Fueling the Cycle: Attachment, Cognition, and Emotion in Substance-Using Incarcerated Young Adults

Abstract

Objective

Youth violence, often linked to drug offenses, is a major concern in socially and politically unstable regions worldwide. Early attachment and stressors influence behavioral development, highlighting the importance of addressing underlying psychopathology. This study examined clinical, psychopathological, and cognitive profiles in incarcerated young adults with substance use issues, considering social, familial, and environmental factors.

Method

This cross-sectional study enrolled 40 male young adults (mean age 21.05 ± 1.15 years) with SUD, participating in a resocialization program in Medellin. Participants completed questionnaires assessing affective lability (ALS-SF), emotion dysregulation (DERS), executive functions (BRIEF-A), ADHD symptoms (ASRS), attachment styles (CA-MI-R), and stressful life events (SRRS). Data were analyzed using non-parametric tests, Spearman's rank correlations, and multiple linear regressions.

Results

Multiple linear regression analyses revealed significant predictive relationships. The number of substances used was predicted by poorer emotional control (β = -0.440, p = .007), greater executive dysfunction (β = 0.060, p = .015), higher childhood trauma (β = -0.360, p = .006), and a higher CA-MI-R score (β = 2.316, p = .017). Childhood trauma reported was predicted by greater executive dysfunction (β = 0.536, p = .013), lower socioeconomic status (β = -0.119, p = .035), a greater number of substances used (β = -0.256, p = .006), benzodiazepine use (β = -0.299, p = .014), and poorer emotional control (β = -0.331, p = .016). Affective lability, emotion dysregulation, and executive dysfunction were significantly intertwined with ADHD traits.

Conclusions

This study provides evidence for the complex interplay of attachment, executive function, emotion regulation, and ADHD symptoms in incarcerated young adults with SUD. Executive dysfunction, impulsivity, emotional dysregulation, and attachment insecurity significantly contribute to substance use and childhood trauma, fueling a vicious cycle. Interventions addressing relational trauma, deficits, and broader factors are needed to disrupt this cycle, promote rehabilitation, and reduce recidivism.

Introduction

Youth violence, frequently associated with drug-related offenses, remains a major global public health challenge, particularly in regions marked by prolonged social and political instability (Otero-Lopez et al., 1994; Erskine et al., 2015; Rubiano et al., 2018; Schindler, 2019; WHO, 2024; Liu et al., 2025).

In Colombia, decades of exposure to armed conflict normalized violence, disrupted social structures, and fueled socio-economic disparities, disproportionately affecting vulnerable youth (Fraser et al., 2021; Seff et al., 2022; Mora Gámez, 2023).

This enduring socio-political violence and terrorism led to widespread poverty, numerous victims, and ongoing internal displacement and stigma towards those fleeing problematic areas (Zapata, 2003; Reidy et al., 2018). Mass incarceration of individuals from minority and disadvantaged backgrounds further impacts children adversely (Leckman et al., 2021).

In recent years, researchers have been documenting the different ways in which adolescents are exposed to violence within their family settings, schools, and communities, with severe implications for their health and psychosocial wellbeing (Browne et al., 2019; Gaias et al., 2019).

Available data highlight the importance of considering multiple factors in understanding youth violence, including family characteristics, individual traits, and socio-economic determinants (Li et al., 2021). In particular, low socioeconomic status, limited education, and a lack of financial resources are strongly associated with higher rates of youth violence and are recognized as significant barriers to healthy childhood development (Toumbourou, Hemphill, et al., 2007; Toumbourou, Stockwell, et al., 2007; Bundy et al., 2017; Flórez, 2021; Li et al., 2021).

This study examined the relationships between deviant behavior, disorganized attachment, and substance use disorder in a sample of Colombian young adults incarcerated for serious crimes. We also considered the role of attention-deficit/hyperactivity disorder (ADHD), given its frequent comorbidity with substance use disorder (SUD) and its potential influence on impulsivity and behavioral control (Egan et al., 2017; Mochrie et al., 2020; Johansson Capusan et al., 2022; Maremmani et al., 2022; Taubin et al., 2022; Rohner et al., 2023; Hernández et al., 2025). Our investigation was guided by a developmental psychopathology framework, which posits that early adverse experiences, such as disorganized attachment, can increase vulnerability to later maladjustment, including deviant behavior and substance use (Lyons-Ruth, 1996; Hoeve et al., 2012; Fearon et al., 2016; Wallinius et al., 2016; Fairbairn et al., 2018; Schindler, 2019; Gerra et al., 2021; Bosmans & Borelli, 2022). It is important to clarify that the inclusion of ADHD is based on its well-documented comorbidity with SUD and the role of impulsivity in risky behaviors (Molina & Pelham, 2014; Zulauf et al., 2014; Barbuti et al., 2023; El Rasheed et al., 2023). While ADHD is characterized by deficits in executive functions, it also involves impulsivity and emotional dysregulation, traits that are often associated with risky behaviors and substance abuse. Although related, these features are conceptually distinct from trauma-related impulsivity rooted in early relational traumas (Urcelay & Dalley, 2012; Roberts et al., 2014; Ortal et al., 2015; Slobodin et al., 2015; Miranda et al., 2016). We included ADHD as a relevant moderator, recognizing that impulsivity can intensify the effect of disorganized attachment on deviant behaviors and substance use.

Early childhood development (ECD), attachment, stressors, and related neurobiological changes are crucial individual factors. Scientific literature indicates how inadequate child-rearing environments affect brain function, leading to issues of self, interpersonal problems, and affect dysregulation (Martins et al., 2011; Carr et al., 2013; Schiavone et al., 2015; Sloman & Taylor, 2015; Ventriglio et al., 2015; Targum & Nemeroff, 2019; Smith & Pollak, 2020; Nakama et al., 2023).

Institutionalized children show altered cortisol patterns, possibly affecting stress-sensitive brain regions like the prefrontal cortex (PFC), the limbic system and the hippocampus (Carlson & Earls, 1997; Bremner, 2006; Elzinga et al., 2010; Norman et al., 2012; Hodel et al., 2015; Kim & Choi, 2020; Britto et al., 2021; Kirsch & Lippard, 2022). Alterations of glucose metabolism have also been reported in the hippocampus and in the amygdala that also resulted, respectively, smaller and larger (Chugani et al., 2001; Tottenham et al., 2010; Hodel et al., 2015).

It is vital to understand that disorganized attachment often results not merely from isolated adverse events, but more frequently from recurrent relational traumas, such as ongoing neglect and abuse (Lyons-Ruth et al., 2003; Lahousen et al., 2019; White et al., 2019; Szeifert et al., 2025; Turgeon et al., 2023). These chronic relational traumas disrupt the development of secure attachment, leading to disorganized patterns that are associated with difficulties in emotional regulation, interpersonal functioning, and increased vulnerability to maladaptive behaviors later in life (Dvir et al., 2014; Messman-Moore & Bhuptani, 2017; Raudales et al., 2019).

The potential consequences of toxic stress are considerable. Adolescents with multiple risk factors are more likely to start drinking alcohol at a younger age as a coping strategy (Shonkoff & Garner, 2012; Marshall, 2014), and this may also explain why “Adverse Childhood Experiences” (ACE) correlate with tobacco use, illicit drug abuse, obesity, and risky sexual behaviors (Thompson et al., 2019; SAMHSA, 2023). Higher rates of risk-taking are also associated with difficulties in maintaining supportive social networks (Felitti, 2002; Hustedde, 2021; Weems et al., 2021).

