Early Childhood Behavioral and Academic Antecedents of Lifetime Opioid Misuse among Urban Youth

Abstract

Objective:

Opioid misuse has become an epidemic in the United States. In the present study, we examine potential malleable early childhood predictors of opioid misuse including whether childhood achievement, aggressive behavior, attention problems, and peer social preference/likeability in first grade predicted opioid misuse and whether these relationships differed depending on participant sex.

Method:

Data are drawn from three cohorts of participants (N = 1,585; 46.7% male) recruited in first grade as part of a series of elementary school-based, universal preventive interventions conducted in a Mid-Atlantic region of the US. In first grade, participants completed standardized achievement tests, teachers reported on attention problems, and peers nominated their classmates with respect to their aggressive behavior and social preference/likeability. At approximately age 20, participants reported on their misuse of opioids defined as lifetime use of heroin or misuse of prescription opioids.

Results:

Higher levels of peer nominations for aggressive behavior in first grade predicted a greater likelihood of opioid misuse. An interaction between participant sex and attention problems was observed such that females higher in attention problems were more likely to misuse opioids, particularly prescription opioids, than females lower in attention problems. An interaction was also found between participant sex and peer likeability such that males lower in peer-nominated likeability were more likely to misuse opioids relative to males higher in likeability.

Conclusion:

Given the malleable nature of attention problems, aggression, and social skills in early childhood, prevention programs that target these behaviors during this developmental period may attenuate risk for opioid misuse.

Misuse of opioids has become a tremendous public health problem and has been associated with unemployment (Perlmutter et al., 2017), psychiatric comorbidities (Wilsey et al., 2008), and a significant loss of life (Spencer et al., 2019). While the current surge in opioid overdose rates is mainly driven by synthetic opioids, including illicit fentanyl, the use of prescription opioids remains a major risk factor for later heroin use (Jones, 2013) and other illicit drugs (Olfson, Wall, Liu, & Blanco, 2018). In addition, although many opioid-related deaths have occurred among European Americans residing in suburban and rural areas, the opioid epidemic has significantly impacted African Americans in urban neighborhoods (Katz & Goodnough, 2017). Indeed, the highest increases in opioid overdoses have occurred among urban, African Americans (Katz & Goodnough, 2017; Spencer et al., 2019), rivaling increases in the number of opioid overdoses among European Americans since 2010 (Childress, 2016). Given the increasing prevalence of opioid misuse among urban, African Americans and the devastating toll on individuals and communities, an examination of factors that predict opioid misuse is warranted. The identification of modifiable risk factors for opioid misuse such as early childhood behaviors, including aggressive behavior, attention problems, peer social preference/likeability, and achievement, may serve to inform the development of preventive interventions to reduce opioid misuse and health disparities (Compton et al., 2019).

Aggressive–disruptive behavior and attention problems in the elementary school years are well-established predictors of a wide range of untoward outcomes in adolescence and young adulthood (Kellam et al., 2008; Petras et al., 2008; Schaeffer, Petras, Ialongo, Poduska, & Kellam, 2003), including the early onset and transition to heavy use of substances (Reboussin, Hubbard, & Ialongo, 2007; Reboussin & Ialongo, 2010); however, there is a dearth of research that has examined whether these early childhood behaviors are predictive of opioid misuse. Patterson and colleagues (Granic & Patterson, 2006; Patterson, Reid, & Dishion, 1992) offer a theoretical framework whereby aggressive-disruptive behaviors, attention problems, and subsequent peer rejection in the early elementary school years may predict later illicit substance use in young adulthood.

According to Patterson and colleagues (1992), a major pathway to illicit substance use in adolescence and young adulthood begins in the toddler years, when parent-child interactions often involve efforts at eliciting child compliance and developing appropriate social skills (Granic & Patterson, 2006; Patterson et al., 1992). Given reciprocal and transactional processes in the parent-child relationship, parental challenges with managing children’s behavior during these formative years may partially contribute to the continuation and exacerbation of children’s oppositional and disruptive behaviors. In the classroom setting, children who exhibit behavior problems may elicit negative responses from teachers or peers and demonstrate less responsiveness to classroom norms and expectations. The attention problems often associated with aggressive-disruptive behavior (e.g., Elkins, McGue, & Iacono, 2007; Rebok et al., 1994) may further interfere with the child’s utilization of corrective feedback from parents, teachers, and peers by disrupting the process of encoding social cues essential to social problem-solving and conflict resolution (Elkins et al., 2007); as a result, such children may experience challenges forming relationships with typically developing or prosocial peers and may evidence decreased achievement in the classroom.

