Psychology of Addictive Behaviors
2015, Vol. 29, No. 2, 329 –337
© 2015 American Psychological Association
0893-164X/15/$12.00 http://dx.doi.org/10.1037/adb0000082
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Prenatal Substance Exposure: What Predicts Behavioral Resilience by
Early Adolescence?
Jane M. Liebschutz
Denise Crooks
Boston Medical Center, Boston, Massachusetts, and
Boston University School of Medicine
Boston Medical Center, Boston, Massachusetts
Ruth Rose-Jacobs
Howard J. Cabral and Timothy C. Heeren
Boston Medical Center, Boston, Massachusetts, and Boston
University School of Medicine
Boston University School of Public Health
Jessie Gerteis
Danielle P. Appugliese
Abt Associates, Inc., Cambridge, Massachusetts
Boston University School of Public Health
Orlaith D. Heymann and Allison V. Lange
Deborah A. Frank
Boston Medical Center, Boston, Massachusetts
Boston Medical Center, Boston, Massachusetts, and Boston
University School of Medicine
Understanding behavioral resilience among at-risk adolescents may guide public policy decisions and future
programs. We examined factors predicting behavioral resilience following intrauterine substance exposure in
a prospective longitudinal birth-cohort study of 136 early adolescents (ages 12.4 –15.9 years) at risk for poor
behavioral outcomes. We defined behavioral resilience as a composite measure of lack of early substance use
initiation (before age 14), lack of risky sexual behavior, or lack of delinquency. Intrauterine substance
exposures included in this analysis were cocaine, tobacco, alcohol, and marijuana. We recruited participants
from Boston Medical Center as mother–infant dyads between 1990 and 1993. The majority of the sample was
African American/Caribbean (88%) and 49% female. In bivariate analyses, none and lower intrauterine
cocaine exposure level predicted resilience compared with higher cocaine exposure, but this effect was not
found in an adjusted model. Instead, strict caregiver supervision (adjusted odds ratio [AOR] ⫽ 6.02, 95%
confidence interval (CI) [1.90, 19.00], p ⫽ .002), lower violence exposure (AOR ⫽ 4.07, 95% CI [1.77, 9.38],
p ⬍ .001), and absence of intrauterine tobacco exposure (AOR ⫽ 3.71, 95% CI [1.28, 10.74], p ⫽ .02)
predicted behavioral resilience. In conclusion, caregiver supervision in early adolescence, lower violence
exposure in childhood, and lack of intrauterine tobacco exposure predicted behavioral resilience among a
cohort of early adolescents with significant social and environmental risk. Future interventions should work
to enhance parental supervision as a way to mitigate the effects of adversity on high-risk groups of adolescents.
Keywords: resilience, intrauterine substance exposure, violence, adolescence
Jane M. Liebschutz, Clinical Addiction Research and Education Unit,
Boston Medical Center, Boston, Massachusetts, and Department of
Medicine, Boston University School of Medicine; Denise Crooks, Department of Family Medicine, Boston Medical Center; Ruth RoseJacobs, Department of Pediatrics, Boston Medical Center, and Boston
University School of Medicine; Howard J. Cabral, Department of
Biostatistics, Boston University School of Public Health; Timothy C.
Heeren, Data Coordinating Center, Boston University School of Public
Health; Jessie Gerteis, Abt Associates, Inc., Cambridge, Massachusetts;
Danielle P. Appugliese, Data Coordinating Center, Boston University
School of Public Health; Orlaith D. Heymann and Allison V. Lange,
Clinical Addiction Research and Education Unit, Boston Medical Center; Deborah A. Frank, Department of Family Medicine, Boston Medical Center, and Department of Pediatrics, Boston University School of
Medicine.
The analyses presented here and preparation of this article were
supported in part by National Institute on Drug Abuse, National Insti-
tutes of Health Grant DA 06532 (Deborah A. Frank, PI), and National
Center for Research Resources, National Institutes of Health Grants
RR000533 and RR025771. Its contents are solely the responsibility of
the authors and do not represent the official view of National Center for
Research Resources, National Institute of Drug Abuse, or the National
Institutes of Health.
Portions of this article were presented at the Pediatric Academic Societies Conference, Baltimore, Maryland, May 2009, and the College of
Problems on Drug Dependence Annual Meeting, June 24, 2009, Reno,
Nevada.
We gratefully acknowledge analytic assistance from Brett Martin, data
collection assistance from Shayna Soenksen and Laura Anatale, manuscript
formatting and submission assistance from Shernaz Dossabhoy, and as
always, the participants and their families.
Correspondence concerning this article should be addressed to Jane M.
Liebschutz, 801 Massachusetts Avenue, Second Floor, Boston Medical
Center, Boston, MA 02118. E-mail: jane.liebschutz@bmc.org
329
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330
LIEBSCHUTZ ET AL.
