overall ACE scores. Total burden of ACEs in an adolescent’s history (total ACE score) and specific ACE histories of sexual abuse, physical abuse, justice system involvement, and abuse from a romantic partner were significantly associated with substance use. PTSD was the only clinical diagnosis that was uniquely associated with current substance use. We found that for each additional ACE experienced in an adolescent’s history, the risk for current substance use was additionally increased by 10.4%. This significant association between ACEs and substance use remained even when adjusting for an active PTSD diagnosis. Given that adolescents with comorbid substance use are at risk for worse treatment outcomes and increased psychiatric problems during young adulthood (Vida et al., 2009; Basedow et al., 2020; Leza et al., 2021), our study adds to the growing understanding of the role of potentially traumatic experiences in substance use in a vulnerable, psychiatrically hospitalized population of adolescents.

Our findings suggest that assessing for and monitoring substance use behaviors among adolescents who are hospitalized in an acute inpatient psychiatric setting may reveal important information for clinicians working with this population. Although adolescents who were diagnosed with a SUD made up only 6.7% of our sample, the overall sample did have a higher-than-average rate of past-year substance use of 40.3% when compared to the general population’s rate of 13.7% (SAMSHA, 2023). Regarding specific substances, 35.6 % of the sample reported using marijuana, followed by alcohol (14.5 %). This may inform important clinical considerations due to the potential for substances to interrupt treatment through interactions with psychiatric medication and worsening of mental health symptoms (Kaminer et al., 2010).

Our findings also suggest that the utilization of a dual diagnostic framework is paramount for this population which may lead to improved mental health outcomes. Given these high rates of substance use, it was essential to understand what factors were closely associated with such behavior. Among the demographic factors analyzed, age was the only significant factor associated with substance use. This is in line with developmental models of substance use in that as one ages the more likely they are to engage in substance use due to changes in brain development, compounding experiences of psychosocial adversity, and learned response behaviors (Lewis, 2018). Clinically, this finding highlights the need for early interventions to prevent and lessen the impact of precursors to substance use (Kirsch and Lippard, 2022). Among the clinical diagnoses within this inpatient psychiatric sample, the presence of PTSD was the sole DSM-5 diagnostic predictor of current substance use, this underscores the unique role traumatic events play in the development of SUD and suggests that it should be a primary target of treatment.

Consistent with prior work that showed that ACEs are associated with substance use (Shin et al, 2018; Leza et al., 2021), one of our most critical findings clearly demonstrated that overall burden of ACE history was associated with substance use behaviors within a sample of inpatient adolescents. These results highlight that comprehensive assessment and consideration of ACEs in acute treatment settings may aid clinicians to devise and provide effective treatment strategies for substance use behaviors. This is especially imperative when considering the widespread prevalence of ACEs, with 63.7% of American adolescents having experienced at least one ACE (Hertz et al., 2023). Greater integration of screening measures for both substance use and ACEs may be helpful to effectively serve this population, especially as drug overdoses become more prevalent among US adolescents (Goldstick et al., 2022). With effective ACE screening, clinicians may be able to effectively direct services to those who are most vulnerable in inpatient settings (Goldenson et al., 2020). Theoretically, these findings suggest that ACEs may be an important factor in the perpetuation and potentially the origins of substance use behaviors. Further research may delineate the causal effects of this relationship as well as its basis in neurological, attachment-based, or learning models (Alvares-Monjaras et al., 2018; Lewis, 2018). Our findings also provide the rationale for further lines of inquiry regarding specific types of substances and their association with overall ACEs for this population.

An item-by-item analysis revealed individual ACEs which were significantly associated with current substance use, including histories of physical and sexual abuse, being detained or incarcerated, and intimate partner abuse. These findings suggest that while overall potentially traumatic experiences should be considered when counseling adolescents, substance use prevention and intervention programs should perhaps be targeted towards those who have experienced physical, emotional, and sexual abuse as well as those who have had interactions with the criminal justice system. More broadly, our findings are in line with previous studies which have found that instances of abuse are highly correlated with substance use during adolescence (Carliner et al., 2016; LeTendre and Reed, 2017). Other researchers have argued that engagement in substance use may be a learned behavior employed as a maladaptive coping strategy against traumatic stressors (Lewis, 2018). Findings from the current study and others (e.g., Thomas et al., 2023) seem to support the implication that substance use may result as a coping strategy from potentially traumatic stressors for adolescent populations with acute psychiatric symptoms. Treatment strategies may wish to focus on fostering adaptive coping strategies in response to severe traumatic experiences.

