MSW WEEK 4 CULTURE DISCUSSION

Environmental paths that inform adolescent substance use prevention Amy Kenney and Cory B. Dennis

School of Social Work, Brigham Young University, Provo, Utah, USA

ABSTRACT Promoting healthy development among youth is one of the grand chal- lenges taken on by social work. Because substance use can negatively affect the health and development of adolescents, this study examined environmental factors affecting substance use among adolescents ages 12 through 17 by gender using data from 17,736 adolescents in the 2013 National Survey on Drug Use and Health. It was hypothesized that environmental inputs such as parenting, involvement in extracurricular activities, and school engagement are associated with substance use differently based on gender. Structural equation modeling was used to test the hypothesis. This model explained 13% of the variance for males and 19% for females. Positive parenting, participation in extracurricular activities, and school engagement were associated with substance use. Results showed the effect of extracurricular activities on substance use was larger for female adolescents than for male adolescents, and that gender moderated the indirect effect of parenting on substance use. Parenting, involvement in extracurricular activities, and school engage- ment are important areas for preventing adolescent substance use in the spirit of promoting their health, and the effect of prevention efforts in these areas can depend on the adolescent’s gender.

KEYWORDS Substance use; adolescents; parenting; school; extracurricular activities; environment

“Ensuring healthy development for all youth” is one of theGrand Challenges taken on recently by the social work field (American Academy of Social Work and Social Welfare, 2018). Adolescent substance use is one measure of healthy development for youth. Adolescent substance use in the United States is prevalent enough that some consider it a normal yet potentially problematic milestone in youth development as regular use of and increasing dependency on substances has largely replaced experimentation (Winters & Lee, 2008). Alcohol and marijuana are the most commonly used substances among adolescents, followed by tobacco. In 2016, approximately 42% of adolescents reported a lifetime use of alcohol, and approximately 29% of adolescents reported a lifetime use of marijuana (Johnston, O’Malley, Miech, Bachman, & Schulenberg, 2017). The lifetime prevalence of alcohol use and marijuana use dropped approximately 27 points and nine points, respectively, in 2016 from their peak year in 1997 (Johnston et al., 2017). Although the recent drop in adolescent alcohol and marijuana use is encouraging, binge drinking and marijuana use among adolescents can have important negative effects, such as on neurocognition (Lisdahl, Gilbart, Wright, & Shollenbarger, 2013). Tobacco use is also prevalent among adolescents. Current trends suggest that using e-vaporizers is more common than cigarettes (Johnston et al., 2017), however,

CONTACT Amy Kenney [email protected] School of Social Work, Brigham Young University, Provo, UT 84602- 0002, USA

JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 2019, VOL. 29, NO. 7, 897–908 https://doi.org/10.1080/10911359.2019.1633982

© 2019 Taylor & Francis Group, LLC

adolescents who smoke cigarettes are more likely to use an illicit substance than those who do not smoke cigarettes (Substance Abuse and Mental Health Services Administration, 2014). Cigarette smoking, then, is a useful indicator of adolescent substance use.

Social work has long established the importance of the reciprocal relationship between people and their environments (Gitterman & Germain, 2008a), and its influence on their well-being (Gitterman & Germain, 2008b). The environment is an influential factor in behavioral decision theory (Jaccard, 2016). Adolescent behaviors embedded in the social environment function as a gateway to important health outcomes in adulthood (Raphael, 2013) such as substance use. Early onset substance use is a risk factor for addiction that can have detrimental and lasting effects on the brain more severe than when substance use begins in adulthood (Robertson, David, & Rao, 2003). Research has shown a relationship between the early onset of substance use and an elevated risk for the later development of a substance use disorder (Winters & Lee, 2008). The longer substance use continues, the more likely it will be associated with health and social problems (United Nations, 2003). Because the social environment can moderate an adolescent’s intention toward substance use, it is important to understand for developing quality programs (Jaccard, 2016) that might protect adolescents against early use. For this study, we consider three factors of the adolescent’s social environment (i.e., parenting, participation in extracurricular activities, and school engagement) that might factor into their use of substances.

