Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation

Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation

G Model CHIABU-2667; No. of Pages 11 ARTICLE IN PRESS Child Abuse & Neglect xxx (2013) xxx–xxx Contents lists available at ScienceDirect Child Abus...

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Child Abuse & Neglect

Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation夽 Natalie Vilhena-Churchill ∗ , Abby L. Goldstein Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, Toronto, ON M6A 1R8, Canada

a r t i c l e

i n f o

Article history: Received 3 July 2013 Received in revised form 7 October 2013 Accepted 15 October 2013 Available online xxx

Keywords: Childhood maltreatment Marijuana problems Coping motives Emotion dysregulation Young adults

a b s t r a c t It is well established that childhood maltreatment is an important predictor of marijuana use, but few studies have examined the mechanisms underlying this relationship. The current study examines marijuana motives as mediators of the relationship between childhood maltreatment and marijuana use in a sample of young adults. In addition, pathways from childhood maltreatment to emotion dysregulation, coping motives, and marijuana use were explored. Participants were 125 young adults (ages 19–25, 66.9% female) recruited through online community advertising. All participants completed questionnaires assessing childhood maltreatment, emotion dysregulation, marijuana motives, past year and past three-month marijuana use, and marijuana problems. Correlational analyses revealed bivariate relationships between childhood maltreatment, emotion dysregulation, marijuana motives and marijuana problems (rs = .24–.50). Mediation analyses revealed that coping motives mediated the relationship between childhood maltreatment and marijuana problems, and emotion dysregulation was associated with marijuana problems both directly and indirectly via coping motives. The present findings highlight emotion dysregulation and coping motives as important underlying mechanisms in the relationship between childhood maltreatment and marijuana problems. © 2013 Elsevier Ltd. All rights reserved.

It is well established that marijuana use is highly prevalent during young adulthood, with young adults comprising the greatest proportion of marijuana users in a number of countries. For example, in Canada, marijuana use is highest among young adults relative to other age groups, with approximately 40% of 18–24 year olds reporting past year marijuana use (Adlaf, Begin, & Sawka, 2005). In the United States, marijuana is the most commonly used illicit drug among 18–25 year olds, with 19% of this age group reporting past month marijuana use (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). In Australia, marijuana use is most common among young adults as compared to other age groups, with approximately 21% of 18–29 year olds reporting past year marijuana use (Australian Institute of Health and Welfare, 2011). Although rates of marijuana use are high among young adults, not all individuals who use marijuana experience problems associated with their use. However, marijuana has been linked with several negative consequences, including impairments in attention and memory, and harmful effects on friendships, social life, physical health, schooling, and work (Davis, Thomas, Jesseman, & Mazan, 2009; Hall, 2001). Although there is no population data available for young adults in particular, data from the Canadian survey indicate that a large percentage of current users of marijuana (i.e., in the past 3 months) experience problems associated with their use, including health, social, and legal problems (6.2%); failing to meet other’s expectations (8.8%); friends expressing concern about their use (19.8%); and a loss of control over their use (42.9%) (Adlaf et al., 2005).

夽 This research was funded by a Connaught Start-Up grant awarded to A. Goldstein. ∗ Corresponding author at: Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, 7th Floor, Room 7-228, Toronto, ON M5S 1V6, Canada. 0145-2134/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.chiabu.2013.10.009

Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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Understanding factors that contribute to marijuana problems among young adults is important for developing interventions that target individuals in the early stages of use, prior to the development of more severe problems. One potentially important predictor of marijuana problems among young adults is a history of childhood maltreatment (including sexual abuse, physical abuse, emotional abuse, and neglect; Bernstein & Fink, 1998). Childhood maltreatment affects a significant proportion of Canadian children and is a significant area of public health concern. According to data drawn from the Canadian Incidence Study of Reported Childhood Abuse and Neglect (CIS; Public Health Agency of Canada [PHAC], 2010), 85,440 reported cases of maltreatment were substantiated by child welfare in 2008 across Children’s Aid Societies nationally (36% of reported cases of maltreatment). In addition, rates of maltreatment were similar across male and female children (PHAC, 2010). Childhood maltreatment has been linked to a number of negative outcomes in adolescence and young adulthood, including increased rates of depression, anxiety, emotion dysregulation, and substance use (Arnow, Blasey, Hunkeler, Lee, & Hayward, 2011; Cicchetti & Toth, 1995; Fergusson, Boden, & Horwood, 2008; Huang et al., 2011; Lee, Lyvers, & Edwards, 2008; Norman et al., 2012; Wright, Crawford, & Del Castillo, 2009). Although the link between child maltreatment and illicit drug use in young adulthood is well established (Clark, Thatcher, & Martin, 2010; Duncan, Saunders, Kilpatrick, Hanson, & Resnick, 1996; Lo & Cheng, 2007), fewer studies have examined the specific relationship between child maltreatment and marijuana problems (e.g., psychological, social, occupational, and legal problems resulting from one’s marijuana use). In addition, previous research on the link between child maltreatment and substance use has typically focused on one or two types of maltreatment (e.g., Grayson & Nolen-Hoeksema, 2005; Molnar, Buka, & Kessler, 2001; Silverman, Reinherz, & Giaconia, 1996), despite evidence that experiencing multiple types of maltreatment is associated with greater impairments among adults (e.g., more symptoms of depression, lower self-esteem, greater suicidality) compared to any single type (Arata, Langhinrichsen-Rohling, Bowers, & O’Farrill-Swails, 2005; Mullen, Martin, Anderson, Romans, & Herbieson, 1996; see also Higgins & McCabe, 2001, for a review). Furthermore, even when multiple forms of maltreatment are considered, much of the research in this area focuses on physical or sexual abuse (Brems, Johnson, & Freemon, 2004; Lo & Cheng, 2007; Simpson & Miller, 2002; Tonmyr, Thornton, Draca, & Wekerle, 2010). This is surprising, given that neglect is the most common form of maltreatment (PHAC, 2010), and emotional maltreatment has been identified as significant in terms of later consequences and pathology (Cohen et al., 2013; Fenton et al., 2013; Glaser, 2002). Researchers have demonstrated that multiple types of maltreatment often co-occur and that individuals who experience maltreatment are likely to experience more than one type (Clemmons, DiLillo, Martinez, DeGue, & Jeffcott, 2003). In addition, experiencing multiple types of maltreatment has been linked to a greater likelihood of alcohol and drug use (see Simpson & Miller, 2002, for a review). For example, Moran, Vuchinich, and Hall (2004) examined the relationship between four different types of maltreatment and substance use among youth and compared the impact of (a) no maltreatment, (b) emotional abuse, (c) physical abuse, (d) sexual abuse, and (e) combined physical abuse and sexual abuse, on alcohol, tobacco, and illicit drug use. They found that those participants with combined physical and sexual abuse were five times more likely to be using alcohol and ten times more likely to be using illicit drugs compared to those students who reported no history of maltreatment. In addition, there appeared to be a linear trend such that students who experienced both physical and sexual abuse were at greatest risk for substance use followed by those who reported sexual abuse alone, those who reported physical abuse alone, and lastly, those who reported only emotional abuse (Moran et al., 2004). Although researchers have started to examine how multiple types of maltreatment contribute to alcohol and illicit drug use and have included experiences that have traditionally been omitted from studies of these relationships (i.e., emotional abuse and neglect), we are not aware of any studies examining populations most at risk of experiencing substance-related problems (i.e., young adults) that have focused on marijuana problems in particular. Finally, less is known about the mechanisms underlying the relationship between child maltreatment and marijuana problems among young adults. Rogosch and colleagues (Rogosch, Oshri, & Cicchetti, 2010) examined a developmental cascade model in which they hypothesized that child maltreatment (yes/no) would influence the development of internalizing and externalizing symptoms and difficulties with social competence in childhood, and marijuana abuse and dependence diagnoses in early adolescence. In addition, they hypothesized that internalizing and externalizing symptoms, problems with social competence, and marijuana abuse and dependence diagnoses at earlier developmental stages (i.e., later childhood, early adolescence) would lead to increased internalizing and externalizing symptoms and marijuana abuse and dependence diagnoses at later developmental stages (i.e., early adolescence, later adolescence). They found that early childhood maltreatment was associated with increased marijuana problems in early and late adolescence, and despite significant cross-lagged relationships between externalizing symptoms assessed earlier in development and problem marijuana use assessed later, these influences did not fully account for the relationship between child maltreatment and problem marijuana use. The authors note that these findings suggest that other processes likely account for the relationship between child maltreatment and problem marijuana use. Using the same sample, Oshri, Rogosch, Burnette, and Cicchetti (2011) found that severity of early child maltreatment (i.e., a latent variable reflecting severity of neglect, physical abuse, sexual abuse, and emotional abuse) was associated with poor ego control, increased externalizing symptoms, and increased symptoms of marijuana abuse and dependence. In addition, both poor ego control and externalizing symptoms mediated the relationship between child maltreatment and marijuana abuse and dependence symptoms in adolescence. These findings highlight the link between child maltreatment and marijuana problems, but findings are limited to younger (age 13–15) and older (age 15–18) adolescents. Additional research is needed to better understand the relationship between child maltreatment and marijuana problems in young adults. Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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One potentially important mechanism that might underlie the relationship between child maltreatment and marijuana problems is motives for using marijuana. Motives reflect individual reasons for using marijuana and include affect-related reasons (i.e., to reduce negative affect or to enhance positive affect), social reasons (e.g., to enhance social situations, to conform to social pressure), and reasons related to enhancing experiences (e.g., to expand awareness and creativity; Simons, Correia, Carey, & Borsari, 1998). Within the substance use literature, motives have been identified as a proximal predictor of marijuana use and problems (Lee, Neighbors, & Woods, 2007; Simons et al., 1998). In addition, in the alcohol literature, motives to regulate mood (i.e., drinking to cope with negative affect and drinking to enhance positive affect), have been identified as important mediators of the relationship between child maltreatment and alcohol problems (Goldstein, Flett, & Wekerle, 2010; Grayson & Nolen-Hoeksema, 2005). These findings suggest that, among individuals with maltreatment histories, alcohol use is motivated by a desire to regulate affect, perhaps due to difficulties with affect regulation associated with early exposure to maltreatment (Cicchetti, Ganiban, & Barnett, 1991). Developmental traumatology perspectives highlight the impact of maltreatment on biological systems involved in regulating responses to stress, including emotion regulation (De Bellis, 2002). Because the ability to regulate emotions develops early (Garber & Dodge, 1991), it can be disrupted early in life (see Cicchetti & Toth, 2005, for a review) and previous researchers have found that maltreated children have fewer adaptive strategies for regulating emotions (Shipman, Edwards, Brown, Swisher, & Jennings, 2005) and that childhood maltreatment contributes to emotion regulation difficulties in young adulthood (Briere & Rickards, 2007; Gratz, 2006; Gratz, Conrad, & Roemer, 2002). Although motives for marijuana use (i.e., marijuana motives) closely parallel motives for alcohol use, we are not aware of any studies that have examined marijuana motives as mediators of the relationship between child maltreatment and marijuana problems. Using marijuana to cope with negative affect and to enhance positive affect may serve a particularly important function for individuals with maltreatment histories because of difficulties with emotion regulation. Although using marijuana to cope and emotion regulation are overlapping constructs, they are different in that coping motives refer to the specific use of marijuana to assist with relief of negative affect, whereas emotion regulation refers to a more general tendency to utilize (or not utilize) specific strategies when faced with negative emotions. Although not all individuals with emotion regulation difficulties will engage in marijuana use, among those who experience difficulty regulating their emotions, marijuana use may be particularly reinforcing, insofar as it alleviates negative affect and enhances positive affect. Difficulties with emotion regulation have been identified as a significant predictor of substance use (Dorard, Berthoz, Phan, Corcos, & Bungener, 2008; Simons & Carey, 2002) and substance use motives (Bonn-Miller, Vujanovic, Boden, & Gross, 2011; Bonn-Miller, Vujanovic, & Zvolensky, 2008). For example, Bonn-Miller et al. (2008) postulated that young adult marijuana users who experienced greater emotion dysregulation may use marijuana to regulate emotions, particularly to reduce negative mood. They found that emotional dysregulation was significantly related to using marijuana to cope with negative mood and that this effect was observed beyond the variance attributable to other factors that were included in their model including marijuana use, tobacco use, alcohol consumption, negative affectivity, and anxiety sensitivity. Another study of 79 young adults (39 women, Mage = 22.29, SD = 6.99) examined the association between posttraumatic stress symptom severity and marijuana motives and found that emotion dysregulation fully mediated the relationship between posttraumatic stress symptom severity and marijuana motives to cope with negative mood (Bonn-Miller et al., 2011). Currently, however, the link between childhood maltreatment, emotion regulation, marijuana motives, and marijuana problems has not been established. The purpose of this study is to further elucidate the mechanisms underlying the link between childhood maltreatment and marijuana problems in a sample of young adults. Specifically, we hypothesized that (a) greater childhood maltreatment (i.e., experiencing multiple types of moderate or severe maltreatment) would be positively associated with higher levels of emotion dysregulation, (b) child maltreatment would be positively associated with emotion dysregulation and motives to modify affect (affect-related motives) for marijuana use (i.e., using marijuana to cope with negative affect or to enhance positive affect) and that this relationship will be strongest between maltreatment and coping motives, and (c) affect-related motives will be associated with marijuana problems.

