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Maturing Out
C H A P T E R
38 Maturing Out Andrew K. Littlefield, Rachel P. Winograd Psychology Building, Columbia, MO, USA
O U T L I N E Introduction
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Maturing Out: Normative But Not Universal
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Definitions of SUDS
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Documenting Maturing Out
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Adult Roles Do Not Always Lead to Decreased Substance Involvement
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Theoretical Models of Maturing Out
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Developmentally Limited SUDS Can Still Be Destructive
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Why Does the Peak Prevalence of SUDS Occur in the Early Twenties?
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Cultural Differences
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Why Do People Tend to Mature Out of Substance Use? 366
Maturing Out in Emerging Adulthood e Higher Rates of Recovery or Decreased Onset of New Cases?
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Adult Role Attainment and Role Incompatibility Theory
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Summary
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Is Personality Change Associated with Maturing Out?
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INTRODUCTION Perhaps contrasting with popular notions, substance use disorders (SUDs) are largely disorders of young adulthood. Data from several large epidemiological studies indicate that the peak prevalence of SUDs, such as alcohol use disorders (AUDs), occurs during the early twenties and then drops precipitously with age. That is, many of the young adults who experience SUDs during young adulthood later remit (often without receiving treatment). This process of normative decline in problematic substance use is referred to as maturing out. In this chapter, empirical data depicting the rise and fall in the prevalence of SUDs in young adulthood will be summarized. Specifically, theories describing potential mechanisms that contribute to the peak substance Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00038-3
use observed during late adolescence/early adulthood will be described. In conjunction, theories that depict processes that contribute to maturing out will be covered. Finally, important considerations relevant to the phenomenon of maturing out will be highlighted.
DEFINITIONS OF SUDS Before describing maturing out in more detail, it is important to note current conceptualizations of SUDs. The Diagnostic and Statistical Manual, version IV-TR, defines two major classes of SUDs: substance dependence and substance abuse. The diagnostic criteria for dependence is defined as “a maladaptive pattern of use, leading to clinically significant impairment or distress, as manifested by three (or more) of the
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38. MATURING OUT
following symptoms occurring at any time in the same 12-month period: (1) tolerance; (2) withdrawal; (3) the substance is often taken in larger amounts or over a longer period than intended; (4) a persistent desire or unsuccessful efforts to cut down or control substance use; (5) a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects; (6) important social, occupational, or recreational activities are given up or reduced because of substance use; and (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance” (p 197). The DSM-IV defines substance abuse as “a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home; (2) recurrent substance use in situations in which it is physically hazardous; (3) recurrent substance-related legal problems; and (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance” (p 198). These general criteria are applied to the diagnoses for specific substances (e.g. AUDs). According to the DSM-IV’s diagnostic hierarchy, individuals who meet criteria for dependence for a given substance do not receive diagnoses for substance abuse, implying that dependence is the more severe of the two SUDs. However, for reasons that are beyond the scope of this chapter, the abuse/dependence distinction will most likely be eliminated in future versions of the DSM, resulting in the combination of the two classes of SUDs into one substance use disorder diagnosis.
DOCUMENTING MATURING OUT Several studies have documented the peak prevalence of substance use and related negative consequences that occur during the early twenties before declining with age. For example, data from the Monitoring the Future study suggest that heavy drinking (i.e. drinking five or more drinks in a row in the past 2 weeks) peaks at ages 21–22 and then decreases linearly with age. Numerous epidemiological studies have documented the rise and fall of SUDs during the third and fourth decades of life. Nationally representative data (for the United States) from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) clearly indicates that the peak prevalence of SUDs, such as AUDs, occurs during young adulthood and declines sharply with age. Notably, many of the individuals
20 18 16 14 Prevalence
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6 4 2 0 18-20 21-24 25-29 30-39 40-49 50-59 60+ Age groups
FIGURE 38.1 Prevalence of alcohol use disorders (AUDs) and drug use disorders (DUDs) from ages 18 to 60 in NESARC data.