Consistent with developmental psychopathology theoretical models (Drabick & Steinberg, 2011), children’s oppositional behaviors and attention problems are not fixed, but rather a byproduct of transactional, bidirectional exchanges among children with adults and peers alike. For example, children’s oppositional behaviors may be reinforced and shaped by inconsistent and coercive teacher disciplinary practices. Ultimately, children that display oppositional behaviors are often at increased risk to be rejected by parents and teachers, as well as normative or prosocial peers (Spooner, 1999), and subsequently to select and experience socialization by antisocial or deviant peers who are similarly rejected. In such peer groups, problem behaviors, including drug use, may be introduced and/or reinforced (Brook, Brook, Zhang, & Cohen, 2009; Chen, Drabick, & Burgers, 2015; Doherty, Green, Reisinger, & Ensminger, 2008). Indeed, more aggressive children may proactively select into deviant peer groups given shared attitudes, values, or behaviors and these contexts may provide an environment where aggressive behaviors are modeled (Chen, Drabick, & Burgers, 2015). Youth who engage in coercive interchanges and exhibit behavior problems are hypothesized by Patterson and colleagues (1992) to be more likely to use substances more frequently and to excess as a means of mitigating the reductions in positive reinforcement dispensed by parents, teachers, and typically developing peers. In addition, the lack of positive reinforcement received may lead to decrements in psychological well-being (Kim, Capaldi, Pears, Kerr, & Owen, 2009; La Greca & Moore Harrison, 2007), which youth seek to alleviate through substance use (Chen, Anthony, & Crum, 1999; Shivola et al., 2008).

There is a paucity of work that has considered early childhood factors (e.g., aggressive behavior, attention problems, peer rejection) that predict opioid misuse specifically, particularly among urban, economically-disadvantaged African American youth. There is, however, a wealth of research that has examined whether adolescent behaviors predict opioid misuse in young adulthood. For example, in a large nationally representative sample, greater substance use engagement (e.g., marijuana, alcohol, or tobacco use) and reduced academic achievement predicted non-medical use of prescription opioids in young adulthood (Arterberry et al., 2016; McCabe et al., 2014; Osborne et al., 2017). Other work also conducted in a nationally representative sample found that adolescent delinquency and correlates (i.e., risk taking, impulsivity) positively predicted prescription opioid use in adulthood (Quinn et al., 2019). To our knowledge, only one study has considered whether early childhood behavior problems predict opioid misuse in adulthood. In an almost exclusively European American, middle- to low-income sample, early childhood hyperactivity, concentration difficulties, and aggression predicted any drug use disorder diagnosis, including heroin, at age 21 (Reinherz, Giaconia, Carmola Hauf, Wasserman, & Paradis, 2000). Thus, an examination of whether early childhood externalizing behaviors and peer processes predict opioid misuse among more diverse samples, such as urban African American youth, across developmental periods is crucial.

Childhood academic achievement may also be an important precursor to opioid misuse in young adulthood. Paralleling research that has investigated the relationship between behavior problems and opioid misuse, the majority of work examining academic achievement and opioid misuse has been limited to adolescence and young adulthood (e.g., Wood, King, Vidourek, & Merianos, 2019). In line with Patterson’s coercion theory (1992), academic challenges in early childhood may persist into adolescence, which may set youth on a trajectory towards reduced school engagement, increased affiliation with deviant peers, decreased attachment to parents and teachers, and subsequent drug use (Trenz, Harrell, Scherer, Mancha, & Latimer, 2012). This possibility is consistent with work indicating that academic difficulties during adolescence were associated with more frequent heroin use among adults (Trenz et al., 2012) and evidence that reduced achievement in early childhood is predictive of adult illicit drug use (Fothergill et al., 2008). Using data drawn from the National Study of Drug Use and Health (NSDUH), Wood et al. (2019) found that lower levels of adolescent academic achievement and school engagement were associated with an increased likelihood of misusing pain relievers. In the only study to our knowledge that has examined the relationship between early childhood academic readiness and substance use in adolescence, higher levels of academic readiness were associated with earlier initiation of alcohol, tobacco, and marijuana use in adolescence (Fleming, Kellam, & Brown, 1982). Thus, although some associations between early childhood achievement and substance use have been reported, research examining these relations in terms of adult opioid misuse is lacking.

The early childhood antecedents of opioid misuse may also vary by sex. For example, early childhood maltreatment is predictive of greater risk for using heroin among women compared to men and there is some evidence that antisocial behavior predicts heroin use among men, but not women (Shand et al., 2011). There also appears to be sex differences in opioid misuse base rates. More specifically, whereas recent work indicates that women are more likely to use prescription opioids compared to men (Serdaveric, Striley, & Cottler, 2017), men may actually be more likely to misuse prescription opioids (Saha et al., 2017). Given sex differences in risk behaviors and base rates for opioid misuse, an investigation into whether sex moderates the relationship between early childhood behavioral, cognitive, and social processes and subsequent opioid misuse is warranted.