The adolescent-parent relationship can influence adolescent substance use. For instance, parental monitoring can function as a protective factor against adolescent substance use (Bobakova, Geckova, Klein, Reijneveld, & van Dijk, 2012; Branstetter & Furman, 2013; Piko & Balázs, 2012), particularly for girls (Bobakova et al., 2012). An adolescent’s respect for their parents can also function to protect against binge drinking (Piko & Balázs, 2012), as can a parent-child connection and quality communication (Carver, Elliott, Kennedy, & Hanley, 2017). Adolescents are less likely to use substances if they perceive their parents as expressive in communication and discuss substance use openly and directly (Choi et al., 2017). The attachment style of parents can affect their knowledge of their adolescent’s activities, which can, in turn, affect the adolescent’s substance use (Jones, Ehrlich, Lejuez, & Cassidy, 2015). Yet, while parents might view their style of parenting as affecting adolescent substance use, adolescents might not (Smith & Hall, 2008). Parental warmth can also have a negative effect on adolescent substance use through its effect on adolescent self-regulation and adolescent peer association (C. Lee, Padilla-Walker, & Memmott-Elison, 2017). Fluctuation in parental warmth, particularly at moderate levels, can affect adolescent substance use (Lippold, Hussong, Fosco, & Ram, 2018).

School connectedness or involvement protects against adolescent substance use (Bond et al., 2007; Ethier, Harper, &Dittus, 2018; Yang, Tan, &Cheng, 2014) and can lessen the effect of social status on adolescent marijuana use (Vogel, Rees, McCuddy, & Carson, 2015). Academic achievement can also protect adolescents against smoking and binge drinking, while positive attitudes towards school and interacting with teachers can protect adolescents against marijuana use (Piko & Balázs, 2012).

Participation in extracurricular activities can protect against adolescent substance use (Guibord, Bell, Romano, & Rouillard, 2011; McCabe, Modecki, & Barber, 2016). Yet, whether participation in extracurricular activities protects against adolescent substance might depend on factors such as the religiosity of peers, the type of substance, or the type

898 A. KENNEY AND C. B. DENNIS

of activity. For instance, Adamczyk (2012) reported a decrease in alcohol use among adolescents involved in extracurricular activities (e.g., athletics) supported by religion regardless of the adolescents’ own religiosity, and an increase in alcohol use among adolescents involved in extracurricular activities not supported by religion. Exposure to religious friends is one reason why participating in religion-supported extracurricular activities might protect adolescents against alcohol use (Adamczyk, 2012). The effect of extracurricular activities on substance use might also vary by substance used or activity. For instance, Lee and Vandell (2015) found that unsupervised time with other adolescents during high school increased the odds of alcohol, marijuana and tobacco use at the end of high school, while participating in sports during high school increased the odds of alcohol use at the end of high school while decreasing the odds of marijuana use. They also found paid employment during high school increased the odds of alcohol and tobacco use among adolescents at the end of high school (K. T. Lee & Vandell, 2015).

Although adolescent boys and girls share common paths to drug use, the paths might also differ by gender (Anderson, Tomlinson, Robinson, & Brown, 2011; Aspy, Tolma, Oman, & Vesely, 2014; Simões et al., 2012). Researchers have also recommended account- ing for gender when developing preventative strategies around protective factors (Bobakova et al., 2012). Understanding how risk factors for substance use might differ by gender among adolescents is important given the relationship between gender roles and development (Pilgrim, Schulenberg, O’malley, Bachman, & Johnston, 2006).

The purpose of the study was to examine the relationship between adolescent substance use and environmental factors while considering the role of gender. We conceptualize environment as (1) level of positive and supportive parenting, (2) positive school engage- ment, and (3) involvement in extracurricular activities. We hypothesized that the envir- onmental effects of parenting, involvement in extracurricular activities, and school engagement affect substance use among adolescents differently by gender.