Another notable finding of our study pertains to the relationship among ACEs, PTSD, and substance use in our sample. We showed that the relationship between ACEs and substance use remained even when controlling for the presence of PTSD. This suggests that, while the two factors may be conceptually similar, they may have different effects on substance use behaviors. The broader conceptualization of potentially traumatic experiences captured by ACEs, compared to the stricter and specific life events captured by PTSD, may explain these differences. Our findings suggest that experiencing multiple and potentially repeated ACEs may play a significant role in the development and perpetuation of substance use during adolescence, above and beyond the contribution that may come from active PTSD symptomatology. Previous research has shown that PTSD symptoms often lead to more severe substance use problems than in those without PTSD symptoms (Basedow et al., 2020; Carliner et al., 2016, Donbaek et al., 2014).

Moreover, other studies have also established an association between ACEs, PTSD, and substance use (Davis et al., 2021; Grummitt et al., 2022). Our findings are in line with other studies that have examined cumulative risk factors and their relationship to clinical symptoms such as substance use (Layne et al., 2014; Charak et al., 2015). The literature suggests that a dose-response relationship exists between cumulative risk factors and the development of a SUD (Hoffman and Jones, 2022). Although few theoretical models exist that account for cumulative risk, further refinement of contemporary models to account for longstanding and repeated stressors such as ACEs may help develop future interventions that reduce or prevent SUDs (Hoffman and Jones, 2022). Clinical interventions may wish to target ongoing repeated stressors to reduce trauma-related symptomology in those at risk for substance use.

Limitations

This study has several limitations that warrant consideration. The exclusive focus on inpatient adolescents in our sample may limit the generalizability of our findings to a broader population. Moreover, our sample was composed of primarily non-Hispanic White participants (67.3%), potentially impacting the generalizability of our findings to individuals identifying with historically marginalized racial or ethnic groups. It is noteworthy that adolescents with primary concerns related to a SUD may have been directed to specialized treatment programs rather than the general psychiatric unit from which our sample was drawn, as reflected in slightly lower number of adolescents diagnosed with a SUD in our sample (6.7%) when compared to national samples (8.7%). (SAMSHA, 2023). Targeted sampling of adolescent substance use programs may yield further insights into the relationship between ACEs, PTSD, and substance use. Another limitation lies in the lack of detailed information regarding the extent or frequency of substance use in our sample, as well as the absence of access to toxicology reports. This hinders a nuanced understanding of the relationship between ACEs, trauma, and substance use in these adolescents. Future studies interested in researching this population may wish to include a more robust measure of substance use in order to capture lifetime frequencies of use. Moreover, few conceptual models exist that adequately capture the influence of cumulative stressors, such as ACEs, on future substance use (Hoffman and Jones, 2022). Practitioners and researchers would greatly benefit from models that illustrate the effect of cumulative stressors towards risk of substance use.

This study provided a rare examination into correlates of substance use among a diverse and relatively large clinical sample of adolescent psychiatric inpatients, with a particular emphasis on the pivotal role of adverse childhood experiences (ACEs). We found that substance use was common among our sample (40.3%). We showed a significant association between ACEs and substance use above and beyond the presence of PTSD. This suggests that ACEs may be an important clinical factor in treating this population for both substance use and trauma-related symptoms. Clinicians working with this population may wish to consider how significant potentially traumatic experiences contribute to a clinical presentation when substance use is present.