Moreover, adults in high-risk groups often fail to provide stable relationships for their children, perpetuating an intergenerational cycle of adversity marked by limited educational attainment and poor health (Lange et al., 2019). Social inequalities and disrupted social networks contribute to fragile families and parenting challenges (Dufort et al., 2015; Clarke et al., 2019, 2020).

Affiliation is another factor promoting neurobiological processes of resilience that are closely related to the infant's initial dependence on the mother or the primary caregiver, as the brain matures in the context of the mother's body and caregiving behavior (Carter et al., 1997; Depue & Morrone-Strupinsky, 2005; Feldman, 2016). Unfortunately, many children do not receive adequate nurturing care. It is estimated that over 250 million, or 43% of children under age five are at risk of not reaching their developmental potential due to poverty and stunting (Black et al., 2017). Several studies support the link between traumatic childhoods and delinquent behavior, with stress sensitivity potentially leading to SUD (Grella et al., 2005; Marsiglio et al., 2014; Chaplin et al., 2018; Jones & Pierce, 2020; Williams, 2020; Frederick-Ellis, 2022).

We hypothesize that disorganized attachment, reflecting early caregiving disruptions, is associated with increased deviant behavior and a higher likelihood of SUD (Kaplan, 1995; Reynolds et al., 2023). Furthermore, ADHD symptoms, particularly impulsivity, may amplify the connection between disorganized attachment and both deviant behavior and SUD (Kissgen & Franke, 2016; Al-Yagon et al., 2020; Eyüboğlu, 2020; Asadi et al., 2021).

Evidence indicates that SUD often coexists with ADHD, potentially increasing risk for deviant behavior by impairing consequence-based thinking or disengagement from reward pursuits (Helseth et al., 2015; Puiu et al., 2018).

Building upon this understanding, this research examined socio-demographic, clinical and psychopathological features in young adults with addiction-related problems incarcerated for serious crimes committed during adolescence. Specifically, we assessed affective lability, emotional dysregulation, executive functions, and ADHD. We further assessed stressful life events and childhood attachment styles, correlating these with the clinical and psychopathological features.

Materials and methods

Sample recruitment

This study employed an observational, cross-sectional, non-interventional cohort design, consistent with standard clinical practice. The study was conducted on 40 individuals (all of male sex) between 19 and 23 years of age (mean age ± standard deviation: 21.05 ± 1.15) recruited at the San José Labor Educational institution in Colombia, all of whom were also suffering from SUD. The San José Labor Educational institution is a prison community in southern Medellín (Antioquia) specifically for young adults who had committed serious crimes in adolescence, such as robberies, drug dealing, murders, or domestic violence. Our study focused specifically on those who are part of the Comunidad Convivencia San José program, designed to provide a re-socialization and rehabilitation program called “Coexistence”. This program, with free entry, aims to accompany individuals in their comprehensive development through Amigonian pedagogy. The assessment for this study was conducted during the participants' involvement in the “Coexistence” program, and not at the point of entry.

The Amigonian Friars, also known as the Capuchin Tertiary Religious of Our Lady of Sorrows, is a Catholic religious congregation founded in the 19th century in Spain (Montero-Pedrera, 2008). It is a pedagogy rooted in reflective and preventive methods, aiming to address difficulties through dialogue, active participation, and constructive feedback. This approach emphasizes fraternal correction and the development of knowledge through action, fostering a learning environment where challenges are met collaboratively, and solutions are built through shared experiences (Corredor & Zuluaga, 2019). It also emphasizes the recognition and acknowledgment of their addiction problem, enabling them to break free from the situation. Initially, the program assesses behavioral problem profiles and substance use, thus implementing a therapeutic community program. Around 70% of the individuals taking part in “Coexistence” successfully resume their lives, often leveraging this opportunity to complete high school, despite the loss of their family support (Calderón, 2015). The process is enhanced by group dynamics that strengthen their motivation and will to change.

One-hour clinical assessment and interviews per week were carried out with participants, and the six questionnaires were administered in three different sessions. The study was approved by the “Comité scientifico y directivo de la Escuela de trabajo San Jose Equipo Interdisciplinario de la comunidada San Jose, nùmero di referencia, 1 de marzo de 2023”. All subjects volunteered to be included in the study and signed a written consent form.

Data collection and assessment instruments

This research gathered comprehensive data across several key domains to provide a well-rounded understanding of the participants. Socio-demographic information was collected, focusing on the participants' origins, whether from Medellin or displaced from rural areas, and their family organization, specifically noting single-parent households with absent fathers, maternal figures with stepfathers, presence of both biological parents, or absence of both parents. Clinically, data were obtained regarding the age of the first contact with drugs, the specific substances they consumed - including cannabis, alcohol, cocaine, clonazepam, tusi, crack, and sacol - the number of different substances used, the crimes they had committed such as armed robbery, drug dealing, domestic violence, and murder, and whether they were currently using psychotropic medications like mood stabilizers, antidepressants, or antipsychotics. Psychopathological aspects were explored through family history, noting the presence of psychiatric illnesses such as mood disorders, anxiety disorders, psychotic spectrum disorders, neurodevelopmental disorders, and SUD. This multifaceted approach allows for a thorough examination of the factors contributing to the participants' current situation, particularly the interplay between early adverse experiences, substance use, and deviant behavior, as highlighted in the study's guiding framework.

The following questionnaires were used: the short version of the Affective Lability Scale short-form (ALS-SF) (Look et al., 2010); the Difficulties in Emotion Regulation Strategies (DERS-SF) (Cancian et al., 2019); the Behavior Rating Inventory of Executive Function - Adult version (BRIEF-A) (Biederman et al., 2022); the Adult ADHD Self-Report Scale (ASRS v1.1) (Ramos-Quiroga et al., 2009); Caregiver-Adolescent-Mutuality-Revised questionnaire (CA-MI-R) (Balluerka et al., 2011); and the Social Readjustment Rating Scale (SRRS) (Holmes & Rahe, 1967).

ALS-SF. The ALS-SF is a widely used 18-item scale for assessing emotional lability, derived from the original ALS-54 (Aas et al., 2015). The ALS-SF uses a 4-point Likert scale, typically ranging from “very uncharacteristic of me” to “very characteristic of me”. The scale assesses shifts between anxiety and depression, and depression and elation, also measuring anger. Three factors were identified in the ALS-SF: anxiety/depression, depression/ elation, and anger.

DERS. The DERS is a 36-item self-report questionnaire designed to assess multiple aspects of emotion dysregulation. Responses are given on a 5-point Likert scale, ranging from “almost never” to “almost always”. Factor analyses have identified six key factors:

1. Non-acceptance of emotional responses.

2. Difficulties engaging in goal-directed behavior when experiencing negative emotions.

3. Impulse control difficulties.

4. Lack of emotional awareness.

5. Limited access to effective emotion regulation strategies.

6. Lack of emotional clarity.

BRIEF-A. The BRIEF-A is a standardized self-report instrument designed to assess various behavioral aspects of executive functioning and self-regulation in adults within their everyday environments, designed for individuals aged 18+. The BRIEF-A consists of 75 items that describe different behaviors, and respondents rate how often each behavior has been a problem for them using a 3-point scale: “never”, “sometimes”, or “often”.

The items are grouped into eight clinical scales: Inhibition, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Task Monitoring, and Material Organization.