who recover from AUDs do not abstain from drinking but rather continue to consume alcohol at more moderate levels. Although some research suggests that heavy drinking among blacks and Hispanics may peak later compared to whites, and that the overall rates of AUDs differ among various racial-ethnic groups, the tendency for AUDs to decline with age is consistent among whites, blacks, Native Americans, Asians, and Hispanics. Similarly, NESARC data indicate that the past 12-month prevalence for drug use disorders (abuse and/or dependence for a broad range of substances including cannabis, cocaine, and heroin) is significantly higher in younger age cohorts (see Fig. 38.1). Thus, agerelated declines in prevalence seem to be robust across substances and, at least in the United States, across racial-ethnic groups.
THEORETICAL MODELS OF MATURING OUT There are two essential questions regarding the phenomenon of maturing out: why does the peak prevalence of SUDs tend to occur in the early twenties, and why is there a dramatic normative decrease in both substance use and SUDs across the third and fourth decades of life? Potential explanations that have been provided by theorists and researchers are summarized below.
WHY DOES THE PEAK PREVALENCE OF SUDS OCCUR IN THE EARLY TWENTIES? Several reasons have been proffered to explain the high rates of substance use and misuse that occur during the transition between late adolescence and adulthood.
I. THE NATURE OF ADDICTION
WHY DOES THE PEAK PREVALENCE OF SUDS OCCUR IN THE EARLY TWENTIES?
Theorist Jeffery Arnett referred to the transition from late adolescence to adulthood as emerging adulthood, and describes it as a unique developmental period in which several factors contribute to problematic substance use. According to Arnett, emerging adulthood lasts approximately from ages 18 to 25, though it can extend throughout the twenties and beyond for some individuals, depending on completion of developmental milestones such as marriage and parenthood. Arnett noted significant demographic changes over the past halfcentury in industrialized countries, such as prolonged educational pursuits and subsequent delayed entry into the workforce. This more recent focus on higher education could contribute to a later adoption of adult roles for some individuals. Indeed, compared to previous generations, both men and women are currently getting married and having children at later ages. Arnett suggests these demographic shifts result in the developmental period of emerging adulthood that is characterized by instability, self-focusing, feeling “in-between” adolescent and adult, increased optimism about the future, and identity exploration. As each one of these factors may contribute to delayed acquisition of adult roles, so too might they contribute to the increased use and misuse of substances. For example, there are various forms of instability that are evident during emerging adulthood. As documented by Arnett’s research, individuals frequently change residence, romantic partner, and educational and job status during emerging adulthood. As Arnett explains, this instability could result in anxiety and sadness, resulting in some emerging adults to use substances to “self-medicate” these negative emotions. Emerging adulthood is also a time of exceptional selffocus. As opposed to adolescents (who are governed by parents and teachers) and adults (who have commitments to work and family), emerging adults have relatively few daily obligations to other people. As described by Arnett, self-focusing results in more volatile and ephemeral social networks and friendships, which in turn creates an overall lack of imposed social control compared to other age periods. This lack of social control coupled with relatively fewer responsibilities may also explain the heightened substance use during emerging adulthood. Feeling “in-between” adolescence and adulthood is common during emerging adulthood. Arnett’s research suggests that emerging adults consider reducing substance use and associated risk behaviors (e.g. drunk driving) as crucial criteria for adulthood, even more so than the adult transitions of graduating from college and getting married. However, since emerging adults feel “in-between” adolescence and adulthood, many may consider that this age period is a time where