Alvarez-Monjaras, M., Mayes, L. C., Potenza, M. N., & Rutherford, H. J. (2018). A developmental model of addictions: Integrating neurobiological and psychodynamic theories through the lens of attachment. Attachment & Human Development, 21(6), 616–637. https://doi.org/10.1080/14616734.2018.1498113
Arakelyan, M., Freyleue, S., Avula, D., McLaren, J. L., O’Malley, A. J., & Leyenaar, J. K. (2023). Pediatric mental health hospitalizations at acute care hospitals in the US, 2009-2019. JAMA, 329(12), 1000. https://doi.org/10.1001/jama.2023.1992
Baldwin, J. R., Wang, B., Karwatowska, L., Schoeler, T., Tsaligopoulou, A., Munafò, M. R., & Pingault, J.-B. (2023). Childhood maltreatment and mental health problems: A systematic review and meta-analysis of quasi-experimental studies. American Journal of Psychiatry, 180(2), 117–126. https://doi.org/10.1176/appi.ajp.20220174
Basedow, L. A., Kuitunen-Paul, S., Roessner, V., & Golub, Y. (2020). Traumatic events and substance use disorders in adolescents. Frontiers in psychiatry, 11, 559. https://doi.org/10.3389/fpsyt.2020.00559
Boxer, P., & Terranova, A. M. (2008). Effects of multiple maltreatment experiences among psychiatrically hospitalized youth. Child abuse & neglect, 32(6), 637–647. https://doi.org/10.1016/j.chiabu.2008.02.003
Carliner, H., Keyes, K. M., McLaughlin, K. A., Meyers, J. L., Dunn, E. C., & Martins, S. S. (2016). Childhood trauma and illicit drug use in adolescence: A population-based national comorbidity survey replication-adolescent supplement study. Journal of the American Academy of Child and Adolescent Psychiatry, 55(8), 701–708. https://doi.org/10.1016/j.jaac.2016.05.010
Castellanos-Ryan, N., O'Leary-Barrett, M., & Conrod, P. J. (2013). Substance-use in childhood and adolescence: A brief overview of developmental processes and their clinical implications. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 22(1), 41–46.
Charak, R., Koot, H. M., Dvorak, R. D., Elklit, A., & Elhai, J. D. (2015). Unique versus cumulative effects of physical and sexual assault on patterns of adolescent substance use. Psychiatry Research, 230(3), 763–769. https://doi.org/10.1016/j.psychres.2015.11.014
Chen, K. W., Banducci, A. N., Guller, L., Macatee, R. J., Lavelle, A., Daughters, S. B., & Lejuez, C. W. (2011). An examination of psychiatric comorbidities as a function of gender and substance type within an inpatient substance use treatment program. Drug and Alcohol Dependence, 118(2–3), 92–99. https://doi.org/10.1016/j.drugalcdep.2011.03.003
Davis, J. P., Tucker, J. S., Stein, B. D., & D'Amico, E. J. (2021). Longitudinal effects of adverse childhood experiences on substance use transition patterns during young adulthood. Child abuse & neglect, 120, 105201. https://doi.org/10.1016/j.chiabu.2021.105201
Donbaek, D. F., Elklit, A., & Pedersen, M. U. (2014). Post-traumatic stress disorder symptom clusters predicting substance abuse in adolescents. Mental Health and Substance Use, 7(4), 299–314. https://doi.org/10.1080/17523281.2013.873071
Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564–572. https://doi.org/10.1542/peds.111.3.564
Fehon, D. C., Grilo, C. M., & Lipschitz, D. S. (2001). Correlates of community violence exposure in hospitalized adolescents. Comprehensive psychiatry, 42(4), 283–290. https://doi.org/10.1053/comp.2001.24580
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8
Gray, K. M., & Squeglia, L. M. (2018). Research review: What have we learned about adolescent substance use? Journal of Child Psychology and Psychiatry, 59(6), 618–627. https://doi.org/10.1111/jcpp.12783
Groth-Marnat, G., & Wright, A. (2016). Handbook of Psychological Assessment, 6th edition. John Wiley & Sons.
Grummitt, L., Barrett, E., Kelly, E., & Newton, N. (2022). An umbrella review of the links between adverse childhood experiences and substance misuse: What, why, and where do we go from here?. Substance abuse and rehabilitation, 13, 83–100. https://doi.org/10.2147/SAR.S341818
Goldenson, J., Kitollari, I., & Lehman, F. (2020). The relationship between ACEs, trauma-related psychopathology and resilience in vulnerable youth: Implications for screening and treatment. Journal of child & adolescent trauma, 14(1), 151–160. https://doi.org/10.1007/s40653-020-00308-y
Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current causes of death in children and adolescents in the United States. The New England journal of medicine, 386(20), 1955–1956. https://doi.org/10.1056/NEJMc2201761
Harris, N. B., & Renschler, T. (2015). Center for youth wellness ACE-questionnaire (CYW ACE-Q child, teen, teen SR). Center for Youth Wellness. San Francisco, CA.
Hertz, M., Heim Viox, M., Massetti, G. M., Anderson, K. N., Bacon, S., Fordyce, E., Mercado, M. C., & Verlenden, J. V. (2023). Adverse childhood experiences among US adolescents over the course of the COVID-19 pandemic. Pediatrics, 151(6). https://doi.org/10.1542/peds.2022-060799
Hoffmann, J. P., & Jones, M. S. (2022). Cumulative stressors and adolescent substance use: A review of 21st-century literature. Trauma, Violence, & Abuse, 23(3), 891–905. https://doi.org/10.1177/1524838020979674
IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp
Isohookana, R., Riala, K., Hakko, H., & Räsänen, P. (2013). Adverse childhood experiences and suicidal behavior of adolescent psychiatric inpatients. European child & adolescent psychiatry, 22(1), 13–22. https://doi.org/10.1007/s00787-012-0311-8
Kaminer, Y., Goldberg, P., & Connor, D. F. (2010). Psychotropic medications and substances of abuse interactions in youth. Substance abuse, 31(1), 53–57. https://doi.org/10.1080/08897070903442665
Kirsch, D. E., & Lippard, E. T. C. (2022). Early life stress and substance use disorders: The critical role of adolescent substance use. Pharmacology, Biochemistry and Behavior, 215, 173360. https://doi.org/10.1016/j.pbb.2022.173360
Layne, C. M., Greeson, J. K., Ostrowski, S. A., Kim, S., Reading, S., Vivrette, R. L., Briggs, E. C., Fairbank, J. A., & Pynoos, R. S. (2014). Cumulative trauma exposure and high risk behavior in adolescence: Findings from the national child traumatic stress network core data set. Psychological Trauma: Theory, Research, Practice, and Policy, 6(1). https://doi.org/10.1037/a0037799
LeTendre, M. L., & Reed, M. B. (2017). The effect of adverse childhood experience on clinical diagnosis of a substance use disorder: Results of a nationally representative study. Substance use & misuse, 52(6), 689–697. https://doi.org/10.1080/10826084.2016.1253746
Lewis, M. (2018). Brain change in addiction as learning, not disease. New England Journal of Medicine, 379(16), 1551–1560. https://doi.org/10.1056/nejmra1602872
Leza, L., Siria, S., López-Goñi, J. J., & Fernández-Montalvo, J. (2021). Adverse childhood experiences (ACES) and substance use disorder (SUD): A scoping review. Drug and Alcohol Dependence, 221, 108563. https://doi.org/10.1016/j.drugalcdep.2021.108563
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 & Mental Disease, 191(11), 714–721. https://doi.org/10.1097/01.nmd.0000095123.68088.da
McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic stress disorder and co‐occurring substance use disorders: Advances in assessment and treatment. Clinical Psychology: Science and Practice, 19(3), 283–304. https://doi.org/10.1111/cpsp.12006
Mergler, M., Driessen, M., Havemann-Reinecke, U., Wedekind, D., Lüdecke, C., Ohlmeier, M., Chodzinski, C., Teunißen, S., Weirich, S., Kemper, U., Renner, W., & Schäfer, I. (2018). Differential relationships of PTSD and childhood trauma with the course of substance use disorders. Journal of Substance Abuse Treatment, 93, 57–63. https://doi.org/10.1016/j.jsat.2018.07.010
Ports, K., Ford, D., Merrick, M., & Guinn, A. (2020). ACEs: Definitions, measurement, and prevalence. In G. Asmundson & T. Afifi, Adverse Childhood Experiences (pp. 17–34). Academic Press. https://doi.org/10.1016/B978-0-12-816065-7.00002-1
Rytilä-Manninen, M., Lindberg, N., Haravuori, H., Kettunen, K., Marttunen, M., Joukamaa, M., & Fröjd, S. (2014). Adverse childhood experiences as risk factors for serious mental disorders and inpatient hospitalization among adolescents. Child Abuse & Neglect, 38(12), 2021–2032. https://doi.org/10.1016/j.chiabu.2014.10.008
Schimmenti, A., Billieux, J., Santoro, G., Casale, S., & Starcevic, V. (2022). A trauma model of substance use: Elaboration and preliminary validation. Addictive Behaviors, 134, 107431. https://doi.org/10.1016/j.addbeh.2022.107431
Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., Milo, K. M., Stock, S. L., & Wilkinson, B. (2010). Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The Journal of clinical psychiatry, 71(3), 313–326. https://doi.org/10.4088/JCP.09m05305whi
Shin, S. H., McDonald, S. E., & Conley, D. (2018). Patterns of adverse childhood experiences and substance use among young adults: A latent class analysis. Addictive behaviors, 78, 187–192. https://doi.org/10.1016/j.addbeh.2017.11.020
Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report
Sullivan, T. P., Fehon, D. C., Andres-Hyman, R. C., Lipschitz, D. S., & Grilo, C. M. (2006). Differential relationships of childhood abuse and neglect subtypes to PTSD symptom clusters among adolescent inpatients. Journal of traumatic stress, 19(2), 229–239. https://doi.org/10.1002/jts.20092
Thomas, S. A., Thompson, E., Peters, J. R., Micalizzi, L., Meisel, S. N., Maron, M., … Wolff, J. C. (2023, preprint). Investigating substance use as a coping strategy among adolescent psychiatric inpatients: A comparative analysis before and during the COVID-19 pandemic. https://doi.org/10.31219/osf.io/hy8vu
Wolitzky-Taylor, K., McBeth, J., Guillot, C. R., Stone, M. D., Kirkpatrick, M. G., Zvolensky, M. J., Buckner, J. D., & Leventhal, A. M. (2016). Transdiagnostic processes linking anxiety symptoms and substance use problems among adolescents. Journal of addictive diseases, 35(4), 266–277. https://doi.org/10.1080/10550887.2016.1207969
Vida, R., Brownlie, E. B., Beitchman, J. H., Adlaf, E. M., Atkinson, L., Escobar, M., Johnson, C. J., Jiang, H., Koyama, E., & Bender, D. (2009). Emerging adult outcomes of adolescent psychiatric and substance use disorders. Addictive behaviors, 34(10), 800–805. https://doi.org/10.1016/j.addbeh.2009.03.035