ASRS v1.1. The ASRS v1.1 is an 18-item self-report questionnaire designed to screen for ADHD symptoms in adults. It's based on the DSM-IV criteria (Diagnostic and statistical manual of mental disorders, 4th ed, 1994), modified to reflect the presentation of ADHD in adults. The ASRS is designed to be easily administered and suitable for use in large population surveys. Respondents rate the frequency of each symptom over the past 6 months using a five-point Likert scale.

The 18 items are divided into two parts: Part A contains 6 items considered most predictive of ADHD, while Part B contains 12 additional items that provide further information about symptom presentation. For a client's symptoms to be considered consistent with an ADHD diagnosis, they require 4 or more responses at specific severity levels in Part A of the ASRS. The ASRS is a useful tool for initiating dialogue and confirming potential ADHD symptoms.

CA-MI-R. The CA-MI-R is a questionnaire designed to assess attachment cognitions. It consists of 32 items that evaluate seven dimensions of attachment and family functioning. Respondents rate the items on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire allows to assess the following 7 dimensions:

1. Security

2. Family concerns

3. Parental interference

4. Value of parental authority

5. Parental permissiveness

6. Self-sufficiency and resentment against parents

7. Childhood trauma

The CA-MIR-R builds upon attachment theory, linking past experiences of family relationships to the current state of mind.

SRRS. The SRRS is a tool designed to investigate the relationship between life events, stress, and the likelihood of illness. It consists of a list of 43 life events, each scored from 0 to 100 units of life change (ULC), representing the degree of adjustment required to cope with the event. Respondents indicate which events they have experienced over a specific period, and their ULC scores are summed. A total score between 0 and 149 ULC is interpreted as indicating no significant stress. A score of 300 LCU or higher suggests a high level of stress, which may be associated with an increased risk (e.g., 80%) of illness or health changes.

Statistical Analyses

Demographic, clinical, and laboratory data were summarized using descriptive statistics. Continuous variables are presented as mean ± standard deviation (SD) with the range (minimum and maximum values), or median, where appropriate. Categorical variables are expressed as frequencies (n) and percentages.

The distribution of each continuous variable was assessed for normality using the Kolmogorov-Smirnov test. In light of the non-parametric distribution of our variables based on the Kolmogorov-Smirnov, group comparisons were performed using non-parametric methods. Specifically, the Wilcoxon-Mann-Whitney test (a test comparing two independent groups) and the Kruskal-Wallis test (a non-parametric equivalent of ANOVA used to compare three or more independent groups) were applied for continuous variables. Categorical variables were compared using the Chi-squared test or Fisher's exact test, as appropriate.

Spearman’s rank correlation coefficient was used for non-normally distributed or ordinal data.

To determine the independent contribution of multiple psychological, behavioral, and demographic variables on the outcomes, a multiple linear regression analysis was conducted. This method allows for the simultaneous examination of several predictors, controlling for potential confounding effects and identifying the strongest associations.

Statistical analyses were performed using SPSS 25.0 software.

Results

Socio-demographic features

The socio-family characteristics of our sample were the following: 28 (70.00%) subjects were originally from Medellin, and 12 (30.00%) were displaced from rural areas to the city to escape from the armed conflict. The family organization was mainly structured in a single parent with an absent father (17, 42.50%), or a maternal figure with a stepfather (12, 30.00%), biological parents (4, 10.00%), or absence of both parents (7, 17.50%). The mean age + SD of initial drug contact was 11.58 ± 2.07 years (range 6-15).

The most consumed drugs in decreasing frequency were THC (40, 100.00%), alcohol (32, 80.00%), cocaine (24, 60.00%), clonazepam, a BDZ (18, 45.00%), tusi (a mix of ketamine and MDMA) (16, 40.00%), crack (10, 25.00%), and sacol (toluene) (2, 5.00%) (figure 1). Seventeen (42.50%) individuals had used three drugs, 8 (20.00%) four, 7 (17.50%) five, 6 (15.00%) two, 1 (2.50%) one, and 1 (2.50%) seven substances.

Figure 1.

Prevalence rates of substance use in the sample

The most frequent crimes were armed robbery (35, 87.50%), drug dealing (34, 85.00%), domestic violence (19, 47.50%), and murder (13, 32.50%). Sixteen (40.00%) participants had committed two crimes, 12 (30.00%) three crimes, 7 (17.50%) four crimes, and 5 (12.50%) had committed one crime. Twenty-seven (67.50%) subjects had a positive family history of psychiatric disorders, specifically, 15 (37.50%) had a mood disorder, 9 (22.50%) - an anxiety disorder, 2 (5.00%) had a psychotic spectrum disorder, and 1 (2.50%) had a neurodevelopmental disorder. In addition, 35 (87.50%) had a family history of SUD. Twenty-three (57.50%) subjects were not taking psychotropic drugs, 5 (12.50%) were taking mood stabilizers, 8 (20.00%) were taking antidepressants, and 4 (10.00%) were taking antipsychotics.

Correlation analysis

The ALS-SF Total score shows a positive association with the BRIEF-A domains of Inhibition (ρ = 0.41, p = 0.008) and Emotional Control (ρ = 0.41, p = 0.009).

ALS Anxiety/depression exhibits a positive correlation with the BRIEF-A domains of Inhibition (ρ = 0.33, p = 0.035) and Emotional Control (ρ = 0.33, p = 0.041).

ALS Anger demonstrates a positive correlation with the BRIEF-A domains of Inhibition (ρ = 0.46, p = 0.005), Emotional Control (ρ = 0.45, p = 0.004), and Shift (ρ = 0.37, p = 0.020) (table 1).

Table 1.

Correlations between ALS and BRIEF Domains

ALS Variable	BRIEF Domain	ρ	p-value
Anxiety/Depression	Inhibition	0.33	0.035
Anxiety/Depression	Emotional Control	0.33	0.041
Depression/Elation	Impulse Control Difficulties	0.40	0.011
Depression/Elation	Limited access to emotion regulation strategies	0.55	<0.001
Anger	Inhibition	0.44	0.005
Anger	Emotional Control	0.45	0.004
Anger	Shift	0.37	0.020
ALS-SF Total	Inhibition	0.41	0.008
ALS-SF Total	Emotional Control	0.41	0.009

The ALS-SF Total score has a positive association with the DERS domains of Impulse control difficulties (ρ = 0.47, p = 0.003), Non-acceptance of emotional responses (ρ = 0.45, p = 0.004), Limited access to effective emotion regulation strategies (ρ = 0.56, p < 0.001), and Total score (ρ = 0.47, p = 0.002).

ALS Anxiety/depression shows a positive correlation with the DERS domains of Impulse control difficulties (ρ = 0.35, p = 0.026), Non-acceptance of emotional responses (ρ = 0.39, p = 0.012), Limited access to effective emotion regulation strategies (ρ = 0.46, p = 0.003), and Total score (ρ = 0.41, p = 0.009).

ALS Depression/elation shows a positive correlation with the DERS domains of Impulse control difficulties (ρ = 0.40, p = 0.011), Limited access to effective emotion regulation strategies (ρ = 0.55, p < 0.001), and Total score (ρ = 0.35, p = 0.027).

ALS Anger is positively correlated with the DERS domains of Impulse control difficulties (ρ = 0.44, p = 0.005), Non-acceptance of emotional responses (ρ = 0.43, p = 0.006), Limited access to effective emotion regulation strategies (ρ = 0.41, p = 0.009), and Total score (ρ = 0.43, p = 0.006) (table 2).