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substance use is relatively acceptable compared to later age periods. In line with this perception of acceptability, research suggests that perceived norms of substance use is one of the strongest correlates of substance use behaviors among emerging adults. In fact, many emerging adults overestimate rates of peer substance use compared to their own use as well as the general acceptance of substance use and related behaviors. These beliefs may explain why many people engage in substance use during emerging adulthood but not later in life. Arnett also describes emerging adulthood as the “age of possibilities,” that is, a time period when people believe that they can make dramatic changes in their life and optimism for the future is exceptionally high. This optimistic bias, according to Arnett, may result in emerging adults to discount the myriad negative consequences associated with substance use, resulting in increased substance use during this age period. Supporting this conjecture, research suggests that many emerging adults base their decision to drink on perceived positive expectancies of substance use rather than potential risks. Further, Arnett hypothesizes that many emerging adults will have a high sense of well-being and use substances based on enthusiasm, whreas some emerging adults have a lower sense of well-being and use substance to cope with negative emotions. Supporting this notion, a large body of empirical literature suggests that alcohol use is increased among individuals who endorse relatively high levels of enhancement (e.g. I drink to have fun) and coping (e.g. I drink to relieve negative moods) motives to drink compared with individuals with lower levels of these motives. Further, alcohol problems are indirectly related to enhancement motives through increased alcohol, whereas coping motives directly predict alcohol-related problems. Thus, individuals who report higher motivations to drink tend to consume higher amounts of alcohol and subsequently experience more alcohol-related problems. As Arnett describes, identity explorations may include emerging adults’ desire to have a wide range of experiences before transitioning into adulthood, including experimenting with various substances. Further, distress related to forming a stable identity may result in some emerging adults to use substances as a means of coping with identity confusion (though there is limited existing empirical evidence to support this notion). Related to identity exploration, levels of sensation seeking (i.e. the pursuit of novel and intense experiences), a significant predictor of substance use, tend to be higher during emerging adulthood compared to later ages (see section “Why do People Tend to Mature Out of Substance Use?” for further discussion). Therefore, identity explorations that are common during emerging adulthood may contribute to the high prevalence of SUDs.
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In line with Arnett’s description of increased sensation seeking during emerging adulthood is a burgeoning collection of research that suggests overall mean levels of personality traits related to substance use are higher during emerging adulthood than perhaps during any other age period. For example, traits related to impulsivity (a broad construct that is related to making rash decisions and sensation seeking) and neuroticism (the tendency to experience negative emotional states) correspond to the increased use and misuse of a range of substances. For many individuals, these traits may be most pronounced during emerging adulthood and directly and indirectly relate to problematic substance involvement. For example, numerous studies have documented that individuals higher in traits related to impulsivity and neuroticism are more likely to have greater motivation to use alcohol. These motives in turn predict both alcohol use as well as alcohol-related problems. As will be described in more detail later in the chapter, changes in personality and motives across time may also influence the maturing out of substances. In summary, the peak prevalence of substance use and SUDs occurs during emerging adulthood. This age period is marked by several factors that are conducive to substance use, such as increased freedom and exploration (compared to adolescence) and decreased responsibilities (compared to adulthood). Further, compared to older age groups, personality characteristics that are linked to substance use motives, substance use, and associated negative consequences seem to be relatively high during this timeframe. These features may help explain why substance use and misuse is the highest during emerging adulthood.
WHY DO PEOPLE TEND TO MATURE OUT OF SUBSTANCE USE? As noted above, theorists and researchers have provided several explanations of the heightened use and misuse of substances that is observed during emerging adulthood. There is also a large body of work describing why there is a sharp decrease in substance use across the twenties and into the thirties. Primary findings from this literature are summarized below.