Guided by life course theoretical frameworks and conceptual models, the present study sought to uncover early childhood origins of opioid misuse in an urban, predominantly economically-disadvantaged, African American sample—a population at clear risk for opioid misuse, but one that has been understudied. As noted above, although early childhood aggression, attention problems, peer rejection, and academic achievement have been predictive of illicit drug use (Reboussin & Ialongo, 2010; Trenz et al., 2012), it is unclear whether these behaviors also predict opioid misuse and whether these relations differ by sex. Abuse of opioids is a complex phenomenon that has, to date, been relatively difficult to predict. As such, the present study investigated whether early childhood aggression, attention problems, peer social preference/likeability (a proxy for peer rejection), and scholastic achievement measured in first grade predicted opioid misuse in young adulthood among an urban, largely African American sample. Such work has the potential to elucidate upstream risk behaviors that contribute to opioid misuse and may guide early preventions aimed at combating the opioid crisis.

Method

Participants

The study’s analytic sample was drawn from three cohorts of participants in a series of randomized controlled trials of elementary school-based universal preventive interventions targeting early aggression and academic achievement. The trials occurred within a single urban school district in Baltimore, Maryland, USA when children were in first grade. In terms of inclusion criteria, children had to attend one of the participating schools, be in first grade, and be in a mainstream as opposed to a self-contained special education classroom. The initial trial featured 2 consecutive cohorts, which were recruited in the fall of 1985 and 1986, respectively (see Dolan et al., 1993). The second trial consisted of one cohort, which was recruited in the fall of 1993 (see Ialongo et al., 1999). Although the goals of the interventions were the same in the two trials, the nature of the interventions differed. Nonetheless, across all three cohorts, the interventions were administered universally, or classroom-wide, in first grade and participants were followed from first grade to young adulthood. The trials and follow-up studies were approved by a University Institutional Review Board and participants provided informed consent as adults and assent prior to the age of 18.

Three-thousand and one hundred and ten participants were available for recruitment in first grade across the three cohorts, of which 1,585 participants reported on their opioid misuse in young adulthood and had standardized achievement scores and teacher and peer nominations of the putative risk behaviors in early childhood. Demographic information for the sample is outlined in Table 1.

Table 1.

Sample Characteristics (N=1,585)

Characteristic	n (%)
Sex
Male	740 (46.7%)
Female	845 (53.3%)
Race
Black	1282 (80.9%)
White	303 (19.1%)
Free/Reduced-Price Meals
Yes	1157 (73.0%)
No	428 (27.0%)
Intervention
Yes	815 (51.4%)
No	770 (48.6%)
Cohort Identification
Cohort 1 (1985)a	630 (39.7%)
Cohort 2 (1986)a	500 (31.5%)
Cohort 3 (1993)a	455 (28.7%)
Opioid Misuse
Ever Heroin Use b
Yes	42 (2.6%)
No	1543 (97.4%)
Ever Misuse of Prescription Opioids b
Yes	62 (3.9%)
No	1520 (96.1%)
Ever Use of Heroin or Misuse of Prescription Opioids
Yes	81 (5.4%)
No	1501 (94.6%)

^aYear participants were in first grade in each cohort.

^bThe numbers noted do not reflect unique use of heroin and misuse of prescription opioids.

With respect to differences in first grade demographic characteristics between the analytic sample (i.e., 1,585 participants) and the sample missing either baseline and/or young adult reports of opioid misuse, the analytic sample featured a significantly greater proportion of African Americans, females, participants who received free or reduced lunch (a proxy for family income) in first grade, and who were assigned to an intervention condition. No differences were found in terms of the distribution of participants across cohorts or age at the young adult interview. Baseline demographics and opioid misuse frequency by cohort can be found in Table 2.

Table 2.