Resilience is a dynamic process, influenced by multiple factors
encompassing genetics, biology, environment, psychology, and
exposure to adversity (Rutter, 2006). Resilience can be defined as
positive adaptation or recovery in the context of adversity. An
individual may display resilience in one functional domain at one
period of development, but not necessarily in multiple domains or
over different developmental epochs (Luthar & Brown, 2007). Of
particular interest for policy and scientific inquiry is understanding
behavioral resilience among children, adolescents, and young
adults who grow up with the most extreme adversity, such as
witnessed parental violence, parental addiction, and poverty. In
this study, we focused specifically on a cluster of multiple problem
behaviors in a high-risk cohort, as problem behaviors tend to
co-occur and are also negatively related to prosocial behaviors
(e.g., school attendance) and positive health behaviors (e.g., exercise, diet; Jessor, Donovan, & Costa, 1991).
There are known links between intrauterine substance exposure
(IUSE) and indicators of poorer behavioral and health outcomes in
adolescence. In this study, we focused on intrauterine cocaine
exposure (IUCE), intrauterine tobacco exposure (IUTE), intrauterine alcohol exposure (IUAE), and intrauterine marijuana exposure
(IUME) because there is substantial literature linking these exposures to negative developmental and health outcomes in children
and adolescents. IUCE has been linked to adolescent substance use
(Delaney-Black et al., 2011; Frank et al., 2011; Richardson,
Larkby, Goldschmidt, & Day, 2013), childhood externalizing behavior problems (Bennett, Marini, Berzenski, Carmody, & Lewis,
2013), inattention, and impulsivity (Richardson, Goldschmidt,
Leech, & Willford, 2011). IUTE has been associated with childhood and adolescent conduct disorder, externalizing behavior
(Cornelius, Goldschmidt, De Genna, & Larkby, 2012; Piper, Gray,
& Birkett, 2012; Stene-Larsen, Borge, & Vollrath, 2009), adolescent delinquent behaviors, and adult criminal behavior (Paradis,
Fitzmaurice, Koenen, & Buka, 2011; Rantakallio, Läärä, Isohanni,
& Moilanen, 1992). IUAE has been correlated with attention
difficulties (Mattson, Crocker, & Nguyen, 2011; Underbjerg et al.,
2012), delinquent behaviors (Schonfeld, Mattson, & Riley, 2005),
and higher rates of attention-deficit/hyperactivity disorder
(Mattson et al., 2011). IUME in the context of environmental
disadvantage has been linked to increased attention problems and
aggression in 18-month-old girls (El Marroun et al., 2011), future
substance use (Frank et al., 2011), delinquency in late childhood
(Goldschmidt, Day, & Richardson, 2000) and adolescence (Day,
Leech, & Goldschmidt, 2011), and poor academic performance
(Goldschmidt, Richardson, Willford, Severtson, & Day, 2012).
Given this well-established literature on intrauterine exposure to
individual substances and adolescent outcomes, we examined multiple forms of IUSE simultaneously to see whether some exposures
are more detrimental than others and to avoid mistakenly attributing the effects of one substance on outcomes to another.
A prospective study design and biological markers to confirm
IUSE are of particular importance when studying resilience because of the temporal relationship of the predictors of resilience
and the markers of resilience over the lifetime of children and
adolescents and to avoid ascertainment bias. For this reason, it is
inappropriate to examine predictors of resilience and markers of
resilience in a cross-sectional survey. Like many other research
teams that have examined resilience (Bennett et al., 2013;
Delaney-Black et al., 2011; Frank et al., 2011), we employed a
prospective design. We also confirmed IUSE with at least one
biological marker from each mother–infant dyad, including either
maternal or neonatal urine drug tests or meconium radioimmunoassays.
To gain a clearer understanding of what contributes to resilience, it is essential to examine the effects of IUSE in the context
of other components that influence resilience. Other factors that
influence adolescent resilience that we examined in this study
included parental supervision, exposure to violence, and sex.
Population-based studies in the United States have found that
social support, including parental support and monitoring, increases healthy resilient behaviors in adolescents (Goldstein,
Faulkner, & Wekerle, 2013; Mistry, McCarthy, Yancey, Lu, &
Patel, 2009; Tiet, Huizinga, & Byrnes, 2010). In previous work,
we found that parental incarceration correlated with depressive
symptoms and externalizing behaviors (Wilbur et al., 2007), and
others have found that it appears to increase not only antisocial
behaviors but also mental health problems, drug use, or educational underperformance (Murray, Farrington, & Sekol, 2012).
Thus, it is not clear how parental incarceration impacts long-term
resilience. In violent neighborhoods and among high-risk populations, close parental supervision and monitoring increase adolescent resilience (Burlew et al., 2009; Li, Feigelman, & Stanton,
2000; Stanton et al., 2002). Macrosystem community influences,
particularly exposure to violence and neighborhood safety, can
strongly impact coping skills (Benzies & Mychasiuk, 2009; Li,
Nussbaum, & Richards, 2007). Li et al. (2007) found that neighborhood hassles and violence exposure increased internalizing and
externalizing symptoms in adolescents. Neighborhood cohesion
may lead to positive behavioral outcomes for adolescents, whereas
neighborhood disorganization may be related to delinquency (Cantillon, 2006; Chung & Steinberg, 2006). In addition, exposure to
violence, either as victim or witness, correlates with increased
suicidal ideation in 9- and 10-year-olds and delinquent behavior in
early adolescence, irrespective of IUCE or parental distress
(Gerteis et al., 2011; O’Leary et al., 2006).