ADULT ROLE ATTAINMENT AND ROLE INCOMPATIBILITY THEORY The most prominent explanation as to why many individuals mature out of problematic substance use is the attainment of adult roles. Numerous studies have
documented that transitions into full-time employment, marriage, and parenthood are linked to decreased substance use and substance-related problems, especially alcohol use and misuse. The link between adult role attainment and reduced problematic substance involvement may reflect selection or socialization processes. That is, the link between adult roles and maturing out might reflect the tendency of SUD remitters to later adopt adult roles (i.e. selfselect). Contrastingly, adult roles may influence substance use through socialization processes, such as bringing about increased responsibilities, which result in substance use reduction for individuals who enter into these roles. Work by Denise Kandel and Kazuo Yamaguchi suggests that both role selection and role socialization processes influence substance use. For example, findings suggest that marijuana use is associated with delayed entry into marriage and parenthood (i.e. a selection effect). Marriage and parenthood are also associated with increased rates of stopping marijuana use (i.e. a socialization effect). Additionally, using a longitudinal sample of college students, Kenneth Sher and colleagues concluded that the socialization effect of marriage on later AUDs seems to be more plausible than role selection effects of AUD on later marriage. Data taken from NESARC suggest that the relation between decreased alcohol dependence and getting married and having children reflect socialization processes, whereas the effects of school and work transitions were more consistent with selection effects. Yamaguchi and Kandel proposed that the link between decreased substance involvement and adult roles could be attributed to role incompatibility, that is, adult roles associated with increased responsibility, such as marriage and parenthood, are “incompatible” with heavy substance use. For example, as Patrick O’Malley noted, marriage and parenthood result in numerous changes in social and recreational activities that are not conducive to maintaining a heavy drinking lifestyle. Specifically, compared to single individuals, those who are married attend fewer social functions that are compatible with substance use, such as parties and gatherings at bars. Increased responsibilities associated with child rearing also result in limited time for social activities involving substance use. Indeed, O’Malley noted that parenthood “is the key event” that propels men to reduce their drinking. Further, many women reduce their substance use during pregnancy because of concerns that substances such as alcohol can harm the developing fetus. Thus, many individuals seem to reduce their substance use in the presence of increased responsibilities and reduced free time that are brought about through the assumption of adult roles.
I. THE NATURE OF ADDICTION
IS PERSONALITY CHANGE ASSOCIATED WITH MATURING OUT?
IS PERSONALITY CHANGE ASSOCIATED WITH MATURING OUT? Although much of the research involving the maturing out of problematic substance involvement has focused on adult role obtainment, more recent work suggests that changes in personality may also be an important developmental factor. Despite personality being traditionally considered a stable, enduring construct, numerous studies have empirically documented mean level changes in personality across time and especially during emerging adulthood. These changes tend toward increased maturity, with people typically becoming less impulsive and more emotionally stable with age. This tendency has been referred to as the maturity principle. As with decreased substance use, increases in traits associated with maturity have been linked to adult role attainment and experiencing satisfaction in adult roles, such as marital and occupational satisfaction. Recent work by Andrew Littlefield, Phillip Wood, and Kenneth Sher suggests that individual differences in personality change seem to influence the tendency to mature out of alcohol-related problems. That is, despite normative trends, there seems to be significant individual differences in both the tendency to mature out of problematic substance use and to experience increased psychological maturity. Thus, not all individuals show reductions in substance use and misuse or display beneficial changes in personality. Using longitudinal data from a cohort of college students, Littlefield and colleagues demonstrated that changes in neuroticism and impulsivity were linked to changes in alcohol problems from ages 18 to 35. Findings suggested that individuals who displayed sharper declines in neuroticism and impulsivity across this period also were more likely to undergo steeper decreases in alcohol problems. Subsequent analyses suggested these relations remained significantly linked even when adjusting for the influence of marriage and parenthood, demonstrating the unique importance of personality change in addition to the adoption of adult roles. Using data from the same longitudinal sample, Littlefield and colleagues recently demonstrated that a group of individuals characterized by considerable decreases in impulsivity from ages 18 to 25 were more likely to show decreases in alcohol consumption and alcohol-related problems when compared to other groups with high and relatively stable levels of impulsivity. These findings suggest that individuals with relatively high levels of impulsivity who do not show significant decreases in that trait may be less likely to mature out of problematic alcohol involvement. These