Methods Participants In total, 271 young adults (ages 19–25) responded to an online study advertisement, and 142 of these individuals endorsed past year marijuana use. Only past year marijuana users were included in the current analyses. Seventeen individuals were excluded from the analyses as their responses were incomplete. The final sample consisted of 125 young adults for whom we had complete data. On average, participants were 22.46 years old (SD = 1.89), and the majority of the sample was female (66.9%) and current university or college students (61.7%). With regards to education, approximately 18% of our sample completed high school or less, 14% college or trade school, 31% some university, 29% a university degree and 8% a post graduate degree. In terms of ethnicity, the sample was 77.6% Caucasian, 8.8% Asian Canadian, 1.6% Black/African Canadian, 1.6% Hispanic Canadian, and 0.8% First Nations. The remaining participants (9.6%) identified their ethnicity as other. Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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Procedures Participants were recruited for a study of alcohol and marijuana use, childhood experiences, and current psychological wellbeing through various public community websites (e.g., Craigslist, Kijiji) and one local university website. Interested individuals clicked on a link directing them to the online survey. Participants indicated their consent and age. Anyone whose response was outside the study age range (19–25) was directed out of the survey. To further confirm that study participants met the age criterion, we repeated the age question later in the survey and requested participants’ year of birth. No participant was deemed ineligible because of their age. Participants who completed the online survey were given the option to enter a draw for $50. All study procedures were reviewed and approved by the University of Toronto Research Ethics Board. Measures Participants completed a series of questionnaires, including demographic items assessing their age, ethnicity, and current education level. Marijuana use. Participants completed a series of items pertaining to quantity and frequency of their marijuana use over the past three months. Specifically, participants indicated how many times they had used marijuana in the past three months and how many ‘joints’ they smoked for each day of the week on a typical week. Participants were asked to estimate the number of joints smoked even if they used marijuana through different means (e.g., smoking from a pipe, bong-hits, and eating cookies or brownies which contained marijuana.) Marijuana problems. Marijuana problems were assessed using the 19-item Marijuana Problems Scale (MPS; Stephens, Roffman, & Curtin, 2000), which assesses severity of problems associated with marijuana use in various domains including: psychological, social, occupational, and legal. Using a 3-point scale (0 = no problem, 2 = serious problem), participants indicated the extent to which they experienced each problem in the past 90 days. For the purposes of this study, we asked participants to indicate the extent to which they experienced each problem in the past year. The MPS demonstrated good internal consistency in the current sample (˛ = 0.89). Childhood maltreatment. Childhood maltreatment was assessed with the 25-item Childhood Trauma Questionnaire – Short Form (CTQ-SF; Bernstein et al., 2003). The CTQ assesses five domains of child maltreatment (Emotional Abuse, Physical Abuse, Sexual Abuse, Emotional Neglect, Physical Neglect). Participants rated their agreement with each statement about their childhood experiences on a 5-point scale (1 = never true to 5 = very often true). Alphas for the current sample ranged from .77 (Physical Neglect) to .95 (Sexual Abuse). Previous research assessing the validity of the CTQ-SF has shown that the five-factor structure provided a good fit using data from three groups of individuals: adults with a substance use disorder diagnosis, adolescents who were psychiatric inpatients, and a sample drawn from the community. The CTQ-SF demonstrated strong measurement invariance indicating that the scale can be used in both clinical and non-clinical samples (Bernstein et al., 2003). In addition, each of the CTQ-SF scales was moderately to highly correlated with therapist ratings of abuse in each domain (rs = .36–.75; Bernstein et al., 2003). Using cut-off scores established by Bernstein et al. (2003), we created dichotomous scores for each of the maltreatment subscales with 0 = no to mild maltreatment and 1 = moderate to severe maltreatment. Moderate to severe maltreatment cut off scores are as follows: emotional abuse = 13, Physical abuse = 10, Sexual abuse = 8, Emotional neglect = 15, and Physical neglect = 10. The dichotomous scores were summed to create a cumulative maltreatment variable, with 0 = no to mild maltreatment, 1 = one type of moderate to severe maltreatment, and 2 = two or more types of moderate to severe maltreatment (see Anderson, Tiro, Webb Price, Bender, & Kaslow, 2002; Goldstein et al., 2010). Motives for marijuana use. Marijuana motives were assessed using the 25-item Marijuana Motives Measure (MMM; Simons et al., 1998). Participants indicated the frequency with which they use marijuana for five motives: coping motives (e.g., “To forget your worries”), enhancement motives (e.g., “Because it gives you a pleasant feeling”), social motives (e.g., “To be sociable”), conformity motives (e.g., “Because my friends pressure me to use marijuana”), and expansion motives (e.g., “So I can understand things differently”). All items are rated on a 5-point scale ranging from 1 (Almost never/Never) to 5 (Almost always/Always). Subscale scores reflect the average score across items and all five factors demonstrated high internal consistency in the current sample (˛’s ranging from .84 [conform] to .94 [expansion]). Emotion dysregulation. Emotion dysregulation was assessed with the 36-item Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). DERS items are rated on a 5-point scale (with scores ranging from 1 = almost never to 5 = almost always) and the scale is comprised of six factors and a total score including: nonacceptance of emotional response, difficulties engaging in goal directed behavior, impulse control difficulties, lack of emotional awareness, and lack of emotional clarity. The DERS total score was used in the current study and demonstrated high internal consistency (˛ = .94). Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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Table 1 Descriptive statistics for marijuana motives, marijuana use and emotion dysregulation. None/minimal M (SD)