Method

Participants and procedures

We used data from the 2013 National Survey on Drug Use and Health (NSDUH) for this study (United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality, 2015). Data came from a sample of non-institutionalized United States citizens, age 12 or older at the time of the survey. Interviewers screened 160,325 addresses and completed 67,838 interviews. To screen households, the interviewer asked to speak with an adult household resident (age 18 or older) of the household. Then, using a handheld computer, the interviewer and respondent completed a 5-minute screening procedure, listing the basic demographic information of household members that a computer algo- rithm used to select zero to two people from each household based on its composition. The design of the selection process was to reach sample sizes necessary for specific age groupings (Substance Abuse and Mental Health Services Administration, 2014).

We used for this study data from 17,736 adolescent participants (ages 12–17). As shown in Table 1, the majority of participants White (56%), followed by Hispanic (20%), and Black/African American (14%). Approximately half of the respondents were female

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(49.62%), with a range in education from grade 5 to grade 12, and a median family income of $50,000-$74,999.

Measures

Parenting We measured parenting using the following three questions from the Youth Experiences section of the NSDUH survey (see codebook p. 501–502): (1) “During the past 12 months, how often did your parents provide help with your homework when you needed it?” (2) “During the past 12 months, how often did your parents let you know you’d done a good job?” (3) “During the past 12 months, how often did your parents tell you they were proud of you for something you had done?” Participants responded to each question with “always,” “sometimes,” “seldom,’ or “never.’ The items showed internal consistency (α = .77).

Extracurricular activities We measured extracurricular activities using four questions from the Youth Experiences section of the NSDUH survey (see codebook p. 509–510). Participants responded to the following questions: (1) “During the past 12 months, in how many different kinds of school-based activities, such as team sports, cheerleading, choir, band, student government, or clubs, have you participated?” (2) “During the past 12 months, in how many different

Table 1. Characteristics for all adolescents participants (N = 17,736). Variable Frequency Percentage

Gender Male 9,119 51.4 Female 8,617 48.6

Race Non-Hispanic White 9,920 55.9 African American 2,420 13.6 Native American 263 1.5 Pacific Islander 89 0.5 Asian 644 3.6 Multi-Race 875 4.9 Hispanic 3,525 19.9

Age 12 years old 2,725 15.4 13 years old 2,925 16.5 14 years old 3,039 17.1 15 years old 3,006 16.7 16 years old 3,058 17.2 17 years old 2,983 16.8

Mother in the Home Yes 16,247 91.6 No 1,489 8.4

Father in the Home Yes 12,664 71.4 No 5,072 28.6

Income Less than 20,000 3,288 18.6 $20,000-$49,999 5,408 30.4 $50,000-$74,999 3,078 17.4 $75,000 or more 5,962 33.6

900 A. KENNEY AND C. B. DENNIS

kinds of community-based activities, such as volunteer activities, sports, clubs, or groups have you participated?” (3) “During the past 12 months, in how many different kinds of church or faith-based activities, such as clubs, youth groups, Saturday or Sunday school, prayer groups, youth trips, service or volunteer activities have you participated?” and (4) “During the past 12 months, in how many different kinds of other activities, such as dance lessons, piano lessons, karate lessons, or horseback riding lessons, have you participated?” Participant responses for each question ranged from “none” to “3 or more.” The items showed internal consistency (α = .67).

School engagement We measured school engagement with the following four questions from the Youth Experiences section of the NSDUH survey (see codebook p. 499): (1) “During the past 12 months, how often did you feel that the school work you were assigned to do was meaningful and important?” (2) “How important do you think the things you have learned in school during the past 12 months are going to be to you later in life?” (3) “How interesting do you think most of your courses at school during the past 12 months have been?” and (4) “How often did your teachers at school let you know when you were doing a good job with you school work?” Responses to Questions 1 and 4 ranged from “always,” to “never.” Responses to Question 2 ranged from “very important” to “very unimportant”, and responses to Question 3 ranged from “very interesting” to “very boring.” The items showed internal consistency (α = .74).