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findings are consistent with recent longitudinal data suggesting that individuals who stopped smoking between the ages of 18 and 26 made corresponding larger increases in constraint (a construct considered to be the antithesis of impulsivity) and more pronounced decreases in negative emotionality compared to other individuals. Individual differences in personality change also seem to influence changes in drinking motives, which in turn influence the tendency to experience alcoholrelated problems. Individuals who exhibit more rapid decreases in impulsivity and neuroticism during emerging adulthood also seem to display larger decreases in coping motives to use alcohol. These reductions in coping motives predict more pronounced declines in alcohol-related problems. Thus, changes in personality and reasons for drinking seem to contribute to the maturing out of problematic alcohol involvement and most likely other substances as well. Another potential, though somewhat speculative, explanation of the decline of substance use after emerging adulthood is the ongoing cognitive neurodevelopment that occurs during this timeframe. There is significant development in the prefrontal cortex during adolescence and emerging adulthood. These changes are thought to coincide with subsequent development of several processes, including affect regulation, selfcontrol, cognitive control, and regulating behavior in general. Thus, declines in substance use after emerging adulthood, as well as the ostensibly adaptive personality changes detailed above, may be due in part to cognitive development. In summary, the normative acquisition of roles associated with adulthood seems to strongly relate to the maturing out of substance use. This relationship likely reflects both role selection and role socialization processes. Just as the relatively lower amounts of responsibility and relatively higher amounts of freedom associated with emerging adulthood are conducive to substance use and misuse, the increasing responsibilities and time demands associated with adulthood seem to be largely incompatible with a heavy substance using lifestyle. Individuals also seem to undergo changes in personality during emerging adulthood, and changes in certain personality constructs seem to relate to changes in motives to use substances and decreased substance involvement. Normative cognitive neurodevelopment may also contribute to the maturing out of substance-related problems. In reality, changes in role status, personality, substance use motives, and cognition, as well as other factors, most likely affect each other and interact to produce dynamic, complicated influences on substance use behaviors (Table 38.1).
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TABLE 38.1 Factors Potentially Contributing to Peak SUDs during Emerging Adulthood and Factors Potentially Contributing to Maturing Out Factors potentially contributing to heightened substance use during emerging adulthood
Factors potentially contributing to declining substance use during early adulthood
• Increased freedom/relatively less responsibilities
• Adult role attainment/ increasing responsibilities
• Instability in roles, residence
• Role incompatibility
• Increased self-focus, decreased social demands
• Increased social demands
• Feeling “in-between” adolescence and adulthood
• Neurocognitive development
• Decreased focus on negative outcomes
• Decreased motives to use substances
• Identity exploration
• Identifying as an adult
• Social acceptance of substance use
• Decreased social acceptance of substance use
• Heightened levels of risky personality traits
• Decreases in risky personality traits
MATURING OUT: NORMATIVE BUT NOT UNIVERSAL As described briefly above, there is considerable variability in the developmental course of SUDs. That is, although the normative trend is for rates of substance use and misuse to peak during the early twenties before declining with age, many individuals do not follow this typical pattern. For example, even among substance users, many individuals are not diagnosed with an SUD during emerging adulthood or later in life. Other individuals do not undergo normative decreases in problematic substance use but rather display chronic patterns of heavy use and SUDs across their lifespan. Still others experience SUDs and problematic substance use off and on at various intervals during their life. Thus, although the maturing out of substance use seems to be the norm (at least in the United States and other industrialized countries – see section “Cultural Differences” for further discussion), it by no means reflects the developmental course of substance use for all individuals.