One type M (SD)

Two or more types M (SD)

Total M (SD)

1.47 (0.69) 3.36 (1.15) 1.19 (0.51) 2.06 (0.90) 1.84 (1.19)

2.10 (1.11) 3.18 (1.14) 1.14 (0.25) 2.18 (1.13) 1.87 (1.05)

1.96 (1.14) 3.10 (1.12) 1.52 (0.74) 2.01 (0.83) 2.33 (1.16)

1.69 (0.93) 3.23 (1.14) 1.26 (0.56) 2.07 (0.92) 1.96 (1.17)

Marijuana variables No. of marijuana use days in past 3 months No. marijuana problems

28.24 (42.58) 2.45 (3.40)

33.42 (40.55) 5.10 (4.73)

31.70 (41.82) 4.47 (4.35)

29.87 (41.81) 3.36 (4.00)

Emotion dysregulation

71.21 (17.90)

83.50 (27.31)

94.73 (30.40)

78.82 (24.93)

Variable Marijuana motives Cope Enhance Conform Social Expansion

Data analysis Prior to data analysis, all variables were examined for significant violations from normality. Four outliers (scores greater than 3 SDs from the mean) on the marijuana use items were changed to a raw score that was one unit larger than the next largest item (Tabachnick & Fidell, 2007). We also conducted a series of t-tests to examine gender differences on the primary variables of interest. With the exception of past three months marijuana use, where males used significantly more marijuana than females t(57.60) = 2.06, p = .04, there were no significant differences between males and females on emotion dysregulation, marijuana problems, or any of the marijuana motives. A nonparametric test of gender differences (Mann–Whitney U) revealed no significant differences between men and women on the cumulative maltreatment variable. Because there were no gender differences and because we had relatively few men in our sample, we did not include gender in subsequent analyses. To examine the mediating effects of marijuana motives, we used bootstrap resampling methods outlined by Preacher and Hayes (2008). This approach allows for easier identification of the extent to which specific mediator variables (in this case, motives for marijuana use) mediate the relationship between maltreatment and marijuana problems. By including several mediators in the model, we could determine the relative strength of the specific indirect effect of each motive. Furthermore, the primary advantage to using this method as opposed to a simple meditation model with a single mediator (as described by Baron & Kenny, 1986) is that testing a single mediator at a time may increase parameter bias due to omitting variables (Preacher & Hayes, 2008). Thus, using a simple mediation method runs the risk of producing results that are not a valid estimate of the relationships being measured because there may be significant mediation with a single variable when in fact there are other variables not being accounted for that play a role in the mediation. Therefore, although only the affect-related motives (coping motives and enhancement motives) are theoretically important in the current study, we included all five motives as previous research (e.g., Simons et al., 1998; Zvolensky et al., 2007) has shown that the motives are correlated. Furthermore, this study is one of the first to examined motives as mediators of the relationship between child maltreatment and alcohol problems, and we wanted first to establish mood regulation motives as the most important mediators, even when considering other correlated motives. Finally, path analysis using AMOS 5.0 (Arbuckle, 2003) was conducted to assess various pathways from child maltreatment to emotion dysregulation, marijuana motives, and marijuana problems and to provide path coefficients and tests of overall model fit. Specifically, we examined the pathways from (a) maltreatment to emotion dysregulation, (b) emotion dysregulation to coping motives, and (c) coping motives to marijuana problems. An important part in the application of path analysis is the assessment of model fit, which is accomplished through examination of several fit indices. The chi-square statistic tests the hypothesis that the model is a good approximation of the observed data but is sensitive to sample size, and larger sample sizes can produce a significant chi-square even in situations where the model represents a good fit. Therefore, in addition to the chi-square statistic, we used the Root Mean Square Error of Approximation (RMSEA; Steiger & Lind, 1980) and the Comparative Fit Index (CFI; Bentler, 1990). The RMSEA measures the discrepancy between an optimal model with a known population covariance matrix and a hypothesized model with an estimated covariance matrix. The discrepancy is expressed per degree of freedom, so the index is sensitive to the complexity of the hypothesized model. Values less than .05 indicate a good fit though values between .05 and .06 are also acceptable (Browne & Cudeck, 1993). The CFI is based on a comparison of the hypothesized model against a baseline model, typically the independence model where all correlations equal zero. Values for the CFI range from 0.00 to 1.00. Values greater than .90 represent a good fit; values greater than .95 reflect an excellent fit. In addition, we used Sobel’s test to evaluate the strength of the indirect relationships in the path models (Sobel, 1982). Results Descriptive statistics are listed in Table 1. Consistent with previous research (e.g., Simons et al., 1998; Zvolensky et al., 2007), the most frequently endorsed motives for using marijuana were enhancement motives, followed by social motives, Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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Table 2 Bivariate correlations of marijuana use, marijuana problems, maltreatment, all marijuana motives, and emotion dysregulation. Variable 1. Marijuana use past 3 mos 2. Marijuana problems 3. Maltreatment 4. Coping motives 5. Conformity motives 6. Enhancement motives 7. Social motives 8. Expansion motives 9. Emotion dysregulation

1. .32*** .04 .44*** −.06 .42*** .34*** .38*** −.04

2.

.24** .46*** .22** .33*** .38*** .39*** .40***

3.

4.

.25** .22** −.10 −.01 .17 .40***

5.

.12 .34*** .40*** .41*** .39**

−.15 .14 .14 .35***

6.

7.

.50*** .40*** −.06

.42*** .03

8.