Substance use We measured substance use with the following three questions from the Core Substance Abuse section of the NSDUH survey (see codebook p. 5, 25, 29): (1) “How long has it been since you last smoked part or all of a cigarette?” (2) “How long has it been since you last drank an alcoholic beverage?” (3) How long has it been since you last used marijuana or hashish?” Each question asked participants about their most recent use of the substance, ranging from “within the past 30 days,” to “never.” The items showed internal consistency (α = .78).

Control variables We controlled for race and income. Income was measured as “Less than $20,000,” “$20,000-$49,999,” “$50,000-$74,999,” or “$75,000 or More.” To simplify our model and limit redundancy, we recoded race as minority or non-minority. See Table 1 for descrip- tive data of the participants.

Data analysis

We used structural equation modeling (SEM) to test the effect of parenting, extracurri- cular activities, and school engagement on adolescent substance use across two groups, male and female adolescents. We used Stata (v.15.1) for descriptive analyses and Mplus (v.7) for SEM, with weighted least square means and variance (WLSMV) estimation. We assessed model fit using the root mean square error of approximation (RMSEA), com- parative fit index (CFI), and the Tucker-Lewis Index (TLI).

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Results

We ran the measurement model grouping participants by male and female. While the model showed adequate fit with the data (RMSEA = .05; CFI = .98; TLI = .98), the model was only partially invariant across groups with factor loadings differing by gender for alcohol use (Wald = 8.275, df = 1, p = .004), school-work interesting (Wald = 5.447, df = 1, p = .020), community-based activities (Wald = 7.670, df = 1, p = .006), and other activities (Wald = 31.004, df = 1, p = .000). The other factor loadings (excluding for the reference indicators where factor loadings were fixed at one; see Figure 1) were statistically equiva- lent (p > .05). The factor loadings reported in Figure 1 are based on a model freely estimating the factor loadings alcohol use, school work interesting, community-based activities, and other activities across gender (RMSEA = .05; CFI = .98; TLI = .98).

We next tested for invariance of the structure model (see Figure 2). We found adequate model fit (RMSEA = .05; CFI = .97; TLI = .96) and partial structural invariance (Wald = 15.977, df = 7, p = .025), with male adolescents differing significantly from female adolescents for substance use on extracurricular activities (Wald = 3.928, df = 1, p = .048), and for school on parenting (Wald = 6.901, df = 1, p = .009). We then ran the full

Parenting

Activities

School

Substance Use

-.30/-.35.46/.47

.17/.23 -.15/-.24

Gave Praise

Expressed Pride

Offered Help1

School-Based Activities1

Community- Based

Activities

Faith-Based Activities

Other Activities

School-Work Meaningful1

School-Work Important

School-Work Interesting

Teacher Offered Praise

Cigarette Use1

Alcohol Use

Marijuana Use

.50/.57*.52/.49.86/.82*.74/.77

.87/.86

.84/.83*

.91/.92

.91/.95

.58/.63

.90/.92

.74/.76 .76/.76 .73/.76*

.60/.59

.20/.16

-.28/-.35

Figure 1. Full measurement model, with standardized estimates: Male/Female. 1 = Reference indicator. * = statistically different by gender (p< .05).

902 A. KENNEY AND C. B. DENNIS

model, freely estimating the structural paths found to differ by gender (RMSEA = .05; CFI = .97; TLI = .97).

As shown in Figure 2, among male adolescents, parenting, extracurricular activities, school engagement had statistically significant effects on adolescent substance use. Specifically, with a standard unit increase in parenting, substance decreased by .24 standard units. Further, parenting had a statistically significant indirect effect on substance use via school engagement (z = −0.11(.01), p < .000) and extracurricular activities (z = −.02(.004), p < .000) for male adolescents. With a standard unit increase in extra- curricular activities, substance use decreased by .08 standard units. With a standard unit increase in school engagement, substance use decreased by .22 standard units. Among male adolescents, this model explained 13% of the variance in substance use.