The relationship between sex and resilience is complex and not
consistent across studies. Females show increased likelihood of
behavioral resilience in young adulthood in some samples (Ackerman, Riggins, & Black, 2010; Skinner, Haggerty, Fleming, &
Catalano, 2009). This may be the result of increased parental
monitoring among female adolescents (Li et al., 2000). However,
other samples have shown that female sex correlates with less
resilience (Tusaie, Puskar, & Sereika, 2007). The interactions
between sex and IUSE effects are also inconsistent (Bennett et al.,
2013; Bridgett & Mayes, 2011; Dennis, Bendersky, Ramsay, &
Lewis, 2006; Dixon, Kurtz, & Chin, 2008; El Marroun, et al.,
2011). Non-White race has been associated with decreased resilience (Dumont, Widom, & Czaja, 2007; Fantuzzo, LeBoeuf,
Rouse, & Chen, 2012; Mistry et al., 2009), not as a biologic factor
but as a marker for discrimination and material deprivation, low
socioeconomic status, or lack of supportive social networks
(Brown, 2008; Li et al., 2007; Tusaie et al., 2007). In contrast, a
sample of 489 rural African American youth developed psychosocial competence under conditions of high risk, even as they
displayed lower health resilience outcomes (Brody et al., 2013).
An ecological model, which takes into account the individual,
family, community, environment, and larger social context, can
facilitate understanding of contributing factors toward behavioral
PRENATAL SUBSTANCES AND ADOLESCENT RESILIENCE
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resilience in adolescents who have experienced violence and
IUSE. Using an ecological model, this exploratory study examined
selected predictors of components of resilience among high-risk
adolescents. We hypothesized that both IUSE and the family and
social environment during childhood and adolescence would predict presence or absence of behavioral resilience in adolescence.
Specifically, we hypothesized that lower levels of intrauterine
exposure to substances, lower household substance use, lower
exposure to violence, lower rates of parental incarceration, greater
parental supervision, and greater neighborhood cohesion would be
associated with greater adolescent behavioral resilience.
Method
Study Design
This was a masked prospective longitudinal cohort study of
adolescents recruited at birth to examine the effects of levels of
IUCE on behavior and development. Participants and their caregivers were repeatedly assessed from birth, using interviews and
urine assays, as well as neuropsychological and behavioral assessments that have been reported elsewhere (Frank et al., 2011;
Gerteis et al., 2011).
Sample Selection
Sample recruitment took place at the postpartum unit of Boston
City Hospital (now Boston Medical Center) from 1990 to 1993.
Mother–infant dyads met the following eligibility criteria: maternal age ⱖ18 years; infant gestational age ⱖ36 weeks; no need for
neonatal intensive care; no diagnosis of fetal alcohol syndrome;
and no indication (either by neonatal or maternal urine toxic screen
or meconium assay or by history in medical record) of intrauterine
exposure to illegal opiates, methadone, amphetamines, phencyclidine, barbiturates, or hallucinogens; and no history of HIV seropositivity in the infant or mother. Further information about recruitment procedures and sample characteristics has been
previously described (Tronick, Frank, Cabral, Mirochnick, &
Zuckerman, 1996). Boston Medical Center Institutional Review
Board approval was obtained yearly. Mothers or primary caregivers also provided ongoing informed consent. Beginning at 8 years,
study participants provided assent.
Of the original 252 cohort members, we analyzed data from the
136 participants examined at early adolescence, targeted for ages
12.5–14.5 years. Due to challenges in getting participants for
interviews in the target range, the actual age range was 12.4 –15.9
years. These participants did not differ significantly from the
nonparticipants in terms of sex, ethnicity, maternal age at birth, or
intrauterine exposure to alcohol, tobacco, marijuana, or cocaine.
331
and sexual activity were asked as part of an audio computerassisted self-interview (ACASI) in which the participant read and
listened via headphones to written and audio text of the questions
and answers. The participant answered questions by clicking the
computer mouse. Using the ACASI is thought to promote more
truthful answers to questions on potentially sensitive subjects than
would be obtained via face-to-face interview (Riley et al., 2001).
ACASI questions included items from the Hooked on Nicotine
Checklist (DiFranza et al., 2002), parts of the Centers for Disease
Control and Prevention’s 2005 Youth Risk Behavior Surveillance
System (Eaton et al., 2006), the Wisconsin Youth Risk Behavior
Surveillance Middle School Questionnaire and the Wisconsin
Youth Risk Behavior Surveillance High School Questionnaire. In
addition, urine samples were tested for cotinine, marijuana, and
other illicit drugs (Frank et al., 2011).
Dependent Variable
Resilience was defined as the absence of three outcomes: HIV
risk behavior, early initiation of substance use, and delinquency.