.18*

Note. Maltreatment refers to the cumulative maltreatment score (i.e., the sum of types of moderate to severe maltreatment experiences). * p < .05. ** p < .01. *** p < .001. Table 3 Multiple mediation analyses examining indirect effects of child maltreatment on marijuana problems through marijuana motives. Variable

Product of coefficients Point estimate

IV = Maltreatment DV = Marijuana problems Coping motives Conformity motives Enhancement motives Social motives Expansion motives Total

0.2913* 0.1598 −0.0788 −0.0047 0.1005 0.4681**

Bootstrapping 95% CI

SE

Z

Lower

Upper

0.1449 0.1045 0.0832 0.0515 0.0875 0.2645

2.0097 1.5295 −0.9466 −0.0905 1.1481 1.7697

0.0341 −0.0108 −0.3274 −0.1512 −0.0219 −0.1120

0.7663 0.6062 0.0300 0.1135 0.4339 1.0407

Note. IV = independent variable, DV = dependent variable. Maltreatment refers to the cumulative maltreatment score (i.e., the sum of types of moderate to severe maltreatment experiences). This model was re-run with covariates (gender, age, student status – university student, college student, non-student). None of the covariates were significantly associated with marijuana problems and the indirect effect for coping motives in the model remained significant (95% Confidence interval 0.02–0.80). * p < .05. ** p < .10.

expansion motives, coping motives, and conformity motives. The average score on the DERS was also similar to that in other studies (e.g., Gratz & Roemer, 2004). The CTQ-SF scale scores were, on average, below the cut off points for moderate and severe abuse. Means (SDs) for the CTQ-SF subscales are as follows: Emotional Abuse M = 9.55 (SD = 4.83), Emotional Neglect M = 10.10 (SD = 4.73), Physical Abuse M = 7.10 (SD = 3.91), Physical Neglect M = 7.34 (SD = 3.18), and Sexual Abuse M = 6.10 (SD = 3.28). In terms of the frequency with which participants experienced moderate to severe maltreatment, the rates were as follows: Emotional Abuse (22.40%) followed by Physical Abuse (19.20%), Emotional Neglect (17.60%), Physical Neglect (16.80%) and Sexual Abuse (13.60%). In addition, 60% of the current sample reported experiencing none or minimal maltreatment, 16% reported experiencing at least one type of maltreatment in the moderate or severe range, and 24% reported experiencing two or more types of maltreatment in the moderate or severe range. Bivariate analysis Correlations between child maltreatment, marijuana motives, emotion dysregulation, marijuana use, and marijuana problems are presented in Table 2. We found significant correlations between child maltreatment, coping motives, conformity motives, marijuana problems, and emotion dysregulation. In addition, all five marijuana motives were associated with marijuana problems. Emotion dysregulation was associated with marijuana problems, coping motives and conformity motives. Mediation analysis Results from the multiple mediation analysis are presented in Table 3 and include point estimates (beta coefficients), standard errors, and Z-scores for the individual and total mediation (i.e., indirect) effects. Coping motives emerged as a significant mediator of the relationship between maltreatment and marijuana problems, over and above the other marijuana motives. Although the total indirect effect of motives was not significant, Preacher and Hayes (2008) note that a significant total effect is not a prerequisite for investigating specific indirect effects. The model accounted for 28.43% of the variance in marijuana problems. Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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Child Maltreatment

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.40*** Emotion Dysregulation

.38*** Coping Motives .36***

.24**

Marijuana Problems

Fig. 1. Final path model of associations between maltreatment, emotion dysregulation, coping motives and marijuana problems. Numbers represent standardized path coefficients. **p < .01; ***p < .001.