Table 2.

Correlations between ALS and DERS Domains

ALS Variable	BRIEF Domain	ρ	p-value
Anxiety/Depression	Impulse Control Difficulties	0.35	0.026
Anxiety/Depression	Non-Acceptance of Emotional Responses	0.39	0.012
Anxiety/Depression	Limited access to effective emotion regulation strategies	0.46	0.003
Depression/Elation	Impulse Control Difficulties	0.40	0.011
Depression/Elation	Limited access to effective emotion regulation strategies	0.55	<0.001
Anger	Impulse Control Difficulties	0.44	0.005
Anger	Non-Acceptance of Emotional Responses	0.43	0.006
Anger	Limited access to effective emotion regulation strategies	0.41	0.009
ALS-SF Total	Impulse Control Difficulties	0.47	0.003
ALS-SF Total	Non-Acceptance of Emotional Responses	0.45	0.004
ALS-SF Total	Limited access to effective emotion regulation strategies	0.55	<0.001

Regarding the DERS, the domain of Limited access to effective emotion regulation strategies showed a positive correlation to the ASRS domains of Hyperactivity (ρ = 0.37, p = 0.018), Inattention (ρ = 0.41, p = 0.009) and Total score (ρ = 0.40, p = 0.10). The Total score of DERS was positively correlated to ASRS domains of Hyperactivity (ρ = 0.40, p = 0.010), Inattention (ρ = 0.46, p = 0.003) and Total score (ρ = 0.44, p = 0.004).

Furthermore, Impulse control difficulties of DERS exhibited a positive significant correlation with the ASRS domains of Hyperactivity (ρ = 0.40, p = 0.010), Inattention (ρ = 0.47, p = 0.002) and Total score (ρ = 0.44, p = 0.005).

A positive correlation was also noted between the Impulse control difficulties domain of the DERS and the Childhood trauma domain of CA-MI-R (ρ = 0.33, p = 0.038). The DERS Total score was significantly and positively related to the SRRS “UCL” score (ρ = 0.42, p = 0.007) (table 3).

Table 3.

Correlations between DERS Domains, BRIEF Domains, CA-MI-R and SRRS

DERS Domain	ASRS Domain	ρ	p-value
Limited access to effective emotion regulation strategies	Hyperactivity	0.37	0.018
Limited access to effective emotion regulation strategies	Inattention	0.41	0.009
Limited access to effective emotion regulation strategies	Total score	0.40	0.10
Impulse control difficulties	Hyperactivity	0.40	0.010
Impulse control difficulties	Inattention	0.47	0.002
Impulse control difficulties	Total score	0.44	0.005
Total score	Hyperactivity	0.40	0.010
Total score	Inattention	0.46	0.003
Total score	Total score	0.44	0.004
Impulse control difficulties	CA-MI-R Childhood trauma	0.33	0.038
Total score	SRRS “UCL” score	0.42	0.007

The domain of Limited access to effective emotion regulation strategies of DERS showed a positive correlation with the BRIEF-A domain of Inhibition (ρ = 0.40, p = 0.010), Emotional Control (ρ = 0.48, p = 0.002), Initiate (ρ = 0.39, p = 0.012) and Total score (ρ = 0.44, p = 0.004).

The domain of Impulsivity of DERS showed a positive correlation with the BRIEF-A domains of Inhibition (ρ = 0.46, p = 0.003), Emotional Control (ρ = 0.53, p < 0.001), Shift (ρ = 0.37, p = 0.018), Initiate (ρ = 0.42, p = 0.007) and Total score (ρ = 0.52, p = 0.001).

The Total score of DERS showed a positive correlation with the BRIEF-A domain of Inhibition (ρ = 0.49, p = 0.001), Emotional Control (ρ = 0.53, p < 0.001), Initiate (ρ = 0.50, p = 0.017) and Total score (ρ = 0.57, p < 0.001) (table 4).

Table 4.

Correlations between DERS Domains and BRIEF Domains

DERS Variable	BRIEF-A Domain	ρ	p-value
Limited access to effective emotion regulation strategies	Inhibition	0.40	0.010
Limited access to effective emotion regulation strategies	Emotional Control	0.48	0.002
Limited access to effective emotion regulation strategies	Initiate	0.39	0.012
Impulsivity	Inhibition	0.46	0.003
Impulsivity	Emotional Control	0.53	<0.001
Impulsivity	Shift	0.37	0.018
Impulsivity	Initiate	0.42	0.007
Impulsivity	Total score	0.52	0.001
Total score	Inhibition	0.49	0.001
Total score	Emotional Control	0.53	<0.001
Total score	Initiate	0.50	0.0017
Total score	Total score	0.57	<0.001

Regarding the BRIEF, significant positive correlations were observed between the Inhibition domain and the ASRS domains of Hyperactivity (ρ = 0.54, p < 0.001), Inattention (ρ = 0.38, p = 0.015), and Total score (ρ = 0.47, p = 0.002); the Emotional Control domain and the ASRS domains of Hyperactivity (ρ = 0.40, p = 0.010), Inattention (ρ = 0.38, p = 0.017), and ASRS Total score (ρ = 0.41, p = 0.009); the Initiate domain and the ASRS domains of Hyperactivity (ρ = 0.34, p = 0.030) and Total score (ρ = 0.33, p = 0.040); and the BRIEF Total score domain and the ASRS domains of Hyperactivity (ρ = 0.49, p = 0.001), Inattention (ρ = 0.45, p = 0.004), and Total score (ρ = 0.49, p = 0.001) (table 5).

Table 5.

Correlations between BRIEF-A Domains and ASRS Domains

BRIEF-A Domain	ASRS Domain	ρ	p-value
Inhibition	Hyperactivity	0.54	<0.001
Inhibition	Inattention	0.38	0.015
Inhibition	Total Score	0.47	0.002
Emotional Control	Hyperactivity	0.40	0.010
Emotional Control	Inattention	0.38	0.017
Emotional Control	Total score	0.41	0.009
Initiate	Hyperactivity	0.34	0.030
Initiate	Total Score	0.33	0.040
Total score	Hyperactivity	0.49	0.001
Total score	Inattention	0.45	0.004
Total score	Total score	0.49	0.001

Finally, the CA-MI-R Security domain was significantly and inversely correlated with the SRRS “UCL” score (ρ = -0.33, p = .040) and with the number of substances used (ρ = -.166, p = .306). The CA-MI-R Self-sufficiency and resentment against parents domain shows a statistically significant positive correlation with the number of substances used (ρ = .305, p = .055).

SRRS “UCL” score shows a statistically significant positive correlation with the number of substances used (ρ = .178, p = .271).

No other significant correlations were detected.

Group comparison analysis

Parental Permissiveness and Criminal Behavior

Individuals who had committed murder showed a statistically significantly higher score on the CA-MI-R Parental Permissiveness domain, as compared with those who committed other crimes (Z = 2.34, p = .019). No correlation with other types of crimes (robbery, drug trafficking, and domestic violence) was noted.

DERS and CA-MI-R Scores and family history of psychiatric disorders

Individuals with a family history of psychiatric disorders, compared to those without it, exhibited significantly higher scores in the DERS domains of Non-acceptance of emotional responses (Z = 2.13, p = 0.033), Limited access to effective emotion regulation strategies (Z = 2.10, p = 0.036), and DERS Total score (Z = 2.20, p = 0.028), and CA-MI-R Childhood trauma (Z = 2.45, p = 0.014).