TABLE 1. Adverse Childhood Experiences (ACES) and percent of study sample (N=551) who endorsed a history of a given ACE, as reported on the Center for Youth Wellness Adverse Childhood Experiences Questionnaire (CYW ACE-Q) Teen Self-Report

At any point since you were born…	% of study sample with endorsement
Your parents or guardians were separated or divorced	62.8%
You lived with a household member who served time in jail or prison	29.6%
You lived with a household member who was depressed, mentally ill or attempted suicide	61.5%
You saw or heard household members hurt or threaten to hurt each other	46.6%
A household member swore at, insulted, humiliated, or put you down in a way that scared you OR a household member acted in a way that made you afraid that you might be physically hurt	56.6%
Someone touched your private parts or asked you to touch their private parts in a sexual way that was unwanted, against your will, or made you feel uncomfortable	31.4%
More than once, you went without food, clothing, a place to live, or had no one to protect you	16.2%
Someone pushed, grabbed, slapped or threw something at you OR you were hit so hard that you were injured or had marks	45.6%
You lived with someone who had a problem with drinking or using drugs	44.1%
You often felt unsupported, unloved and/or unprotected	54.1%
You have been in foster care	12.3%
You have experienced harassment or bullying at school	62.8%
You have lived with a parent or guardian who died	11.1%
You have been separated from your primary caregiver through deportation or immigration	2.4%
You have had a serious medical procedure or life threatening illness	9.3%
You have often seen or heard violence in the neighborhood or in your school neighborhood	39.4%
You have been detained, arrested or incarcerated	14%
You have often been treated badly because of race, sexual orientation, place of birth, disability or religion	32.7%
You have experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)	24.7%

TABLE 2. Demographic variables, clinical diagnoses, neuropsychological variables, and overall Adverse Childhood Experiences (ACE) in the overall sample and by substance use status.