ADULT ROLES DO NOT ALWAYS LEAD TO DECREASED SUBSTANCE INVOLVEMENT Although transitions into adult roles seem to be a crucial element of maturing out, not all individuals
who engage in adult roles reduce problematic substance involvement. Despite the harms associated with substance use during pregnancy, not all women quit (or even reduce) substance use habits when carrying a child; therefore, parenthood does result in reduced substance use in everyone. NESARC data suggest that entry into marriage is significantly associated with nonabstinent recovery (i.e. low-risk drinking) from alcohol dependence for many people. However, some individuals remained dependent after getting married and these individuals were less likely to subsequently recover from alcohol dependence. Additionally, though becoming a parent doubled the likelihood of becoming abstinent (i.e. eliminating alcohol use), this influence of parenthood was decreased among individuals who remained dependent after three or more years of starting full-time work. Therefore, not all individuals seem to mature out of SUDs after undergoing adult role transitions. There are several reasons why adult role transitions may not always lead to reductions in substance involvement. Some occupations may be more conducive to substance use and misuse than others, and thus occupational obtainment may not always lead to decreased substance use. Occupational obtainment may also result in increased stress, which may result in increased substance use to cope with job-related stress. Positive assortative mating (the tendency for individuals to marry individuals with similar characteristics) may result in couples comprised of individuals who both engage in problematic substance use. Such relationships may not facilitate reduced substance use and, in some cases, may promote it. For example, Kenneth Lenoard and his colleague Gregory Homish found that individuals with antisocial characteristics, a family history of alcoholism, higher levels of negative affect, and positive alcohol expectancies were more likely to engage in postmarital drinking. Drinking after marriage was influenced by partner drinking for both men and women. Decreased relationship quality (which may or may not be related to substance use) also seemed to predict later alcohol problems. The social network of the married couple may also moderate the influence of marriage on subsequent substance involvement. Leonard and Homish showed that the number of “drinking buddies” (i.e. social contacts that primarily involve activities associated with alcohol consumption) for both husbands and wives were longitudinally linked to both heavy drinking and alcohol problems. Taken together, these findings suggest that the characteristics of the individuals entering into marriage, as well as the nature of the marital relationship, moderate the protective influence of marriage on substance use. There is also some evidence that the protective influence associated with adult role transitions may be
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limited to certain age periods. Results from a meta-analysis of several studies suggested that never marrying was significantly related to increased alcohol consumption for men aged 18–39 but not older men. Findings also suggested that marriage/divorce was related to decreased/increased alcohol consumption in young but not older women. Thus, the specific age period in which adult transitions occur may alter the influence of adult roles on substance use.
DEVELOPMENTALLY LIMITED SUDS CAN STILL BE DESTRUCTIVE Research documenting the phenomenon of maturing out suggests that many, if not most, individuals with SUDs during late adolescence and emerging adulthood later recover. Notably, this does not suggest developmentally limited SUDs are somehow benign. Extreme substance use, especially in the case of alcohol, is strongly linked to many of the injuries and deaths that occur during emerging adulthood. Many of the crimes that occur during this time period, such as vandalism, assault, and rape, are also alcohol related. SUDs that occur during emerging adulthood may also have detrimental influences on subsequent occupational and relational obtainment for the individual. Thus, though many individuals recover from SUDs, developmentally limited forms of pathological substance use still result in many negative consequences for societies, families, and individuals.
CULTURAL DIFFERENCES Although most of the research described in this chapter is based largely on US samples, a meta-analysis of studies from ten different countries has suggested an international presence of maturing out. This pattern was consistent across most countries studied, indicating the cultural robustness of this normative trend. However, it should be noted that the countries included in this study (e.g. Germany, Poland, Switzerland, United Kingdom) are similar to the United States in their levels of Westernization/industrialization; thus, caution should be used when generalizing to other countries and cultures. Just as legal drinking ages and drinking customs vary among regions, so too does the manner in which people develop and “grow out” of problematic use. For example, in countries with strict religious affiliations, often any amount of substance use is seen as destructive, whereas other regions that view drinking as an intrinsic part of the culture and heritage may have a more lenient stance on alcohol use. Thus, cultural and regional differences may affect the manner in which people mature
out. Lastly, there is marked variability in the developmental course of SUDs in most, if not all, countries, with many people and subcultures not necessarily following the patterns and trends discussed throughout this chapter.