Socio-economic status and childhood trauma

Subjects with a low socioeconomic status, compared to those with a middle socioeconomic status, presented higher values of CA-MI-R Childhood trauma (Z = 2.45, p = 0.014).

Stressful life events and evaluation scales

The comparison of the mean rank of evaluation scales based on the “Stressful Life Events” grouping was done on the sample divided into 3 groups based on the score of the SRRS: first group: score <150; second group: score 150-300; third group: score >300; third group.

Subjects belonging to the third group (SRRS score >300) exhibited a significantly higher value on the DERS Impulse control difficulties (H = 8.63, p = 0.010).

Familial history of mood disorders

Subjects with a familial history of mood disorders exhibited a statistically significant higher score on the DERS domain of Non-acceptance of emotional responses (H = 11.63, p = 0.006) and CA-MI-R domain Value of parental authority than those with a family history for psychotic spectrum disorder (H = 7.97, p = .048) or anxiety disorders (H = 13.33, p = .003).

Pattern of substance use

Subjects using five substances showed a significantly higher score on DERS domain of Non-acceptance of emotional responses (H = 11.43, p = .011) than those using four substances. Furthermore, subjects using five substances, compared to all others combined, presented a higher score on ALS Anxiety/Depression (Z = 2.02, p = 0.044).

Assessment scales scores based on BDZ, Alcohol or BDZ plus Alcohol use

The comparison of medians highlighted that individuals with BDZ use showed significantly higher scores than those without BDZ use in the following domains: CA-MI-R Self-sufficiency and resentment against parents (Z = 1.97, p = 0.049), CA-MI-R Family concerns (Z = 2.19, p = 0.029), DERS Impulse control difficulties (Z = 2.10, p = 0.036 and Total score (Z = 2.05, p = 0.040), and ALS Anger (Z = 2.16, p = 0.031).

Individuals with alcohol use exhibited significantly higher scores compared to those without in the CAMI-R Value of parental authority (Z = 2.19, p = 0.028) and CA-MI-R Self-sufficiency and resentment against parents (Z = 2.00, p = .045).

Those who used both alcohol and BDZ had significantly higher scores on the CA-MI-R Value of parental authority (Z = 2.27, p = 0.023), CA-MI-R Self-sufficiency and resentment against parents (Z = 2.47, p = 0.014), and CA-MI-R Childhood trauma (Z = 2.24, p = 0.025).

CA-MI-R scores and psychostimulant use

Individuals taking psychostimulants (tusi, crack, or cocaine) showed a lower score on the CA-MI-R Value of parental authority than those who did not (Z = 2.03, p = 0.043). Individuals using tusi had a lower score on the CA-MI-R Value of parental authority compared to those who did not (H = 2.15, p = 0.032).

The results listed above are grouped in table 6.

Table 6.

Group comparison analysis

Comparison	Details	Test Statistic	p-value	Findings
Parental Permissiveness & Criminal Behavior	Murder vs. other crimes (robbery, drug trafficking, domestic violence)	Z = 2.34	.019	Higher parental permissiveness in murderers
Family History of Psychiatric Disorders & Scores	With vs. without family psychiatric disorders	Z = 2.13	.033	Higher DERS Non-acceptance
		Z = 2.10	.036	Higher DERS Limited access to emotion regulation
		Z = 2.20	.028	Higher DERS Total score
		Z = 2.45	.014	Higher CA-MI-R Childhood trauma
Socioeconomic Status & Childhood Trauma	Low vs. middle SES	Z = 2.45	.014	Higher CA-MI-R Childhood trauma in low socio-economic status
Stressful Life Events & Evaluation Scales	SRRS score >300 vs. <150 and 150-300	H = 8.63	.010	Higher DERS Impulse control difficulties in SRRS >300 group
Family History of Mood Disorders	Mood disorder vs. psychotic spectrum or anxiety disorders	H = 11.63	.006	Higher DERS Non-acceptance in mood disorders
		H = 7.97	0.003	Higher CA-MI-R Value of parental authority in mood disorders
Substance Use Pattern	Using five substances vs. four substances	H = 11.43	.011	Higher DERS Non-acceptance in five substances group
		Z = 2.02	.044	Higher ALS Anxiety/Depression (Z = 2.02, p = .044) in five substances users
Assessment Scales & Substance Use	BDZ users vs. non-users	Z = 1.97	.049	Higher CA-MI-R Self-sufficiency and resentment against parents in BDZ users
		Z = 2.19	.029	Higher CA-MI-R Family concerns in BDZ users
		Z = 2.10	.036	Higher DERS Impulse control difficulties in BDZ users
		Z = 2.05	.040	Higher DERS Total score in BDZ users
		Z = 2.16	.031	Higher ALS Anger in BDZ users
	Alcohol users vs. non- users	Z = 2.19	.028	Higher CA-MI-R Value of parental authority and self-sufficiency in alcohol users
	Both alcohol & BDZ vs. others	Z = 2.27	.023	Higher CA-MI-R Value of parental authority
		Z = 2.47	.014	Higher CA-MI-R Self-sufficiency and resentment against parents
		Z = 2.24	.025	Higher CA-MI-R Childhood trauma
Psychostimulant Users & CA-MI-R Scores	Users vs. non-users	Z = 2.03	.043	Lower CA-MI-R Value of parental authority in psychostimulant users
	Tusi vs. non-users	H = 2.15	.032	Lower CA-MI-R Value of parental authority in tusi users

Legend. H = Significance index for the Kruskal-Wallis test; Z = Significance index for the Mann-Whitney U test.

Regression analysis

The residual analysis indicated a satisfactory fit for all models, thus validating the use of multiple linear regression analysis.

1. Prediction of CA-MI-R Childhood Trauma

The regression model was highly significant, F(22, 17) = 28.21, p < .001, and explained approximately 97.3% of the variance (R²= .973; adjusted R²= .939). Several predictors contributed significantly:

• - BRIEF-A Total Score: β = 0.536, p = .013

• - Socioeconomic Level: β = -0.119, p = .035

• - Number of Substances Used: β = -0.256, p = .006

• - Use of Benzodiazepines: β = -0.299, p = .014

• - BRIEF-A Emotional Control: β = -0.331, p = .016

These results suggest that higher executive functioning problems are associated with more severe childhood trauma perceived. Conversely, lower socioeconomic status, greater substance use, benzodiazepine consumption, and poorer emotional control are linked to higher trauma levels.

2. Prediction of Number of Substances Used

The model was statistically significant, F(22, 17) = 4.408, p = .001, explaining about 85.1% of the variance (R²= .851; adjusted R²= .596). Key predictors included:

• - BRIEF-A Emotional Control: β = -0.440, p = .007

• - BRIEF-A Total Score: β = 0.060, p = .015

• - CA-MI-R Childhood Trauma: β = -0.360, p = .006

• - CA-MI-R Total Score: β = 2.316, p = .017

Lower perceived quality of parental attachment, executive dysfunction, impulsivity, and emotional dysregulation may increase the number of substances used. A negative association with childhood violence suggests a complex trauma-substance link.

3. Prediction of Familial Psychopathology and Substance Use

For familial psychological issues, the model explained about 88.4% of the variance (R²= .884), but no predictors were significant. Trends suggested that greater co-use of alcohol and BDZ (β = 3.508, p = .160) and a higher number of substance use (β = –0.964, p = .063) could be relevant, but these did not hold statistical significance.