Path analysis The final set of analyses examined all possible pathways in the relationship from child maltreatment to marijuana problems Specifically we examined the pathways from (a) maltreatment to emotion dysregulation, (b) emotion dysregulation to coping motives, and (c) coping motives to marijuana problems. Based on the results from the mediation analyses, only coping motives were included in this model. To determine whether the best fitting model included direct paths from (a) child maltreatment to marijuana problems and (b) emotion dysregulation to marijuana problems, we compared the fit of three different models. In the first model, we did not include direct relationships from maltreatment to marijuana problems or from emotion dysregulation to marijuana problems. In the second model we included only the direct pathway from maltreatment to marijuana problems, and in the third model, we included only the direct pathway from emotion dysregulation to marijuana problems. The first model did not provide a good fit to the data, 2 = 10.76, p = .01; CFI = .89; RMSEA = .14. The second model, which included the direct pathway from maltreatment to marijuana problems via coping motives, also did not provide a good fit, 2 = 8.09, p = .02; CFI = .92; RMSEA = .16, and did not significantly improve model fit compared to the model with no direct path from maltreatment to marijuana problems. The third model provided an excellent fit to the data, 2 = 2.36, p = 1.18; CFI = 1.00; RMSEA = .038, and significantly improved the model fit when compared to the first model, 2 = 8.40, p < .01. We used this as our final model, as it was the most parsimonious model and included only those direct paths that improved the fit of the model. In the final model, coping motives were a significant mediator of the relationship between emotion dysregulation and marijuana problems (Sobel’s test statistic = 3.19, p < .002). All structural paths between variables in this model were significant (see Fig. 1). Discussion The purpose of the current study was to examine motives and emotion dysregulation as mechanisms that partially account for the relationship between childhood maltreatment and marijuana problems among young adults. Although previous researchers have identified motives for mood regulation as mediators, these studies focused exclusively on the relationship between child maltreatment and alcohol use and problems (e.g., Goldstein et al., 2010; Grayson & NolenHoeksema, 2005; Vilhena & Goldstein, 2011). The current findings indicate that, consistent with the alcohol literature, coping motives for marijuana use are associated with marijuana problems among individuals with maltreatment histories. In addition, although marijuana use is highest among young adults compared to other age groups (e.g., Adlaf et al., 2005), for individuals with maltreatment histories, there may be a greater tendency to experience increased marijuana problems which may be a precursor to more serious marijuana-related issues, including marijuana abuse and/or dependence. These findings highlight the importance of identifying people with maltreatment histories early in their marijuana use experiences. The discussion of analyses presented here may also aid in partially explaining the relationships between maltreatment and marijuana problems. The finding that enhancement motives did not mediate the relationship between maltreatment and marijuana problems may reflect differences in baseline affect associated with endorsement of coping motives versus enhancement motives. Enhancement motives (e.g., to get high, because it’s [marijuana is] fun) imply that the person is experiencing positive affect or at least a neutral affective state. Individuals with a history of maltreatment are at greater risk of experiencing depressed mood (e.g., Bennett, Sullivan, & Lewis, 2010; Courtney, Kushwaha, & Johnson, 2008; Fletcher, 2009; Hankin, 2005) and internalizing symptoms (Oshri et al., 2011) and as a result, may have greater baseline negative affect, which may lead to a greater likelihood of using marijuana to cope (versus to enhance a pre-existing positive mood) and, in turn, greater marijuana problems. Furthermore, in light of the current findings and upon closer examination of the enhancement motives items, it may be that these items do not capture mood modification specifically (e.g., do not refer to using marijuana to feel happy or Please cite this article in press as: Vilhena-Churchill, N., & Goldstein, A.L. Child maltreatment and marijuana problems in young adults: Examining the role of motives and emotion dysregulation. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.10.009

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improve mood), but instead focus on enjoying the sensations marijuana produces (e.g., because I like the feeling; because it’s exciting; to get high). In addition, consistent with previous research (e.g., Zvolensky et al., 2009) enhancement motives in the current sample were highly correlated with social motives, suggesting that there is a common focus on social facilitation. Future research is needed to clarify the relationship between negative affect or depressed mood, child maltreatment, affect regulation motives, and marijuana problems. Consistent with previous research (Simons, Gaher, Correia, Hansen, & Christopher, 2005), our findings indicate that difficulties with emotion regulation influences coping motives and, in turn, marijuana problems. The findings support our original hypothesis that young adults who have experienced more severe maltreatment in childhood will have greater difficulties regulating their emotions in young adulthood, which will be associated with using marijuana to cope with negative moods. Furthermore, one of the primary components of emotion dysregulation is the use of maladaptive behaviors in response to emotional distress (Kennedy-Moore & Watson, 2001). Young adults who lack effective coping strategies may rely on marijuana when experiencing distress, resulting in problematic patterns of use. That this pathway emerges in the context of childhood maltreatment is consistent with a developmental traumatology model of substance use disorders (e.g., De Bellis, 2002). According to this model, repeated exposure to interpersonal trauma contributes to changes in the stress response system and maturational failures in self-regulation, both factors that contribute to emotion dysregulation. It is important to note, however, that coping motives only partially mediated the relationship between emotion dysregulation and marijuana problems. These findings suggest that coping motives may not fully capture reasons for use among those with emotion regulation difficulties. For example, using marijuana to help with sleep or to relieve boredom is related to emotion dysregulation (e.g., difficulty turning off emotion-related thoughts, difficulty tolerating boredom) but may not be directly linked with the coping motives assessed with the MMM (e.g., to forget problems, to relieve tension). In the alcohol use literature, coping motives have been divided into two domains – coping with depressed mood and coping with anxiety (Grant, Stewart, O’Connor, Blackwell, & Conrod, 2007). Although this has not been addressed in the marijuana motives literature, it is possible that the current coping subscale does not fully capture the broad range of experiences for which individuals might use marijuana to cope (e.g., anxiety vs. depression). In addition, there may be other factors that underlie the link between child maltreatment and marijuana problems that were not addressed in the current model. For example one study of women in middle adulthood found that other stressful life events, posttraumatic stress disorder, and delinquency partially mediated the relationship between childhood maltreatment and later illicit drug use and problems (White & Widom, 2008). In addition, we did not assess personality pathology in our sample, despite evidence that childhood maltreatment is associated with various personality difficulties, including Borderline Personality Disorder (e.g., Afifi, Henriksen, Asmundson, & Sareen, 2012), which have been linked to substance use and substance use problems (e.g., Dennhardt & Murphy, 2013; Lev-Ran, Le Foll, McKenzie, George, & Rehm, 2013).