Each of these was measured at the early adolescent interview at
ages 12.4 –15.9 years. The latter two outcomes have been examined individually in previous publications from this study (Frank et
al., 2011; Gerteis et al., 2011). Any of these three behaviors was
considered an indicator that the participant was not showing resilience. Absence of these risk factors was analyzed cumulatively as
a better indicator of resilience (Jessor, 1987). HIV risk behavior
was defined as endorsement of one or more of the following
behaviors: lack of condom use during first intercourse or most
recent intercourse, injection drug use, or pregnancy (self or partner). Early initiation of substances was defined as use of substances (tobacco, alcohol, marijuana, or other illicit substances)
before age 14 years. Specific questions included “How old were
you when you smoked a whole cigarette for the first time?” and
“How old were you when you had your first drink of alcohol other
than a few sips?” It was specified that “a drink of alcohol is equal
to having a can of beer (the same size as a soda can), a glass of
wine, a wine cooler, or a shot of liquor such as rum, gin, vodka, or
whiskey.” For misuse of prescription medications (e.g., amphetamines, steroids, oxycodone and other pain killers, or benzodiazepines), the question was “How old were you when you first tried
taking [substance of interest] without a doctor or nurse telling you
to take them?” In the case of illicit substances (marijuana, heroin,
cocaine, “club drugs”), a quantity was not specified, with the
question framed as “How old were you when you first tried
[substance] for the first time?” Delinquency was defined as selfreport of at least three delinquent activities in response to seven
questions on minor criminal behavior from the National Longitudinal Study of Adolescent Health (Gerteis et al., 2011; Udry,
2003).
Data Collection
This study used data collected at birth and ages 8.5 years, 9.5
years, 11 years, and early adolescence (12.4 –15.9 years). The
primary outcomes were obtained during early adolescence. Primary caregivers were interviewed in parallel with the participants
at each time point. Children’s evaluators were masked to participants’ IUCE status and to all information furnished by their
caregivers. Questions about delinquent behavior, substance use,
Independent Variables
We identified a priori a set of caregiver and adolescent variables
to be tested as predictors of behavioral resilience in the context of
an ecological model: (a) no IUSE, (b) lack of household substance
use during participants’ early adolescence, (c) lower exposure to
violence, (d) higher neighborhood cohesion, (e) strict supervision
during adolescence, (f) no history of parental incarceration, (g)
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332
LIEBSCHUTZ ET AL.
female sex, and (h) birth mother’s race/ethnicity (African American/African Caribbean vs. other).
IUSE. Levels of IUSE were determined by infant urine and
meconium assays as well as urine assays and postpartum interviews of the mothers using an adaptation of the Addiction Severity
Index (5th ed.; McLellan et al., 1992). IUCE was classified as
heavier, lighter, or none, where heavier was defined as the top
quartile of self-reported days of maternal cocaine use during the
index pregnancy and/or the top quartile of cocaine metabolites in
the infant’s meconium. All other intrauterine cocaine use was
defined as lighter. Self-reported IUTE was coded as yes/no and
none, ⬍[1/2] pack per day, and ⱖ[1/2] pack of cigarettes per day.
IUTE was initially coded in a three-level variable, but both levels
of tobacco exposure had similar results. To conserve degrees of
freedom in the analysis, we chose to combine them into a single
variable (exposed or not) for the multivariable analyses. Selfreported IUAE was coded as none versus any drinking by the
mother during last 30 days of the index pregnancy. IUME was
determined by a positive result on any one of the following:
mothers’ self-report and urine and meconium assays (any detection
was considered positive), obtained from the mothers and newborns. A third of the marijuana users in this cohort who denied
marijuana use were identified solely on the basis of meconium or
urine assay.
Household substance use. At each study visit, household
substance use was determined by the caregivers’ responses to
questions asking whether any member of the household where the
child was living or spent considerable time used individual substances (marijuana, cocaine, tobacco, heroin, prescription medications not taken as prescribed, methadone) or had a drinking problem. Household tobacco use (yes/no) was analyzed separately from
other household substance use because it was thought that it might
have unique effects separate from other substances (Weitzman,
Gortmaker, & Sobol, 1992). Of note, because caregiver’s own
substance use was too highly correlated with prenatal exposure to
give an independent effect, substance use by members other than
the caregiver was used for this variable.
Exposure to violence. Children’s self-reported exposure to
violence (as either a witness or a victim) was measured using the
Violence Exposure Scale for Children—Revised (Fox & Leavitt,
1995). This measure was used in its original cartoon format accompanying the questionnaire at ages 8.5, 9.5, and 11 years, and
then as a modified questionnaire without cartoons in early adolescence. Scores at each age were grouped in quartiles, with the
fourth quartile being the highest level of exposure and the first
quartile being the lowest level of exposure. Quartiles were chosen
because the scale total score is not weighted for severity (Frank et
al., 2011; Gerteis et al., 2011). Others have used rank order in
quartiles as a mode of analysis (Shahinfar, Fox, & Leavitt, 2000).
Never being in the highest quartile of self-reported violence exposure at any study assessment was used as a predictor of resilience.
Neighborhood cohesion. Caregiver-reported neighborhood
cohesion during early adolescence was a composite variable of
caregivers’ responses to three questions drawn from the National
Survey of Children’s Health (U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, &
National Center for Health Statistics, 2003) on perceived aspects
of the neighborhood (e.g., “We watch out for each other’s chil-
dren,” “People in my neighborhood help each other out,” and
“There are people I can count on in this neighborhood”). The
instrument uses a 7-point Likert scale that ranges from very
strongly disagree to very strongly agree, with a composite score
ranging from 3 to 21 (low to high cohesion).