The regression model evaluating predictors of familial history of substance use was not statistically significant (F(33, 6) = 1.671, p = 0.131). The model demonstrated a high R²of 0.931, indicating that approximately 93.1% of the variance in familial substance history was explained by the included predictors. However, the adjusted R²was quite low (0.551), which may reflect overfitting given the large number of predictors relative to the sample size.

None of the individual predictors reached significance; however, the co-use of alcohol and BDZ showed a trend towards significance with a positive coefficient (β=3.508, t=1.571, p=0.160).

4. Prediction of ASRS Total score

This model was non-significant: F(33, 6) = 2.730, p = .085, despite explaining a very high proportion of variance (R²= .962) and an adjusted R²of .587, which suggests overfitting due to the small sample size relative to the number of predictors. No individual predictor reached significance at the 0.05 level; however, the co-use of alcohol and BDZ showed a trend toward significance (β = 73.224, p = .090).

5. Prediction of the perceived life stressors

The regression model was not statistically significant, F(33, 6) = 0.458, p = .930, but explained a considerable proportion of variance with R²= .716. None of the predictors reached significance (all p > .05). There was a trend with the co-use of alcohol and BDZ (β = 73.224, p = .090), indicating a possible association where more frequent co-use of these substances could relate to the degree of perceived life stressors.

The main results are summarized in table 8.

Table 8.

Overview of Significant Predictors

Outcome	Key Predictors	Notes
Number of Substances Used	BRIEF-A Emotional Control BRIEF-A Total score CA-MI-R Childhood trauma CA-MI-R Total Score	Lower perceived quality of parental attachment, executive dysfunction, impulsivity, and emotional dysregulation may increase the number of substances used. A negative association with childhood violence suggests a complex trauma-substance link.
Familial Psychopathology	Number of Substances Trends for alcohol and BDZ co-use	A positive family history of psychiatric disorders may be associated with an elevated risk of both polysubstance use and alcohol-benzodiazepine co-use.
Familial Substance Use	Trend for alcohol and BDZ co-use	A positive family history of substance use may be associated with an elevated risk of alcohol-benzodiazepine co-use.
ASRS Total Score	Trend for alcohol and BDZ co-use	Potential association between alcohol/BDZ co-use and ADHD symptoms severity.
Life Stressors	Trend for alcohol and BDZ co-use	More frequent use of these substances for calming purposes, emotional relief, or as a form of avoidance coping, might correlate with higher perceived stress degree.
CA-MI-R Childhood Trauma	Socioeconomic Level Number of Substances Benzodiazepine Use CA-MI-R Total Score BRIEF-A Emotional Control BRIEF-A Total Score	Strong links: higher executive functioning problems are associated with more severe childhood trauma perceived. Conversely, lower socioeconomic status, greater substance use, benzodiazepine consumption, and poorer emotional control are linked to higher trauma levels.

Table 7.

Associations Between Emotional Dysregulation, Executive Dysfunction, Substance Use and Psychosocial Factors: A Summary of Key Findings

Theme	Key Findings	Implications
Interconnection of Emotional Regulation & Executive Function	ALS, DERS, BRIEF scores are positively correlated.	Difficulties in emotional regulation are tightly linked to executive dysfunction and ADHD symptom severity.
ADHD & Emotional Dysregulation	DERS domains strongly associated with hyperactivity, inattention.	Emotional dysregulation may be a core feature of ADHD, not just a comorbidity.
Psychosocial Factors & Emotional Regulation	Family psychiatric history, trauma, socio- economic status, stress levels perceived influence regulation difficulties.	Environmental and familial factors significantly shape emotional and behavioral patterns.
Substance Use & Behavioral Profiles	Use of multiple substances, BDZ, alcohol, and stimulants linked to higher emotional dysregulation, trauma, and ADHD symptoms.	Substance use exacerbates emotional, psychopathological and behavioral problems.
Severe Behavior & Family Dynamics	Murder correlates with higher parental permissiveness.	Family factors may contribute to extreme behavioral outcomes, emphasizing family-based interventions.

Discussion

The study aimed to investigate attachment dimensions, with a focus on relational dynamics involving key figures in an individual's life. It sought to shed light on the associations between attachment patterns and behavioral outcomes, highlighting the most influential relational dimensions. Additionally, we examined clinical aspects related to neurocognitive functioning and emotional regulation, and their roles in substance use and maladaptive or deviant behaviors. The subjects were carefully assessed using a battery of questionnaires exploring a series of psychopathological features, including affective lability, emotional dysregulation, executive functions, ADHD symptoms, perceived childhood attachment styles, and stressful life events.

This sample was drawn from a high-risk population in Medellín, a city recognized as a “hot zone” due to a confluence of social and economic challenges (Velez-Gomez et al., 2013). The data reflect the difficult social and familial context, characterized by disrupted family organization and economic hardship, with many participants coming from impoverished backgrounds. These challenging environmental and cultural conditions contribute to easy access to different psychoactive substances, as demonstrated by the high rates of polysubstance abuse among the patients. Early exposure to substances increases the risk of committing crimes to finance substance use or cope with extreme economic difficulties. This cycle is further reinforced by a significant family history of psychiatric disorders and SUD, which can create a transgenerational cycle of vulnerability (Jawaid et al., 2018; Yehuda & Lehrner, 2018). This familial history can also suggest a role of genetics in predisposing individuals to substance use patterns, increasing the risk of developing a SUD, experiencing psychopathological symptoms, and exhibiting deviant behaviors (Isaza et al., 2013; Martínez-Magaña et al., 2021). Consequently, these young individuals face an elevated risk of engaging in criminal activities, sometimes including extreme acts like homicide. Furthermore, these conditions increase the individuals' susceptibility to stressful life events and negatively impact their capacity for resilience (Hiyoshi et al., 2015; Chakraborti et al., 2016; Kennedy et al., 2019). Given these challenges, understanding the potential impact of substance use on cognitive functions, psychopathological symptoms, and behaviors is crucial.

The relationship between substance use and executive dysfunction is a complex, bidirectional interaction (Kim-Spoon et al., 2017; Brockett et al., 2018; Inozemtseva & Mejía Núñez, 2019; Kräplin et al., 2022; Lunga et al., 2025). Substances can directly impair prefrontal cortex function, disrupt reward circuitry, and create neurotransmitter imbalances, all of which compromise executive functions like planning, decision-making, and impulse control (Kaag et al., 2018; Jakubiec et al., 2022; Chirokoff et al., 2023; Morawetz et al., 2023; Chirokoff, Berthoz, et al., 2024; Chirokoff, Pohl, et al., 2024). This creates a self-reinforcing cycle: substance use worsens executive function, which in turn leads to further substance use (Hardin & Ernst, 2009; Heitzeg et al., 2015; Wilcox et al., 2016; Watters et al., 2018; Hamidullah et al., 2020; Thorpe et al., 2020).