As shown in Figure 2, among female adolescents, parenting, extracurricular activities, school engagement had a statistically significant effect on adolescent substance use. Specifically, with a standard unit increase in parenting, substance use decreased by .19 standard units. Parenting also had a statistically significant indirect effect on substance use via school engagement (z = −0.12(.01), p < .000) and extracurricular activities (z = −.04 (.004), p < .000) for female adolescents. With a standard unit increase in school engage- ment, substance use decreased by .22 standard units. With a standard unit increase in

Parenting

School

Activities

Substance Use

m -.09(.02)-.08*a

f -.15(.02)-.14*a

m -.24(.02)-.16* f -.24(.02)-.19*

m .30(.02).23* f .30(.02).24*

m .66(.02).51*a

f .58(.02).51*a m -.26(.02)-.22* f -.26(.02)-.24*

d

d

d

m .95 f .94

m .87 f .81

m .74 f .74

Figure 2. Structural model with unstandardized estimate (standard error) standardized estimate. m = male. f = female. d = disturbance. Proportion of variance explained = 1 – disturbance. * p < .05. a = different by gender (p > .05)

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extracurricular activities, substance use decreased by .14 standard units. Among female adolescents, this model explained 19% of the variance in substance use.

Because the path school on parenting was significantly different by gender (Wald = 6.901, df = 1, p = .009), we tested whether the indirect effect of parenting on substance use via school was also different by gender. The results showed a statistically significant difference between male and female adolescents on this indirect path (p = .002).

We controlled for the effects of income and minority status. Among female adolescents, substance use was .05 (p < .000) units higher among participants from a nonminority racial or ethnic group compared to participants from a minority racial or ethnic group. Further, for a standard unit increase in income, substance use decreased by .09 (p < .000) standard units. Among male adolescent clients, substance use was .05 (p < .000) units higher among participants from a nonminority racial or ethnic group compared to participants from a minority racial or ethnic group. Further, for a standard unit increase in income, substance use decreased by .08 (p < .000) standard units. Using “model test:” command in Mplus, gender was not found to moderate the effects of income and minority status on substance use.

Discussion

Preventing substance use among adolescents is an important challenge of focus for the social work field (Hawkins et al., 2015). The social environment is an important mod- erator that can function to constrain or facilitate an adolescent’s decision-making toward behavioral health problems such as substance use (Jaccard, 2016). In this study, we were interested in understanding how gender might moderate the effect of three environmental factors on adolescent substance use: parenting, involvement in extracurricular activities, and school engagement. Parenting, involvement in extracurricular activities, and school engagement are important environmental factors to pay attention to in prevention efforts because they can protect against adolescent substance use. Because paths toward substance use can differ by gender (Anderson et al., 2011; Aspy et al., 2014; Simões et al., 2012), gender is also important to consider in prevention efforts (Bobakova et al., 2012). While each of these environmental factors had a statistically significant effect in this study on adolescent substance use, the effect of extracurricular activities was larger for females than for males. Based on our study, engaging in extracurricular activities might be especially important to consider for female adolescents. The context of the activities observed in this study (i.e., school-based activities, community-based activities, faith-based activities, and activities occurring in other arenas) might offer direction for considering ways to enhance adolescents’ participation in extracurricular activities to promote their well-being.

According to behavioral decision theory, parenting, involvement in extracurricular activities, and school engagement, and the way they were measured in this study, might well represent environmental factors that moderate adolescents’ intentions to use sub- stances. However, this is just one component of behavioral decision making and is influenced by other variables (Jaccard, 2016). We hypothesized that the effect of an adolescent social environment, as we measured it, would depend on gender; that the environment would affect substance use behaviors differently for female and male adoles- cents. While this hypothesis was supported for extracurricular activities, it is important to note that participation in extracurricular activities affected both male and female

904 A. KENNEY AND C. B. DENNIS

adolescents in protecting against substance use. A study of rural adolescents found that female adolescents participated with greater frequency in sports and outdoor activities than male adolescents (Sharp, Tucker, Baril, Van Gundy, & Rebellon, 2015). Participation frequency might be one factor that explains the effect of activities on females adolescent substance use was stronger than for males. Research is needed to understand better why adolescent boys might be less inclined to participate in extracurricular activities, and practitioners might consider ways to enhance the appeal of or opportunity for them to participate.