Supervision during adolescence. Participants reported on
their perceptions of caregivers’ parenting during adolescence with
relation to strictness/supervision (Eaton et al., 2006). The supervision scale consisted of questions that asked specifically about
parental strictness about the adolescent’s activities (e.g., “In a
typical week, what is the latest you can stay out on school
nights?”) and parental knowledge about the adolescent’s activities
(e.g., “My parents know exactly where I am most afternoons after
school” [yes/no]; “How much do your parents really know what
you do with your free time?” [don’t know/know a little/know a
lot]). For each of these scale scores, we divided the continuous
scores into quartiles and created a dichotomous variable of the
highest quartile versus others in our sample.
Parental incarceration. Parental incarceration at any time
was determined by any positive caregiver response during childhood or adolescent interviews to the following questions: “In
[child’s] lifetime, has his or her father been in jail or prison?” and
“How many times since [the child] was born, have you been in jail
or prison (either because you were serving a sentence or because
you were detained before a trial)?”
Caregiver type. Caregiver type in early adolescence was defined as birth mother, kin, or unrelated as identified by the adult
accompanying the participant who gave informed consent at each
study visit. This was measured at each study visit.
Analysis
Bivariate analyses using logistic regression models unadjusted
for covariates were performed to determine associations with resilience for the seven theoretical predictor variables. A multivariable logistic regression analysis included all independent variables
that were associated with resilience at p ⬍ .10, age, and all IUSEs,
which were a main focus of the construction of the source sample.
Multicollinearity was not found in the multivariable regression.
Odds ratios (ORs) and 95% confidence intervals (CIs) were computed from the logistic regression models. Statistically significant
results had two-tailed p values less than .05. All analyses were
conducted using SAS, Version 9.3.
Results
Of the 136 participants, the mean age ⫽ 14.2 years (SD ⫽ 0.7,
range 12.4 –15.9 years); 72 (53%) were classified as behaviorally
resilient. Specifically, 94% of the cohort exhibited no HIV risk
behaviors, 76% reported two or fewer delinquent acts, and 59%
had not initiated alcohol, tobacco, or other substance use (see
Table 1).
In bivariate analyses, a number of variables were found to be
significantly (p ⬍ .05) associated with resilience, including lower
levels of violence exposure between ages 8.5–11.5 years, strict
parental supervision, lack of substance use in the home during
adolescence, no IUCE compared with heavy IUCE, and lack of
IUAE and IUTE. Sex and race/ethnicity were not correlated with
behavioral resilience (see Table 1). Scores on acceptance/involve-
PRENATAL SUBSTANCES AND ADOLESCENT RESILIENCE
333
Table 1
Behavioral Resilience by Maternal and Adolescent Characteristics: Bivariate Analyses (N ⫽ 136)
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Variable
Intrauterine cocaine exposure (global p ⫽ .12), n (%)
None
Lighter
Heavier
Intrauterine marijuana exposure, n (%)
No
Yes
Intrauterine tobacco exposure (global p ⫽ .001), n (%)
None
⬍1/2 pack per day
ⱖ1/2 pack per day
Intrauterine alcohol exposure, n (%)
No
Yes
Mean (SD) maternal age at delivery (years)
Mean (SD) education (years)
Ethnicity, n (%)
African American/Caribbean
Other
Adolescent sex, n (%)
Male
Female
Violence exposure, n (%)
Quartiles 1–3
Top quartile
Parental strictness/supervision, n (%)
Quartiles 1–3
Top quartile
Household tobacco use at early adolescence, n (%)
No
Yes
Note.
Statistic
Resilient (%)
Odds ratio [95% CI]
p
61 (45)
50 (37)
25 (18)
61
52
36
2.74 [1.04, 7.19]
1.93 [0.72, 5.17]
Referent
103 (76)
33 (24)
53
52
1.08 [0.49, 2.36]
Referent
.85
66 (49)
32 (24)
38 (28)
68
31
45
2.65 [1.16, 6.03]
0.56 [0.21, 1.50]
Referent
.02
.25
97 (71)
39 (29)
26.6 (5.2)
11.5 (1.3)
60
36
2.66 [1.23, 5.74]
Referent
0.99 [0.93, 1.06]
0.97 [0.75, 1.26]
.01
120 (88)
16 (12)
52
63
1.56 [0.53, 4.56]
Referent
.42
70 (51)
66 (49)
49
58
Referent
1.44 [0.73, 2.83]
.29
79 (58)
57 (42)
66
35
3.56 [1.74, 7.29]
Referent
.0005
105 (77)
31 (23)
44
84
Referent
6.67 [2.38, 18.72]
.0003
104 (76)
32 (24)
57
41
1.92 [0.86, 4.29]
Referent
.11
.04
.19
.74
.83
CI ⫽ confidence interval.
ment, psychological autonomy, parental incarceration, neighborhood cohesion, and caregiver type during early adolescence were
not related to resilience and are not presented here.