Cohort Differences in Baseline Variables and Opioid Misuse (N = 1,585)

	Cohort 1 (N=630)	Cohort 2 (N=500)	Cohort 3 (N=455)
Sex
Males	281 (44.6%)	239 (47.8%)	220 (48.4%)
Females	349 (55.4%)	261 (52.2%)	235 (51.6%)
Race *
Blacks	465 (73.8%)	420 (84.0%)	397 (87.3%)
Whites	165 (26.2%)	80 (16.0%)	58 (12.7%)
Free/Reduced Priced Meals *
Yes	456 (72.4%)	389 (77.8%)	312 (68.6%)
No	174 (27.6%)	111 (22.2%)	143 (31.4%)
Intervention *
Yes	278 (44.1%)	227 (45.4%)	310 (68.1%)
No	352 (55.9%)	273 (54.6%)	145 (31.9%)
Opioid misuse
Ever Heroin Use a *
Yes	30 (4.8%)	5 (1.0%)	7 (1.5%)
No	600 (95.2%)	495 (99.0%)	448 (98.5%)
Ever Misuse of Prescription Opioids a
Yes	16 (3.3%)	14 (3.2%)	32 (5.4%)
No	483 (96.7%)	441 (96.8%)	596 (94.6%)
Ever Use of Heroin or Misuse of Prescription Opioids *
Yes	18 (3.7%)	20 (4.6%)	43 (7.4%)
No	481 (96.3%)	435 (95.4%)	585 (92.6%)

^aThe numbers noted do not reflect unique use of heroin and misuse of prescription opioids.

^*Cohort differences observed among these variables.

Measures

Sociodemographics.

The school district provided information on students’ sex, ethnicity, and free/reduced-priced lunch status. Participant demographic variables and characteristics were coded as follows (sex: female = 0, male = 1; race: European American = 0, African American = 1; free/reduced-priced lunch: 0 = paid lunch, 1 = free/reduced-priced meals; intervention status: no intervention = 0, intervention = 1; and cohort: cohort 1 = 1, cohort 2 = 2, cohort 3 = 3).

Attention Problems.

Attention problems were assessed using the Attention Problems subscale of the Teacher Observation of Classroom Adaptation-Revised (TOCA-R; Werthamer-Larsson, Kellam, & Wheeler, 1991). The TOCA-R is a structured interview designed to be administered by a trained member of the assessment staff. The interviewer follows a script precisely and responds in a standardized way to issues that the teacher initiates. The interviewer records the teacher’s ratings of each child’s level of attention problems. The Attention Problems subscale includes items such as pays attention, is easily distracted, and stays on task. Higher scores reflect higher levels of attention problems. In this sample, attention problems have been predictive of a number of correlates of ADHD including teacher perceptions of the child’s need for medication for emotional and behavior problems in first grade (Ialongo, Poduska, & Kellam, 1995). In addition, for each unit increase on the attention problems subscale in first grade, there was a nearly 50% increase in the risk of being identified as in need of special education by 8^th grade teachers and just under a 60% increase in the likelihood of failing to graduate from high school (Ialongo, Poduska, & Kellam, 1995). Werthamer-Larsson et al. (1991) also observed test-retest correlations of .60 or higher with different interviewers over a four-month interval and an alpha of .85 for the attention problems subscale.

Aggressive Behavior and Peer Social Preference/Likeability.

Peer nominations were employed to measure child aggressive behavior and peer social preference/likeability. The items employed were adapted from the Pupil Evaluation Inventory (Pekarik et al., 1976). In terms of administration, a peer nomination question was read aloud to the class by a member of the study assessment team and the children were then instructed to circle the pictures of all children in their classroom described by the question. Thus, children were able to make unlimited nominations of classmates for each question. Raw scores for each of the nomination items were converted to percentages of nominations received based on the distribution of nominations within a child’s classroom. A composite score made up of 2 peer nominations items (“Which children start fights?” and “Which children get into trouble a lot?”) was employed as a measure of aggressive behavior. Clemans et al. (2015) reported that this composite score in first grade predicted antisocial and high risk sexual behavior in young adulthood. We used peer nominations for “best friends” (“Which children are your best friends?”) as a measure of social preference/likeability. This item was recoded such that higher scores reflect lower peer nominations of social preference/likeability.

Achievement.

In cohorts 1 and 2, the California Achievement Test (CAT) was used to assess early childhood achievement in the fall of first grade. The CAT is one of the most frequently used standardized achievement batteries and includes both verbal (reading, spelling, and language) and quantitative (computation, concepts, and applications) subtests (Wardrop, 1989). Composite scores were used to index reading and math achievement. The CAT has shown concurrent validity with McCarthy’s Scales of Children’s Abilities General Cognitive Index, and convergent validity with the Kaufman Adolescent and Adult Intelligence Test (KAIT) and the Weschler Intelligence Scale for Children-Third Edition (WISC-III). In cohort 3, the Comprehensive Test of Basic Skills (CTBS) was used to measure academic achievement in the fall of first grade. Like the CAT, the CTBS is a common assessment battery used to measure scholastic achievement. Subtests in the CTBS cover both verbal (word analysis, vocabulary, comprehension, spelling, and language mechanics and expression) and quantitative topics (computation, concepts, and applications). Like the CAT, two composite scores were provided to reflect reading and mathematics ability. For the current study, we used scaled scores for both the CAT and CTBS. The mean for reading achievement was 316.36 (SD = 96.99) and the mean for math achievement was 340.00 (SD = 89.98). Given high correlations between reading and math achievement (r = .82, p <.005), a composite achievement variable was created. Higher scores reflect higher academic achievement.