Gender did not moderate the direct effect of parenting and school engagement on substance use. However, the indirect effect of parenting on substance use was found to differ by gender. Specifically, parenting practices can affect substance use differently for adolescent males and females because of the way parenting can affect an adolescent’s school engagement differently depending on their gender. While other research has found that gender does not moderate the indirect effect of attitudes toward school on substance use (Zaharakis et al., 2018), it is important to note that parenting and school engagement are important factors to consider among adolescents in general as a preventative measure against substance use.

A range of behavioral health problems can share common causes but causes unique to specific problems like substance use (Jaccard, 2016) might carry greater weight in under- standing and addressing a particular behavioral health problem (Guilamo-Ramos, Litardo, & Jaccard, 2005). The observed variables in this study might offer insight into unique environmental contributors to adolescent substance use. For instance, empowering par- ents with the resources (e.g., access to tutors, web-based applications) they need to help their adolescent children with homework. Likewise, efforts to expand adolescents’ aware- ness of the range of extracurricular activities available to them might promote greater interest, providing unique protection against adolescent substance use, which might be particularly important for the adolescents who do not make the sports teams, choir, or cheerleading squads. It is worth noting that extracurricular activities promote an active lifestyle that has benefits to overall well-being (Walsh, 2011), and that school adminis- trators seek alternatives to excluding adolescents from extracurricular activities for pro- blematic behavior. While these observed variables may not represent truly unique factors associated with substance use, they do focus in on specific targets for enhancing substance use prevention efforts among adolescents. Strategies specific to substance use, rather than to behavioral health problems in general, are likely important to prevention efforts (Guilamo-Ramos et al., 2005).

However, a limitation of our study is that only partial measurement invariance was found, which might have implications for the structural portion of our model where we test our hypothesis. Further, while using a national dataset can enhance the general- izability of the results, and while the sample size was large, we were limited to asking questions that could be answered with what data were available. Data were from what participants self-reported, which might limit the validity of their responses. Nonetheless, an adolescent’s perception is important for considering ways to be implement prevention efforts that benefit them. For instance, while it is important for parents to have quality relationships and warm, open communication with adolescents to prevent substance use and its negative consequences (Branstetter & Furman, 2013), it is especially important that adolescents perceive these qualities in the relationship. Parents’ perceptions may not

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match the adolescents’ experiences (Branstetter & Furman, 2013; Smith & Hall, 2008), making important the type of communication that results from quality relationships between parents and adolescents. Poor parental communication (e.g., lecturing, permissive messages) can increase the risk of adolescent substance use (Carver et al., 2017).

This study purveys parenting, participation in extracurricular activities, and school engagement as important variables to consider in prevention efforts around adolescent substance use. Specifically, our results suggest that enhancing parents’ ability to express praise, show pride, and help with homework can contribute to the kind of parent- adolescent relationship that protects against adolescent substance use. Our results also suggest that helping adolescents perceive their school-work as meaningful, important, and interesting, and encouraging teachers to extend praise can contribute to prevention efforts aimed at adolescent substance use. Our results also suggest that enhancing adolescents’ access to school-based, community-based, faith-based, and other extracurricular activities can function to prevent adolescent substance use. In this study, the effect of participating in activities on adolescent substance use was greater for females than males. One explana- tion of this is that female adolescents participate more in extracurricular activities. Thus, prevention efforts might focus on ways to enhance male adolescents’ interest and parti- cipation in extracurricular activities to enhance their overall well-being while protecting them against risky substance use. In addition, the effect of parenting practices on school engagement was different for adolescent females and males, a difference that carried over into gender moderating indirectly the effect of parenting practices on substance use.

ORCID

Amy Kenney http://orcid.org/0000-0002-0056-7395

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