At the same time, affective lability, reflecting emotional reactivity and a possible diathesis for bipolar spectrum disorder, is associated with increased executive dysfunctions and difficulties in inhibiting impulsive behaviors (Mitchell et al., 2012; Schreiber et al., 2012; Jiang et al., 2016; Davis et al., 2019; Moreno-Manso et al., 2021; Groves et al., 2022; Parr et al., 2022; Fernandes et al., 2023; Koay & Van Meter, 2023; Friedman & Mezulis, 2025; Kenézlői et al., 2025). Concurrently, executive dysfunction, encompassing various domains such as planning, working memory, and decision-making, is linked to difficulties in emotion regulation and impaired inhibitory control (Green et al., 2007; Peters et al., 2014; Mohammed et al., 2022; Hui et al., 2023; Rodas et al., 2024; Carballo-Marquez et al., 2025). This involves dysfunction in the inhibitory circuits of the cortex over subcortical areas involved in emotional reactivity (amygdala, hippocampus) and, on the other hand, potentially implicated in reward processing (involved in substance seeking) and compulsive substance use behaviors typical of addiction (Goldstein & Volkow, 2011; Volkow et al., 2011; Shaw et al., 2014; Richard-Lepouriel et al., 2016; Renard et al., 2017; Luciana et al., 2018; Volkow et al., 2019). This circuit – substance use, worsening of executive functions, emotional dysregulation, reduced inhibitory capabilities – becomes self-reinforcing.

At the same time, the risk of substance use can be amplified by pre-existing vulnerabilities, including neurodevelopmental disorders such as ADHD, which presents with executive dysfunction and emotional and stress response dysregulation, reinforcing the aforementioned cycle (Regalla et al., 2015; Brancati et al., 2021; Masi et al., 2021; Saccaro et al., 2021; Charabin et al., 2023; Townes et al., 2023). Consequently, these individuals may be more sensitive and vulnerable to potentially stressful life events, negatively affected by high-risk social and environmental conditions, and experience dysfunctional family dynamics that strongly impact attachment styles with parental figures (Cavallina et al., 2015; Kim et al., 2020; Konowałek & Wolańczyk, 2020; Cavicchioli et al., 2023; Elbagir et al., 2023; Hussein et al., 2025).

Our study revealed significant predictive relationships between different factors and both substance use and perceived childhood trauma. Specifically, executive dysfunction, impulsivity, emotional dysregulation, and a lower perceived quality of parental attachment were strong predictors of an increased number of substances used. Simultaneously, lower socio-economic status, poorer emotional control, and greater executive functioning problems were strong predictors of more severe perceived childhood trauma. These findings underscore the intricate connections between cognitive and emotional functioning, socio-economic factors, and early life experiences in shaping individual vulnerabilities.

Furthermore, our study provides compelling evidence for a multifaceted relationship between substance use patterns and perceived attachment styles. The absence of a single explanatory model emphasizes the diversity within substance-using populations. While higher scores on self-sufficiency, resentment, and security scales correlated with a greater number of substances used, potentially indicating detachment from parental figures or conflicted feelings toward them, specific substances appeared linked to distinct attachment profiles. Indeed, individuals who used psychostimulants exhibited a lower perceived value of parental authority, whereas those using alcohol, or alcohol in combination with BDZs, paradoxically showed a higher regard for parental authority alongside feelings of self-sufficiency and resentment. This highlights how substance choice might be related to different relational schemas. Building on this, the co-use of alcohol and BDZs emerges as a specific behavioral pattern that may reflect a broader tendency to use substances as a coping mechanism for managing perceived life stressors, particularly in individuals with a history of childhood trauma. This interpretation is strengthened by our finding that a higher number of substances used was positively correlated with a greater degree of reported stressful life events, indicating a possible pattern of escalating substance use in response to increasing stress. Further adding to this complexity, our data revealed a trend suggesting that greater co-use of alcohol and BDZs, along with a higher number of substances used overall, may be predictive of a positive family history for psychiatric disorders. This points to a potential interplay between self-medication, a genetic or familial vulnerability to mental health issues, and the specific types and quantities of substances used. This is especially relevant when we consider that this same group also reports higher levels of childhood trauma, reinforcing the notion that these individuals may be self-medicating to alleviate the emotional pain and distress stemming from early adverse experiences. Furthermore, the observation that individuals with BDZ use exhibited significantly higher scores than those without BDZ use in domains such as CA-MI-R Self-sufficiency and resentment against parents and CA-MI-R Family concerns adds another layer to this picture, suggesting potential difficulties in attachment relationships and family dynamics that may contribute to the reliance on substances as a coping mechanism. The inverse relationships between the number of substances used, BDZ use, and perceived childhood trauma further highlight the intricate interplay at hand, potentially reflecting different pathways to substance use and coping strategies, all influenced by environmental stressors, the ready availability of diverse substances, and familial predispositions to psychiatric disorders.

Figure 2.

Risk Factors: A Pathway to Psychiatric and Behavioral Outcomes

Moreover, our findings suggest a plausible link between patterns of substance use, executive function, and emotional dysregulation. Notably, individuals who reported using five substances exhibited significantly higher scores on the DERS Non-acceptance of emotional responses compared to those using four substances. This suggests that polysubstance use may be associated with a greater difficulty in accepting and managing one's own emotional experiences, potentially leading to further reliance on substances as a maladaptive coping mechanism. Furthermore, when compared to all other participants, individuals using five substances also presented with a significantly higher score on the ALS Anxiety/Depression subscale, indicating a potential association between increased substance use and elevated levels of anxiety and depressive symptoms, which could further complicate treatment efforts. The use of specific substances also had a distinct impact: individuals who used BDZs showed significantly higher scores than non-BDZ users in DERS Impulse control difficulties and Total score, reflecting a greater struggle with impulsivity and overall emotional regulation. This group also showed higher levels of ALS Anger, suggesting a potential connection between BDZ use and increased irritability or difficulty managing anger, which may contribute to behavioral problems and interpersonal conflicts. Adding to this complexity, we observed a trend toward significance in the prediction of ASRS Total score with the co-use of alcohol and BDZs, suggesting a possible relationship between this particular substance use pattern and ADHD-like symptoms. Taken together, these findings converge to highlight the complex and nuanced relationship between substance use patterns, emotional regulation, and executive function. The type and quantity of substances used may have distinct and measurable impacts on these critical domains, particularly as BDZ use may be implicated in a reduction of inhibitory control from cortical functions, potentially leading to an accentuated emotional reactivity, thereby exacerbating existing dysregulation and possibly also eliciting or mimicking symptoms of ADHD.

Crucially, the relationships we've observed are further nuanced by a confluence of interconnected contextual factors. A family history of psychiatric disorders, and more specifically, a familial narrative steeped in mood disorders, resonated with significantly greater challenges in emotion regulation, as evidenced by elevated scores in DERS Non-acceptance of emotional responses, Limited access to effective emotion regulation strategies, and Total score. These individuals also recounted more profound experiences of childhood trauma, reflected in higher CA-MI-R Childhood trauma scores, and displayed divergent perceptions of parental authority when contrasted with individuals from families marked by psychotic or anxiety disorders. This confluence suggests that familial predispositions may sow the seeds of both emotional dysregulation and heightened susceptibility to trauma, thereby setting a course toward substance use. Likewise, subjects from lower socio-economic classes, when compared to their counterparts in the middle range, reported more acute experiences of childhood trauma, underscoring how socio-conomic disadvantage can cast a long shadow on early life, fostering the emergence of maladaptive coping mechanisms, including substance use. The experience of significant stressful life events was also intertwined with a pronounced struggle for impulse control, implying that such adversities may erode the very executive functions essential for self-regulation. These factors, acting in concert, exert influence upon executive functions, emotional dysregulation, perceived attachment security, and overarching levels of perceived stress, weaving a complex network of interacting vulnerabilities that significantly informs the patterns of substance use observed within our study population.