Opioid Misuse.

At age ~ 20, participants reported on whether they had ever used heroin or prescription opioids without a doctor’s authorization, including morphine, oxycodone, hydrocodone, hydromorphone, etc. From these data, we created a variable that reflected whether individuals had ever used heroin or misused prescription opioids (coded as 0 = no lifetime history of ever using heroin or misusing prescription opioids; 1 = lifetime history of ever using heroin or misusing prescription opioids). Although not an outcome considered in the current study, frequency of heroin use and misuse of prescription opioids are provided in the supplementary materials to better contextualize the severity of opioid misuse in the sample.

Statistical Analyses

A series of logistic regressions were conducted in R (R Core Team, 2013) to examine whether early childhood aggression, attention problems, peer social preference/likeability, and achievement predicted lifetime use of misusing opioids, and whether these relations differed depending on participant sex. All continuous variables were mean-centered. Participant sex was included as a covariate given sex differences in drug use that have been observed across the literature (Marsh, Park, Lin, & Bersamira, 2018; Serdarevic, Striley, & Cottler, 2017). Cohort was also included as a covariate given differences in the year of the intervention implementation. We also controlled for free/reduced-priced meals at baseline, which is a common proxy for family income (Hobbs & Vignoles, 2010; Huang & Barnidge, 2016), and has been strongly associated with psychological impairments and substance use problems among youth (Goodman, 1999; Hanson & Chen, 2007). Participant race was also included as a covariate given differences in the base rates of heroin and prescription opioid misuse across racial groups (Pouget, Fong, & Rosenblum, 2018). Last, we controlled for intervention status, given that participation in the interventions has been associated with reduced risk for substance use among youth (Storr et al., 2002).

Two main analytic models were conducted. The first model examined the impact of the early childhood predictors (i.e., aggression, attention problems, achievement, and peer social preference/likeability) on opioid misuse and included participant demographic and baseline characteristics (i.e., sex, race, cohort, free/reduced lunch status, and intervention status) as covariates. The second model included four sex interactions (sex × aggression, sex × attention problems, sex × achievement, sex × peer social preference/likeability); the early childhood variables (i.e., aggression, attention problems, achievement, and peer social preference/likeability) and participant demographic/baseline characteristics were treated as covariates in this model. All significant interactions were plotted using ggplot2 (Wickham, 2016). For significant sex by early childhood variable interactions, post-hoc probing was conducted by stratifying by participant sex and examining whether the predictor was significantly associated with the outcome of interest.

Given theoretical and empirical work that has shown that achievement and aggression may jointly influence substance use outcomes (Okano et al., 2020; Patterson et al., 1992), we conducted ancillary logistic regression analyses to determine whether there were interactions between aggression and achievement in predicting opioid misuse. Models controlled for participant demographic/baseline characteristics and the early childhood variables. Three-way interactions involving participant sex, aggression, and achievement were also conducted to examine these joint influences on opioid misuse. This model controlled for participant demographic/baseline attributes, the early childhood variables, and three, two-way interaction terms (i.e., sex × achievement, sex × aggression, aggression × achievement). For significant 2-way interactions involving achievement and aggression, post-hoc probing involved examining whether the association between aggression and opioid misuse differed depending on high (i.e., 1 SD above the mean), average (M), and low (1 SD below the mean) levels of achievement. Significant 3-way interactions were probed by stratifying by participant sex. Last, logistic regression analyses were also conducted to evaluate whether prediction from the early childhood variables differed depending on whether heroin was considered as an outcome as opposed to misuse of prescription opioids which are presented in the supplementary materials.

Before running the logistic regression models described above, we tested whether the assumptions for logistic regression were met. We evaluated the level of multicollinearity using the variance inflation factor (VIF) and assessed whether linear relationships existed between the predictors and log odds of the outcomes using the Box-Tidwell test (Osbourne, 2015).

Results

Eighty-one individuals (5.4%) endorsed ever using heroin or misusing prescription opioids in their lifetime. Specifically, 32 women and 49 men in the sample reported using either heroin or misusing prescription opioids, respectively. All assumptions to conduct a logistic regression were met, including low multicollinearity among the predictors (VIF < 4) and linear relationships between the predictors and log odds of the outcomes were observed. Results from the primary analyses are presented below.