In multivariable logistic regression analysis, strictest supervision (adjusted odds ratio [AOR] ⫽ 6.02, 95% CI [1.90, 19.00], p ⫽
.002), lower violence exposure (AOR ⫽ 4.07, 95% CI [1.77, 9.38],
p ⫽ .001), and lack of IUTE (AOR ⫽ 3.71, 95% CI [1.28, 10.74],
p ⫽ .02) were statistically significant protective factors associated
with behavioral resilience (see Table 2). Older age appeared protective, with results just above statistical significance (AOR ⫽
0.52, 95 CI% [0.27, 1.02], p ⫽ .06). No statistically significant
interactions were found with IUCE and other salient independent
variables.
To further explore the tobacco results, we conducted a (post
hoc) multivariable analysis limited to those with both lighter and
heavier IUCE to test whether the intrauterine tobacco effects found
were due to high prevalence of IUTE in participants with heavy
cocaine exposure. The results showed no difference by low versus
high IUCE (results not shown).
Discussion
Strict caregiver supervision in early adolescence, lower violence
exposure from ages 8 –14 years, and lack of IUTE were predictors
of behavioral resilience in this exploratory analysis among a cohort
of early adolescents with significant social and environmental risk
regardless of IUCE status. In contrast to our hypothesis, although
heavy IUCE was associated with decreased odds of resilience
when compared with no IUCE in bivariate analyses, this effect was
not identified after controlling for other factors. Viewed from an
ecological stance, the biologic factor of IUTE, the microsystem
factor of parental supervision, and the combined micro-/macrosystem factors of lower violence exposure each contributed significantly to behavioral resilience.
The findings from this current study also support growing understanding of the potent effect of violence on development and behavior. Adverse childhood experiences, including exposure to violence,
have been associated in retrospective studies with a number of lifelong problems, including depression, substance abuse, and high-risk
health behaviors (Felitti et al., 1998). The proposed mechanism for
this relationship is that violence exposure disrupts the normal stress
response of the hypothalamic–pituitary–adrenal axis (Neigh, Gillespie, & Nemeroff, 2009), so that cortisol does not appropriately
increase in response to stress. This blunted cortisol response is highly
associated with depression and other mental health problems (Neigh
et al., 2009). Lester and Padbury (2009) found an exaggerated blunting of the cortisol response in 11-year-olds who had both childhood
exposure to domestic violence and IUCE, compared with those without IUCE, without violence, or without either. In our study, the impact
of not experiencing high levels of violence on behavioral resilience
points to an urgent need to prevent violence exposure.
LIEBSCHUTZ ET AL.
334
Smoking cessation programs should focus on women of childbearing age (Chamberlain et al., 2013; Lumley et al., 2009; Valanis
et al., 2001).
Table 2
Predictors of Resilience: Multivariable Logistic Regression
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Variable
Intrauterine cocaine exposure
None
Lighter
Heavier
Intrauterine marijuana exposure
No
Yes
Intrauterine tobacco exposure
No
Yes
Intrauterine alcohol exposure
No
Yes
Parental strictness/supervision
Top quartile
Quartiles 1–3
Violence exposure
Top quartile
Quartiles 1–3
Household tobacco use at early
adolescence
No
Yes
Age, for each year older
Note.
AOR
95% CI
p
0.67
1.02
Referent
[0.13, 3.39]
[0.27, 3.81]
.97
.63
0.65
Referent
[0.24, 1.76]
.39
4.04
Referent
[1.36, 12.04]
.01
1.88
Referent
[0.59, 5.96]
.29
5.63
Referent
[1.74, 18.25]
.004
[1.49, 8.20]
.004
[0.76, 5.55]
.15
[0.27, 1.02]
.06
Referent
3.49
2.06
Referent
0.52
AOR ⫽ adjusted odds ratio; CI ⫽ confidence interval.
Our findings on parental supervision are consistent with work
conducted in other studies that did not account for documented
IUSE (Steinberg, Lamborn, Darling, Mounts, & Dornbusch,
1994). Chilcoat and Anthony (1996) reported that lower parental
supervision increased the risk for early initiation of substances in
a sample of largely minority children from an urban setting.
Burlew et al. (2009) noted that parental supervision buffered the
impact of increased neighborhood risk for early substance initiation in a sample of African American youth living in low-income
neighborhoods. In intergenerational longitudinal studies, decreased parental monitoring was associated with externalizing
behaviors (e.g., precursors of delinquency; Bailey, Hill, Oesterle,
& Hawkins, 2009). Lahey, Van Hulle, D’Onofrio, Rodgers, and
Waldman (2008) reported that parental knowledge of children’s
peers and limit setting influenced risk of adolescent delinquency,
particularly in adolescents in high-risk neighborhoods. Similarly,
parental monitoring and supervision have been shown to decrease
early sexual activity among high-risk adolescents (Boislard &
Poulin, 2011; Browning, Leventhanl, & Brooks-Gunn, 2005).
The continued impact of IUTE into adolescence confirms other
studies that have shown that such exposure has been associated
with conduct disorder and behavioral problems in childhood and
adolescence in samples without IUCE (Brook, Zhang, Rosenberg,
& Brook, 2006; Desrosiers et al., 2013; Gaysina et al., 2013;
Rantakallio et al., 1992). Furthermore, the findings on IUTE
expose misconceptions about relative impact of intrauterine exposure to legal compared with illegal substances on long-term behavioral outcomes. The fact that tobacco is legal and cocaine is not
is often misinterpreted to suggest that IUTE is less harmful than
intrauterine exposure to illicit substances. However, as our study
has demonstrated, IUTE can have long-lasting behavioral consequences identifiable even when such use co-occurs with IUCE.