Our data provides compelling evidence for the intricate relationship between executive dysfunction, emotional dysregulation, and the phenotypic expression of ADHD, particularly within a population characterized by substance use. The significant positive correlations between the ALS-SF (a measure of mood fluctuations) and both the BRIEF-A (measuring executive functions) and DERS (measuring emotion regulation difficulties) domains clearly demonstrate that heightened affective lability is strongly associated with impairments in both executive functions (inhibitory control and emotional regulation) and pervasive difficulties in managing emotions. This suggests a shared vulnerability, possibly rooted in interconnected neural pathways, wherein deficits in one area can exacerbate challenges in others, creating a self-perpetuating cycle of impaired self-regulation. The strong correlations between DERS domains (Limited access to effective emotion regulation strategies and Impulse control difficulties) and ASRS Hyperactivity and Inattention scores further support this concept, underscoring that difficulties in emotion regulation and impulse control are not merely comorbid conditions in ADHD but rather core components of its presentation. Similarly, the positive correlations between BRIEF-A domains (Inhibition and Emotional Control) and ASRS scores reinforce this view, showing that impairments in specific executive functions are closely linked to hallmark ADHD symptoms.

These findings suggest the possibility of identifying ADHD phenotypic subtypes characterized by distinct cognitive and emotional profiles. Individuals with elevated scores on the ALS-SF's Anger subscale, coupled with impairments across BRIEF-A and DERS domains, may represent a subtype driven by heightened irritability and emotional reactivity that fuels impulsivity and hinders cognitive flexibility. These individuals, characterized by a diminished ability to modulate emotions in the moment and to adapt their thinking, may benefit from targeted interventions that focus on anger management and impulse control, potentially incorporating mood stabilizers that address these specific domains. Similarly, individuals with elevated scores on the ALS-SF's Anxiety/Depression subscale, alongside deficits in BRIEF-A and DERS domains, may represent a subtype in which ADHD is compounded by significant mood symptoms and emotional dysregulation. These individuals might respond more favorably to strategies that directly address emotional processing and promote mood stabilization, potentially through medications that specifically target these domains. Therefore, accurate ADHD diagnosis and treatment in this population characterized by substance use would benefit from comprehensive assessments that consider not only core ADHD symptoms but also patterns of affective lability, the impact of anger and irritability, and the presence or absence of comorbid mood symptoms in order to identify tailored treatment strategies to maximize effectiveness.

Ultimately, individuals burdened by these neurodevelopmental and psychopathological vulnerabilities, characterized by impaired risk assessment, compromised impulse control, executive dysfunction manifesting as difficulties in short- and long-term planning, and further compounded by the psychoactive effects of substances, demonstrate a pronounced susceptibility to deviant and maladaptive behaviors, particularly in the absence of robust familial or social support. This vulnerability aligns with the established understanding that such individuals possess a diminished capacity for resilience when confronted with the inevitable stressors of life. Moreover, our observation that those who committed murder exhibited significantly elevated scores on the CA-MI-R Parental Permissiveness domain, relative to those who committed other offenses, underscores the salient role of early environmental influences in sculpting behavioral trajectories. Indeed, permissive parenting styles may, however, unintentionally, contribute to more extreme manifestations of deviancy in already vulnerable individuals. The synergistic interplay of these factors compels the need for comprehensive and integrated interventions. These interventions should not only target directly substance use and mental health, but also address the underlying cognitive, emotional, and social deficits that conspire to generate maladaptive behaviors within this high-risk population.

Limitations

Several limitations should be considered when interpreting the findings of this study. First, the relatively small sample size (n = 40) may limit the generalizability of our results to broader populations of incarcerated young adults with SUD. While the homogeneity of the sample (all male, similar age range) reduces variability, it also restricts the applicability of the findings to female populations and other age groups. Second, the cross-sectional design of this study precludes the establishment of causal relationships. We were able to identify significant correlations and predictive relationships between key variables, but we cannot determine the directionality or temporal order of these associations. Furthermore, because the assessments were administered during the participants' involvement in the “Coexistence” resocialization program, we cannot fully disentangle the impact of the treatment itself on the psychopathological and neurocognitive dimensions analyzed. It is possible that participation in the program had already begun to influence these factors at the time of assessment. A longitudinal study following individuals from treatment entry would be necessary to fully evaluate the effects of the rehabilitation process on these individuals' wellbeing and recidivism rates. Moreover, participation in the “Coexistence” program is voluntary, potentially introducing selection bias. Individuals who choose to participate in the program may differ systematically from those who do not, which could further limit the generalizability of the findings. Third, the reliance on self-report instruments to collect data on psychopathology, stress sensitivity, attachment styles, and childhood environmental characteristics may introduce biases related to recall, social desirability, and subjective interpretation. Objective measures or collateral reports from family members or other informants could provide a more comprehensive and reliable assessment of these constructs. Fourth, it is important to acknowledge potential limitations associated with the use of multiple linear regression analysis, given that some of the variables may not strictly adhere to the assumptions of parametric tests. While we conducted residual analysis to validate the use of this method, the non-parametric distribution of some variables should be considered when interpreting the regression results. Finally, future research should aim to explore the underlying mechanisms that mediate the relationships observed in this study by examining potential neurobiological or psychosocial pathways that link disorganized attachment, executive dysfunction, emotion dysregulation, and substance use in this vulnerable population.

Conclusion

In conclusion, our findings offer persuasive support for the presence of a critical, self-sustaining vicious cycle that intricately links substance use/addiction, executive dysfunction, and emotional dysregulation. These elements are not isolated entities but rather mutually reinforcing forces, with substance use exacerbating executive deficits and emotional instability, while impaired executive function and unregulated emotions, in turn, increase the likelihood of further substance use as a maladaptive coping mechanism. However, this cycle exists within a dynamic and multi-layered context, its intensity and trajectory profoundly modulated by a constellation of interacting factors. The social and familial environments play a pivotal role, with disrupted family dynamics, economic hardship, and lack of social support serving as potent catalysts for substance use and maladaptive behaviors. A family history of psychiatric disorders, along with predisposing genetic factors, introduces an inherited vulnerability that may lower the threshold for both substance use and mental health challenges. Co-occurring neurodevelopmental and psychiatric conditions, such as ADHD, further complicate the picture, adding layers of cognitive and emotional dysregulation that intensify the cycle's destructive power. Moreover, exposure to potentially stressful life events, coupled with an individual's unique sensitivity to those events, can trigger or exacerbate both substance use and emotional dysregulation, while simultaneously hindering executive functions. Critically, maladaptive or deviant behaviors are not merely downstream consequences of this cycle but act as active contributors, generating further social and psychological stressors that, in turn, fuel the addiction, worsen executive function, and amplify emotional instability. Disrupting this self-perpetuating cycle, therefore, demands a holistic approach that integrates targeted interventions for substance use, executive function enhancement, and emotional regulation with broader strategies to address social and environmental determinants, mitigate familial risk factors, and foster resilience. While these findings offer valuable insights into this complex population, they should be interpreted with caution given the study's limitations, particularly regarding sample size, cross-sectional design, and potential selection biases. Further research is therefore warranted to confirm and extend these observations, and to delineate the intricate mechanisms underlying substance use and related problems in this vulnerable population, with the ultimate goal of informing more effective and sustainable interventions.