In logistic regression models that included participant sex, race, cohort, intervention status, and free/reduced-priced lunch status as covariates, peer nominations for aggressive behavior significantly predicted opioid misuse (aOR = 1.67, 95% CI = 1.30–2.14, p < .005), such that higher levels of peer nominations for aggressive behavior predicted a greater likelihood of opioid misuse relative to fewer peer nominations for aggression (Table 3). Teacher-reported attention problems (aOR = 1.04, 95% CI = 0.76–1.43, p = .803), peer nominations of social preference/likeability (aOR = 1.23, 95% CI = 0.93–1.64, p = .150), and achievement (aOR = 1.54, 95% CI = 0.96–2.47, p =.074) did not predict opioid misuse.

Table 3.

Summary of Logistic Regression Analyses involving Early Childhood Achievement, Attention Problems, Aggression, and Peer Social Preference/Likeability in Predicting Ever Use of Heroin or Misuse of Prescription Opioids (N =1,585)

Model	aORa (95% CIb)	p-value
Model 1: Early Childhood Predictors c
Achievement	1.54 (0.96–2.47)	.074
Attention Problems	1.04 (0.76–1.43)	.803
Aggression	1.67 (1.30–2.14)	<.005
Peer Social Preference/Likeability	1.23 (0.93–1.64)	.150
Model 2: Sex × Early Childhood Interactions d
Sex × Achievement	0.95 (0.54–1.66)	.846
Sex × Attention Problems	0.46 (0.25–0.83)	.010
Sex × Aggression	1.99 (1.16–3.47)	.172
Sex × Peer Social Preference/Likeability	1.50 (0.85–2.72)	.014

^aaOR = Adjusted odds ratio.

^bCI = Confidence interval.

^cThe model controlled for sex, race, intervention status, free/reduced-priced lunch, and cohort.

^dThe model controlled for sex, race, intervention status, free/reduced-priced lunch, cohort, and the predictors (i.e., achievement, attention problems, aggression, peer social preference/likeability).

There was a significant sex by attention problems interaction (aOR = 0.46, 95% CI = 0.25–0.83, p =.010) (Table 3). Females with higher levels of attention problems were more likely to misuse opioids compared to females lower in attention problems (aOR = 1.80, 95% CI = 1.07–3.03, p = .026). Attention problems were not associated with opioid misuse among males (aOR = 0.75, 95% CI = 0.50–1.11, p = .155) (Figure 1A). In addition, there was a significant interaction between sex and peer nominations of social preference/likeability (aOR = 2.00, 95% CI = 1.16–3.47, p = .014). More specifically, males receiving a lower percentage of nominations in terms of peer likeability were more likely to report ever misusing opioids compared to males with a higher percentage of peer likeability nominations (aOR = 1.57, 95% CI = 1.05–2.41, p = .032). Peer nominations of social preference/likeability did not predict opioid misuse among females (aOR = 0.92, 95% CI = 0.62–1.39, p = .701) (Figure 1B).

Figure 1.

A. Relation between attention problems and sex in relation to ever use of heroin or misuse of prescription opioids, and B. Relation between peer social preference/likeability and sex in predicting ever use of heroin or misuse of prescription opioids.

Note. In Figure 1B, the x-axis reflects peer social preference/likeability where higher scores reflect lower social preference/likeability.

Adjusted ORs reflected in the figures are from models stratified by participant sex.

Ancillary Analyses

The interaction between aggression and achievement did not significantly predict opioid misuse (aOR = 1.23, 95% CI = 0.99–1.54, p = .066). The sex × aggression × achievement interaction also did not predict this outcome (aOR = 1.08, 95% CI = 0.58–2.12, p =.805).

Discussion

Misuse of opioids continues to be a significant public health problem and has had a devastating impact on urban communities in recent years (Katz & Goodnough, 2017; Spencer et al., 2019). To date, targeting physician overprescribing has been the predominant public health and policy approach to curtailing the prescription opioid misuse epidemic (Compton et al., 2019); however, opioid misuse is a complex phenomenon and effective prevention of this problem requires the consideration of the multiple pathways through which opioid misuse occurs. The misuse of opioids may stem from early childhood academic, behavioral, and cognitive processes, consistent with previous research examining the relations among these variables and other illicit drug use outcomes in adulthood (Fothergill et al., 2008; Kellam et al., 2008; Petras et al., 2008; Trenz et al., 2012); nevertheless, there is a dearth of research in this area. There is also a paucity of work that has considered whether sex influences the relationship between early childhood behaviors and risk for opioid misuse later in life. Given challenges thus far in curbing the opioid misuse epidemic, the present study sought to examine modifiable risk factors (e.g., aggressive behaviors, attention problems, peer social preference/likeability, performance on standardized achievement tests) that early interventions could potentially target.