Strengths and Limitations
The strengths of this study include the prospective longitudinal
cohort design and the detailed biological information on intrauterine exposures, as well as frequent prospective data collection on
predictors and outcomes of interest. We acknowledge that this
study has several limitations. First, the sample size may have
affected the statistical power to detect a significant association of
IUCE and resilience or lack of resilience. Although we may have
failed to identify all factors associated with resilience because of
lack of power, we did find three factors, one at each level predicted
by the ecological model, which significantly influenced resilience.
Furthermore, we constructed multiple models to test our predetermined hypothesis, which used a limited number of variables in
order to diminish the impact of sample size on statistical power.
Second, use of a dichotomous outcome (i.e., resilient vs. not
resilient) may have obscured more subtle findings that relate to this
complex developmental process. Third, the model in this study
predicting resilience in early adolescence may not have predicted
resilience in other developmental periods. In particular, this sample had a low rate of risky sexual behavior, which may have been
due to the age itself. Prevalence of sexual behavior itself is low in
this age group as compared with older age groups. The risky sexual
behavior measure of resiliency likely played a minor role in this
study, but in older age groups, resiliency to risky sexual behaviors
may be more common. Lastly, our findings may be generalized
only to urban, low-income, predominantly African American/African Caribbean populations. Further research needs to be conducted in other samples, including cohorts that are of higher
socioeconomic status, rural, or of other ethnicities.
Public Health Implications
Family practices and environmental factors, particularly stricter
caregiver supervision and less exposure to violence, may buffer the
negative behavioral impact of IUSE for at-risk urban youth. While
IUTE remains a risk for negative behavioral outcomes, this study
points also to potential postnatal points of modifiable environmental experiences that can moderate early life disadvantages. Because
this is an observational study, it was not known whether an
intervention to reduce violence and increase parental supervision
will enhance behavioral resilience.
Conclusion
Lower exposure to violence in childhood, close parental supervision in adolescence, and lack of IUTE predicted increased behavioral resilience in high-risk urban adolescents, half of whom
had IUCE. Despite the presumed increased risk for adolescent
maladaptive behaviors associated with IUCE, level of IUCE was
not related to lower odds of behavioral resilience after covariate
control. Interventions to enhance parental supervision in adolescence should be tested as a method to mitigate the effects of
harmful exposures for high-risk youth.
PRENATAL SUBSTANCES AND ADOLESCENT RESILIENCE
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Received August 15, 2014
Revision received March 6, 2015
Accepted March 9, 2015 䡲
Correction to Field et al. (2015)
In the Online First August 18, 2014, version of the brief report “The Validity of Different Measures
of Automatic Alcohol Action Tendencies” by Inge Kersbergen, Marcella L. Woud, and Matt Field
(Psychology of Addictive Behaviors, 2015, Vol. 29, No. 1, pp. 225–230. http://dx.doi.org/10.1037/
adb0000009), there was an error in the byline for Inge Kersbergen and Matt Field.
Both authors are affiliated with the University of Liverpool and United Kingdom Centre for
Tobacco and Alcohol Studies, Liverpool, United Kingdom.
All versions of this article have been corrected.
http://dx.doi.org/10.1037/adb0000099
PSY 211 Example Research Design Worksheet
Complete each section of this worksheet. You will use this worksheet to inform the Research
Design section of your final project submission.
Citation of Literature
Bechtold, J., Simpson, T., White, H. R., & Pardini, D. (2015). Chronic adolescent marijuana use
as a risk factor for physical and mental health problems in young adult men. Psychology
of Addictive Behaviors, 29(3), 552–563.
Gap Identification
Many studies look at the effects of marijuana use on prenatal development and possible physical
and psychological effects throughout the life span, particularly in teenagers and young adults.
Researchers have also studied the factors that influence marijuana use across different age
groups and in various environments. Some states are legalizing recreational marijuana use, but
there has not been much time to study how that influences marijuana use among people in
different age groups from varying environmental and racial, ethnic, and cultural backgrounds
(gap).
Research Question
Are adults who smoked marijuana recreationally during their teenage years more likely to
continue recreational marijuana use in states where that use is legal?
Research Design
I would use a qualitative design for this study because I am looking at hard data (chosen design
type and reason for choosing it. Note that this is an experimental design; however, your design
may lend itself to descriptive or correlational). My independent variable is the legal status of
marijuana. Marijuana use in adulthood is the dependent variable (independent and dependent
variables). I would recruit participants from four states—two where recreational marijuana use is
legal and two where it is not legal at all for recreational or medicinal use. I would use Colorado
and Washington as the two legal states and Idaho and Wyoming as the two illegal states. The
studies in my chosen track focused on certain cities, so I chose the latter two states to ensure that
all four choices are within roughly the same geographical region. I chose Idaho and Wyoming
specifically because personal use possession is not decriminalized in those states and is a
misdemeanor rather than a felony (choosing study population).