MATURING OUT IN EMERGING ADULTHOOD – HIGHER RATES OF RECOVERY OR DECREASED ONSET OF NEW CASES? Throughout this chapter, the rapid decrease in prevalence of SUDs that occurs during the third decade of life has been discussed in terms of the high rates of recovery experienced by many emerging adults. However, intriguing new analyses from the NESARC data suggest that much of the rapid decline in the past 12-month prevalence of AUDs may be primarily attributable to a decrease in the rates of new onsets (i.e. new cases of AUDs) rather than increased offsets (i.e. recovery from AUDs) that occur during this time period. These findings suggest that SUDs, such as AUDs, may not be highly stable at any age; that is, recovery from SUDs is not limited to emerging adulthood. Rather, decreases in new cases of AUDs seem to occur more frequently in emerging adulthood than any other age group. Notably, these findings still suggest that AUD diagnoses are less persistent (i.e. a larger percentage of individuals with an AUD diagnosis later recover) during emerging adulthood than in other age periods. Overall, these results highlight the importance of understanding the many factors that contribute to acquisition, persistence, and recovery from SUDs during various age periods.
SUMMARY For many individuals, emerging adulthood represents a time of peak use and misuse of various substances. Substance use during the time period relates to myriad negative consequences that could detrimentally influence life course. Fortunately, many, if not most, of these individuals later mature out of problematic substance use. Notably, these decreases in use typically do not occur in the presence of treatment. Importantly, many individuals continue to use certain substances, such as alcohol, though heavy consumption and negative consequences largely abate. These beneficial decreases are linked to adult role attainment as well as changes in certain personality traits. Despite these normative trends, there is considerable variability in the developmental course of substance use and associated outcomes. Getting older is not a panacea
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for problematic substance involvement. Unfortunately, some individuals continue to engage in risky patterns of consumption and experience negative consequences from substance use throughout their lives. Thus, understanding the contributing factors to risky and potentially chronic patterns of use at all life stages is of paramount importance.
SEE ALSO Alcohol Use Disorders, Impulsivity, Disinhibition, and Risk Taking in Addiction, Interpersonal Factors and Addictive Disorders, Self-Medication, Adolescent Substance Use: Symptoms and Course, Symptoms and Course: Alcohol Use Disorder in Adulthood, Cultural Influences on Youth Alcohol and Drug Use, Costs and Consequences (Morbidity and Mortality) Associated with Adolescent and College Drinking and Related Problems
List of Abbreviations AUDs NESARC SUDs
alcohol use disorders National Epidemiologic Study on Alcohol and Related Conditions substance use disorders
Glossary Constraint a personality trait characterized by the tendency to reflect and deliberate before acting, and avoiding risky behaviors. Broadly, the opposite of impulsivity. Emerging adulthood the transition from late adolescence to adulthood (roughly ages 18–25) that is marked by transitions, increased freedom, and identity explorations and in which peak rates of substance use and substance disorders are observed. Epidemiological a scientific study that focuses on the causes, distribution, and spread of diseases or epidemics within a population. Impulsivity a broad construct of personality that is characterized by the tendency of individuals to engage in behavior without adequate forethought about the plausible negative consequences of their actions. Broadly, the opposite of constraint. Individual differences observed differences in individual characteristics and behaviors. For example, the fact that some people abstain from alcohol, whereas others drink heavily reflect individual differences in alcohol consumption. Maturing out the process of a normative decline in peak problematic substance use that typically occurs across the mid- to late twenties. Maturity principle the theory that people tend to undergo personality changes associated with increased maturity, such as becoming less impulsive and neurotic, thought to develop with the ability to handle the demands of adult roles. Neuroticism a personality trait characterized by the enduring tendency to experience negative emotions and emotional states. Often translated to experiences of anger, guilt, anxiety, and depressed mood. Substance use disorder use of alcohol or other drugs despite problems related to use of the substance. Substance abuse and substance dependence are the primary categories of substance use disorders.