We found that greater peer nominations of aggressive behavior in first grade predicted a nearly 2 fold increased risk of ever using heroin or misusing prescription opioids among the whole sample. Upon examining these outcomes separately, we observed a significant sex by aggression interaction such that males higher in aggression were more likely to misuse prescription opioids specifically compared to males lower in aggression. These findings are consistent with work indicating that higher levels of aggressive-disruptive behaviors are associated with increased drug use in adolescence and young adulthood (Reboussin et al., 2007; 2015). In line with Patterson and colleagues’ life course theory (1992), children who engage in disruptive and aggressive behaviors may be less likely to evoke positive feedback from parents, teachers, and peers alike. These negative interactions may have a cumulative effect whereby such youth affiliate with deviant peers in adolescence to gain social support and acceptance (Chen, Drabick, & Burgers, 2015), which may increase their likelihood of using illicit drugs in young adulthood (Armstrong et al., 2013; Brook et al., 2009). Research investigating why males higher in aggression were at heightened risk for misusing prescription opioids specifically is warranted to aid in the development of targeted interventions aimed at reducing risk for different types of opioid misuse.

Females, but not males, higher in attention problems in first grade were nearly two times more likely to engage in opioid misuse compared to females lower in attention problems. Upon considering heroin use and misuse of prescription opioids as separate outcomes, females higher in attention problems were more likely to misuse prescription opioids specifically compared to females lower in attention problems. These findings are consistent with work that has linked early childhood attention problems to adolescent opioid use (Galera et al., 2008) and illicit drug use in young adulthood (Galera et al., 2013). Females with greater attention problems in early childhood may evidence poorer cognitive control, set shifting, inhibition, and impaired abilities to direct attention to achieve a goal (Miyake & Friedman, 2012). It is possible that these behavioral displays are less normative for females and may be met with less patience and support from parents and teachers alike. As a result, females may be more likely to seek out deviant peers for acceptance, which may exacerbate risk for ever using heroin or misusing prescription opioids later in life. Moreover, persistent attention problems among females may contribute to more impulsive decision making and the favoring of immediate rewards without considering the long-term consequences of their behaviors such as drug use (Kim-Spoon et al., 2017).

In addition, we also found that males who received a lower percentage of peer nominations for likeability were about two times more likely to misuse opioids compared to males who received a higher percentage of peer likeability nominations. This finding is consistent with work indicating that peer rejection in the early and middle school years is associated with a greater likelihood of substance use (Spooner, 1999) or correlates of these behaviors (e.g., externalizing symptoms; Chen et al., 2015; Ettekal & Ladd, 2015). There are several pathways through which peer nominations of likeability in the early childhood years may confer risk for greater substance use in young adulthood among males. Males who received fewer nominations for likeability by their peers may have poorer social skills, exhibit challenges with emotion regulation, and/or experience difficulties meeting developmentally salient tasks (Chen et al., 2015). Social lags and emotion regulation deficits may persist and increase the likelihood that males lower in peer likeability are rejected by prosocial peers. Males who are less liked by mainstream peers may, accordingly, affiliate with deviant peers where heavy, frequent substance use behaviors, such as misuse of prescription opioids, are commonplace and reinforced. Future work should investigate the mechanisms through which lower peer nominations for likeability among males in first grade translate into increased risk for prescription opioids misuse in adulthood.

Results from ancillary analyses did not indicate an interaction between achievement and aggression in predicting opioid misuse. However, as indicated in the supplement, there was an interaction between achievement and aggression in predicting heroin use such that youth with higher levels of aggression and achievement were more likely to use heroin. It is possible that high achieving students in early childhood continue to excel academically in adolescence. These youth may have more opportunities to affiliate with older peers where risk taking behaviors, rebellion against parental rules, and drug experimentation is more normative (Fleming, Kellam, & Brown, 1982; Drabick & Steinberg, 2011). Another possibility is that higher levels of academic achievement confer a greater likelihood of peer victimization, which is consistent with work indicating that higher academic achievement predicted greater peer victimization in the middle school years among ethnic minority youth (e.g., Lehman et al., 2018). Victimization by peers may increase the likelihood of youth behaving oppositionally or using substances to “fit in” (e.g., Sullivan et al., 2006). Future research is needed to investigate factors that underpin the relationship between aggression, achievement, and heroin use. In addition, the study of the interplay between academic achievement and peer victimization in the early childhood years in predicting opioid misuse may also be a worthwhile area of study.