Previous and current marijuana use would be self-reported via questionnaires. I would use both
male and female participants for this study, as the studies in my research track focused on males,
which I see as a potential bias (identification and addressing of potential bias). I would like to see
if there are gender-related differences. I would administer an initial screening assessment asking
about frequency of marijuana use prior to age 20 and the way in which participants viewed their
use (sporadically/experimentally vs. regularly/recreationally). I would select those who use
marijuana recreationally on a regular basis for the actual study. (Additional study details, which
can be added as necessary. Your study may span a longer time period, for example, a month or
even years.)
Issues of Ethics
This study will potentially give me knowledge of people who are using marijuana illegally. I
would make the assessments anonymous and use only demographic information to identify the
subjects (accounting for issues of ethics).
This study involves adults and is simply an assessment, so there are no major ethical problems as
long as I obtain informed consent from all participants. There are no risks in this study, but if
there were, I would need to fully inform potential participants to help them decide whether or not
to give informed consent. If I included teenagers, I would have to get parental consent for those
under age 18 (management of ethics). Previous studies involving minors as participants
addressed this potential ethical issue by obtaining parental consent. For example, in the research
I reviewed involving a group of adolescents from Pittsburgh who were followed through
adulthood and assessed for physical and psychological effects of marijuana use (Bechtold,
Simpson, White, & Pardini, 2015), the researchers obtained consent from both the youngsters
and their parents annually until they reached age 18. Then they obtained consent from the nowadult participants annually (incorporation of things learned).
PSY 211 Milestone Two Guidelines and Rubric
Overview: For this milestone, you will identify a research gap in the articles you reviewed for your chosen track and develop a research question addressing the
gap. Please note there may be more recent developments in the field related to your chosen track but for this assignment you will only focus on the articles
provided. You will then determine an appropriate research design and how you will account for issues of ethics. The final project is meant for you to propose a
hypothetical study. You are not and should not be conducting human subjects research for this project. It is not necessary for the purposes of this assignment. All
human subjects research requires written approval from the SNHU COCE Institutional Review Board in order to protect the welfare and ensure ethical treatment
of the subjects.
Complete each section of the Research Design Worksheet based on the research gap you identified. You will use this worksheet to inform the Research Design
section of your final project submission. The following elements must be addressed as outlined in the worksheet and the Final Project Guidelines and Rubric
document:
A.
B.
C.
D.
E.
Identify a gap in the developmental psychology research presented in your chosen track.
Develop a basic research question addressing the identified gap.
Determine an appropriate research design that addresses your research question regarding developmental psychology, and explain why it was chosen.
Explain how you will account for issues of ethics associated with your proposed research design.
Explain how your approach to accounting for issues of ethics was informed by your review of the research presented in your chosen track.
You will submit your worksheet to your instructor at the end of Module Five.
Guidelines for Submission: Your will submit the completed Research Design Worksheet document with double spacing, 12-point Times New Roman font, oneinch margins, and any sources cited in APA format.
Instructor Feedback: This activity uses an integrated rubric in Blackboard. Students can view instructor feedback in the Grade Center. For more information,
review these instructions.
Critical Elements
Research Plan: Gap
Exemplary (100%)
Meets “Proficient” criteria, and
response demonstrates an
advanced ability to identify
gaps in research
Proficient (85%)
Identifies a gap in the
developmental psychology
research presented in the
chosen track
Needs Improvement (55%)
Identifies a gap in the
developmental psychology
research presented in the
chosen track, but identification
is inaccurate
Not Evident (0%)
Does not identify a gap in the
developmental psychology
research presented in the
course
Value
20
Research Plan:
Research Question
Research Design:
Research Design
Research Design:
Issues of Ethics
Research Design:
Informed
Articulation of
Response
Meets “Proficient” criteria, and
developed research question
demonstrates a keen insight
into how to develop research
questions that address gaps in
research
Meets “Proficient” criteria, and
response demonstrates a
sophisticated awareness of the
research design that would be
appropriate in addressing the
research question
Meets “Proficient” criteria, and
explanation demonstrates an
astute ability to account for
issues of ethics within
proposed research design
Meets “Proficient” criteria, and
explanation demonstrates keen
insight regarding how issues of
ethics are accounted for in
various scenarios
Develops a basic research
question addressing the
identified gap
Develops a basic research
question addressing the
identified gap, but developed
research question is cursory or
illogical
Does not develop a basic
research question addressing
the identified gap
20
Determines an appropriate
research design that addresses
the research question,
explaining why it was chosen
Determines a research design
that addresses the research
question and explains why it
was chosen, but explanation is
cursory or illogical
Does not determine a research
design that addresses the
research question
20
Explains how issues of ethics
would be accounted for with
the proposed research design
Does not explain how issues of
ethics would be accounted for
with the proposed research
design
15
Does not explain how approach
to accounting for issues of
ethics was informed by review
of the research presented in
the chosen track
15
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented
in a professional and easy-toread format
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Explains how issues of ethics
would be accounted for with
the proposed research design,
but explanation is cursory or
illogical
Explains how approach to
accounting for issues of ethics
was informed by review of the
research presented in the
chosen track, but explanation is
cursory or illogical
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
10
Explains how approach to
accounting for issues of ethics
was informed by review of the
research presented in the
chosen track
Total
100%
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