Clinical implications This study is significant as it provides a more in-depth understanding of some of the factors that may contribute to marijuana problems among individuals who are at particular risk for problems resulting from marijuana use (e.g., young adults with a history of maltreatment).1 As such, the current findings have several important clinical implications. First, this study provides additional evidence that clinicians should assess for emotion dysregulation among individuals with a history of maltreatment. Our findings highlight the association between emotion dysregulation and marijuana problems, and previous researchers have found that emotion dysregulation is associated with other maladaptive coping strategies including deliberate self harm (e.g., Gratz, 2003) and disordered eating (e.g., Spence & Courbasson, 2012). Clinicians would also likely benefit from using techniques aimed at changing individuals’ motives for marijuana use, which has also been suggested by other researchers (e.g., Simons et al., 1998). Specifically, targeting coping motives and helping individuals find more adaptive ways of coping may help reduce marijuana problems. This study highlights the importance of assessing for a history of maltreatment when considering individuals for prevention or intervention strategies pertaining to marijuana use. Specifically, the current study supports the need for interventions that address the development of healthy emotion regulation strategies, including Dialectical-Behavior Therapy (DBT; Linehan, 1993). Linehan describes the role of the DBT therapist as one who “...creates a context of validating rather than blaming the patient, and within that context, the therapist blocks or extinguishes bad behaviors, drags good behaviors out of the patient, and figures out a way to make the good behaviors so reinforcing that the patient continues the good ones and stops the bad ones” (Linehan, 1993, p, 97). The DBT therapist approaches this role using two core strategies: Validation and Problem-Solving (Linehan, 1993; Lynch, Trost, Salsman, & Linehan, 2007). These strategies may be particularly useful early in helping young adults with a history of maltreatment to reduce the likelihood of prolonged substance use trajectories, before the development of problems as DBT highlights reinforcement of “good behaviors” and problem-solving to reduce “bad behaviors.”

1

We would like to thank an anonymous reviewer for suggesting this addition.

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Limitations and future directions There are several limitations of the current study that should be noted. First, the cross-sectional nature of the data makes it difficult to draw causal inferences. Although the temporal ordering of child maltreatment → emotion dysregulation → coping motives → marijuana problems makes theoretical sense, longitudinal research is needed to clarify the chronology of these relationships. It is possible, for example, that marijuana use contributes to difficulties with emotion regulation rather than emotion dysregulation leading to increased marijuana use or marijuana problems. Indeed, it is likely that this is a bidirectional relationship, though further research is needed to clarify the nature of these relationships. Second, marijuana is currently an illegal substance in Canada, which may have resulted in some underreporting of marijuana use or problems. In addition, the completion of questionnaires online may have resulted in participants being influenced by other contextual factors (e.g., a friend sitting with them, being under the influence). However, previous researchers have noted that online surveys are at least as reliable as other types of self-report surveys (e.g., Ramo, Hall, & Prochaska, 2011; Tolstikova & Chartier, 2010). Third, self-report measures in general are vulnerable to numerous biases and recall error. Findings reflect self-reported or perceived experiences of maltreatment and not actual maltreatment experiences, although it could be argued that one’s perceptions of their experiences is a worthwhile area of study as it is likely perception that influences one’s subsequent coping behaviors (Wright et al., 2009). This area should be investigated in future research. Another limitation is that participants were primarily recruited from online community websites, and participants completed the study entirely online. As a result, the sample excluded individuals who may not have Internet access, including individuals with more transient living situations (e.g., homeless young adults). In addition, emotional abuse was the most commonly reported type of maltreatment and we may not have captured the range of maltreatment types experienced by more diverse samples of male and female young adults. Finally, although we recruited participants from the community, a large proportion of this sample was college or university students, and many were Caucasian and young women. Thus, our sample lacks diversity in experiences, ethnicity, and gender, and additional research is needed with a more diverse sample of young adults. Furthermore, previous research has identified gender as a powerful moderator of the coping motives and marijuana problems relationship (e.g., Bujarski, Norberg, & Copeland, 2012). Although we did not find significant gender differences on any of the variables included in our meditation models, we may have had insufficient power to detect whether such differences exist. Future research should strive to obtain equal numbers of male and female participants to control for these differences. Nonetheless, the fact that we used a sample that was not explicitly recruited for a study of childhood maltreatment, highlights again the prevalence of maltreatment even among community samples and provides a perspective on the relationship between multiple types of child maltreatment and marijuana use. Despite these limitations, the present study sheds some light on the mechanisms through which child maltreatment impacts marijuana problems. 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