	Overall Sample (n=551)		Substance Users (n=222)		Substance Non-Users (n=329)		P
Demographic Information	M	SD	M	SD	M	SD
Age	15.58	1.704	16.03	1.561	15.28	1.733	<0.001*
Grade/Education Years	9.99	1.71	10.43	1.574	9.7	1.737	<0.001*
%Gender							0.943
Female	54.8		56.3		53.8
Male	35.4		34.2		36.2
Transgender	3.4		3.2		3.6
Non-binary	6.4		6.3		6.4
%Race/Ethnicity							0.726
White	67.3		68.2		67.6
Black	5.8		6.4		5.5
Latinx	12.7		10.9		14.1
Asian	1.8		1.4		2.1
Biracial	10.5		11.8		9.8
Other	1.1		1.4		0.9
%Clinical Diagnosis
MDD	67		67.6		66.6		0.806
PTSD	33.8		44.1		27.1		<0.001*
GAD	30.3		29.3		31.0		0.666
ADHD	8.3		5.9		10.0		0.082
SUD	6.7		16.2		0		<0.001*
Neuropsychological Variables (Mean and SD of Normed Scores)
FSIQ	99.8	13.6	97.8	11.4	101.1	14.8	0.003*
TMTA	38.6	31.3	39.9	31.9	37.7	30.8	0.217
TMTB	24.6	27.1	24.4	26.2	24.7	27.8	0.453
CW	31.3	29.2	31.9	28.5	30.9	29.7	0.362
Overall ACE	6.6	3.8	7.5	4	6	3.6	<0.001*

Note. ACE = Adverse Childhood Experiences; MDD = Major Depressive Disorder; PTSD= Post-Traumatic Stress Disorder; GAD = Generalized Anxiety Disorder; ADHD = Attention Deficit Hyperactivity Disorder; SUD = Substance Use Disorder; FSIQ = Full Scale Intelligence Quotient; TMT = Trail Making Test; CW = Stroop Color Word Inhibition

Table 3. Specific Adverse Childhood Experiences (ACE) by Substance Use Status

% Adverse Childhood Experience (ACE)	Substance Users (n=222)	Substance Non-Users (n=329)	P
Your parents or guardians were separated or divorced	60.8	64.9	0.327
You lived with a household member who served time in jail or prison	29.7	29.9	0.958
You lived with a household member who was depressed, mentally ill or attempted suicide	65.3	59.7	0.183
You saw or heard household members hurt or threaten to hurt each other	50.5	44.6	0.179
A household member swore at, insulted, humiliated, or put you down in a way that scared you OR a household member acted in a way that made you afraid that you might be physically hurt	49.5	55.4	0.344
Someone touched your private parts or asked you to touch their private parts in a sexual way that was unwanted, against your will, or made you feel uncomfortable	40.5	25.6	<0.001*
More than once, you went without food, clothing, a place to live, or had no one to protect you	14.9	17.3	0.443
Someone pushed, grabbed, slapped or threw something at you OR you were hit so hard that you were injured or had marks	49.1	43.8	0.225
You lived with someone who had a problem with drinking or using drugs	47.7	42.2	0.196
You often felt unsupported, unloved and/or unprotected	54.5	54.6	0.977
You have been in foster care	14.9	10.8	0.141
You have experienced harassment or bullying at school	64.7	62.3	0.562
You have lived with a parent or guardian who died	11.3	11.0	0.922
You have been separated from your primary caregiver through deportation or immigration	1.8	2.8	0.470
You have had a serious medical procedure or life threatening illness	11.3	8.0	0.192
You have often seen or heard violence in the neighborhood or in your school neighborhood	43.9	37.9	0.109
You have been detained, arrested or incarcerated	18.1	11.4	0.027*
You have often been treated badly because of race, sexual orientation, place of birth, disability or religion	31.2	34.2	0.474
You have experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)	31.7	20.4	0.003*
Total ACEs (mean)	7.47	6.03	<0.001*

Table 4. Multivariate logistic regression to assess the relationship between total and individual ACE history, and current substance use

	Model 1	Model 2
	aOR [95% CI] P	aOR [95% CI] P
Total ACEs	1.104, [1.051-1.160], 0.001	1.171, [1.014-1.132], 0.015
Individual ACEs
Sexual abuse	2.020, [1.353-3.016], 0.001	1.669, [1.097-2.540], 0.017
Intimate partner violence	1.747, [1.142-2.672], 0.010	1.627, [1.055-2.509], 0.028
Physical abuse	1.526, [1.049-2.221], 0.027	1.321, [0.896-1.947], 0.160

Note: Model 1 adjusted for age and FSIQ. Model 2 adjusted for the covariates included in model 1 in addition to current PTSD diagnosis. Covariates were selected based on significant association with independent and dependent variables of interest.

The authors declare no competing interests.

Predictors of Substance Use Among Adolescent Psychiatric Inpatients: The Role of Adverse Childhood Experiences (ACEs)

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Abstract

Introduction

Methods

Results

Discussion

Conclusion

References

Tables

Additional Declarations

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