There are some limitations of the study to acknowledge. In particular, only a small percentage of participants reported misusing opioids more than a couple of times by age ~ 20. Moreover, opioid misuse was examined at one time point (age ~ 20). There is evidence that substance use behaviors in adolescence and young adulthood change over time (Lin et al., 2016; Miner et al., 2008; Wang & Eccles, 2011) and thus, it is possible that the current findings may not generalize to other developmental periods; future longitudinal research featuring multiple waves of assessments from childhood into adulthood are clearly needed. In addition, we assessed opioid misuse based on whether participants had ever reported using heroin or misused prescription opioids in their lifetime as opposed to opioid abuse or dependence. While lifetime reports of opioid misuse may foreshadow the development of substance use disorders and related impairments, the consideration of frequency of opioid misuse and disorders may be additional metrics that better reflect the severity of opioid misuse in the sample. Consistent with literature indicating that friendship is by definition reciprocal (Vaquero & Kao, 2008), an additional limitation of our work is that our measure of peer likeability did not consider the reciprocity of nominations for best friends. Future research that assesses peer perceptions of friendship reciprocity in relation to substance use is thus warranted. Moreover, the present study reflects a community-based sample from a single city that was not oversampled for youth with clinical conditions (e.g., attention deficit hyperactivity disorder) or other risk factors (e.g., chronic school absenteeism) that may be at heightened risk for opioid misuse (Gakh et al., 2020); thus, replication of our findings in larger, more diverse samples is warranted. Further, as previous research suggests that opioid availability and misuse varies geographically (Jones et al., 2015), future work should investigate whether our findings generalize to individuals in other urban centers as well as less densely populated areas, where opioid availability is lower. This is especially important since Baltimore City has one of the biggest opioid problems of any U.S. city both historically with heroin and more recently with both prescription opioids and heroin (Schwartz et al., 2015) and therefore, different patterns may be observed in other samples.

In conclusion, the results from the current study have a number of implications for prevention and early intervention. There are likely mechanisms subsequent to the early childhood period that contribute to a dynamic cascade leading to opioid misuse across developmental periods. For example, previous theory and research indicate that early childhood conduct problems, peer relations, and parenting are interrelated and mutually influence one another to confer risk for later substance use (e.g., Dodge, Malone, Lansford, Miller, Pettit, & Bates, 2009). Thus, assessments of children in the early elementary school years should include variables that may exacerbate risk for opioid misuse, given they may serve as targets for early interventions that attenuate growth of problematic behaviors and confer resilience during subsequent sensitive periods (e.g., adolescence; Smith, Chein, & Steinberg, 2013). Based on the present results, early identification and intervention in the elementary school years of children exhibiting attention problems, particularly among females, and higher aggression and poorer likeability by peers, particularly among males, is warranted.

As concurrent difficulties with attention problems and aggressive behavior likely contribute to problems with social information processing (e.g., hostile attribution biases; Crick & Dodge, 1994), preventive (CPPRG, 1999) and treatment interventions that target social problem-solving may be particularly beneficial (Eyberg, Nelson, & Boggs, 2008). Moreover, treatment interventions that include both a parent and child component may be superior to those interventions only featuring a child component (Epstein, Fonnesbeck, Potter, Rizzone, & McPheeters, 2015). The Incredible Years suite of programs that includes parent, child, and teacher components are examples of appropriate preventative interventions and treatments for children in early elementary school, given their focus on reducing behavior problems and increasing social competence (Webster-Stratton, Reid, & Hammond, 2004). The Coping Power Program—an example of an indicated preventive intervention— also addresses youth aggressive and disruptive behavior by providing skills for coping with anger, addressing social-cognitive biases, and improving social problem-solving (Lochman & Wells, 2002a, 2002b). Importantly, given that aggressive behaviors, attention problems, and social skills training can be readily assessed and intervened within schools, programs that are designed to be implemented in the school setting may be optimal.

Other intervention options include augmenting current approaches with strategies to address youth attention problems more specifically (Faraone & Antshel, 2014). Although findings have been mixed, potential options for augmentation include mindfulness training (e.g., Cassone, 2015) and working memory training (Chacko, Feirsen, Bedard, Marks, Uderman, & Chimiklis, 2013). Evidence-based practices are typically deemed preferable (Kazak, Hoagwood, Weisz, Hood, Kratochwill, Vargas, & Banez, 2010); however, calls for adaptations of such approaches to better address mental health disparities among ethnic minority individuals (Roberts, Blossom, Evans, Amaro, & Kanine, 2017; Southam-Gerow, Rodríguez, Chorpita, & Daleiden, 2012) suggest that future research that considers such augmentation would be helpful for identifying opportunities for improving care and outcomes among individuals who are at risk for opioid misuse.