Substance use motives an individual’s reasons for using substances (drugs or alcohol). These include both positively reinforcing (e.g. drinking to enhance positive mood) and negatively reinforcing motives (e.g. drinking to cope with negative moods). Role incompatibility theory a theory that describes the phenomenon when an individual’s societal role (e.g. mother) is not compatible with that individual’s behaviors (e.g. frequent drinking at bars). Role selection the process in which individual differences influence the likelihood of assuming a specific role (e.g. emerging adult marijuana users are less likely to subsequently get married). Role socialization the process in which the assumption of specific roles influence behaviors or other individual characteristics (e.g. marriage tends to result in decreased substance use).
Further Reading Arnett, J.J., 2005. The developmental context of substance use in emerging adulthood. Journal of Drug Issues 35, 235–253. Bachman, J.G., Wadsworth, K.N., O’Malley, P.M., et al., 1997. Smoking, Drinking, and Drug Use in Young Adulthood: The Impact of New Freedoms and New Responsibilities. Lawrence Erlbaum Associates, Mahwah, NJ. Dawson, D.A., Grant, B.F., Stinson, F.S., et al., 2006. Maturing out of alcohol dependence: the impact of transitional life events. Journal of Studies on Alcohol 67, 195–203. Jackson, K.M., Sher, K.J., Schulenberg, J., 2008. Conjoint developmental trajectories of young adult substance use. Alcoholism: Clinical and Experimental Research 32, 723–737. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., 2004. Monitoring the Future: National Survey Results on Drug Use. 1975–2003. In: College Students and Adults Ages 19–45, vol. II. National Institute on Drug Abuse, Bethesda, MD. NIH Pub No. 04-45508. Johnstone, B.M., Leino, E.V., Ager, C.R., Ferrer, H., Fillmore, K.M., 1996. Determinants of life-course variation in the frequency of alcohol consumption: meta-analysis of studies from the Collaborative Alcohol-Related Longitudinal Project. Journal of Studies on Alcohol 57, 494–506. Littlefield, A., Sher, K.J., Wood, P.K., 2010. Do changes in drinking motives mediate the relation between personality change and “maturing out” of problem drinking? Journal of Abnormal Psychology 119, 93–105. O’Malley, P.M., 2004–2005. Maturing out of problematic alcohol use. Alcohol Research and Health 82, 202–204. Raskin White, H., Jackson, K., 2004–2005. Social and psychological influences on emerging adult drinking behavior. Alcohol Research and Health 82, 182–190. Sher, K.J., Gotham, H., 1999. Pathological alcohol involvement: a developmental disorder of young adulthood. Development and Psychopathology 11, 933–956. Sobell, L.C., Ellingstand, T.P., Sobell, M.B., 2002. Natural recovery from alcohol and drug problems: methodological review of the research with suggestions for future readings. Addiction 95, 749–764. Yamaguchi, K., Kandel, D.B., 1985. On the resolution of role incompatibility: life event history analysis of family roles and marijuana use. American Journal of Sociology 90, 1284–1325.
Relevant Websites http://www.jeffreyarnett.com/ – Jeffrey Arnett’s website – detailed discussion of “emerging adulthood.” http://www.niaaa.nih.gov – National Institute of Health – National Institute on Alcohol Abuse and Alcoholism, which includes a list of publications using NESARC data.
I. THE NATURE OF ADDICTION
38 Maturing Out Andrew K. Littlefield, Rachel P. Winograd Psychology Building, Columbia, MO, USA
O U T L I N E Introduction
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Maturing Out: Normative But Not Universal
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Definitions of SUDS
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Documenting Maturing Out
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Adult Roles Do Not Always Lead to Decreased Substance Involvement
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Theoretical Models of Maturing Out
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Developmentally Limited SUDS Can Still Be Destructive
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Why Does the Peak Prevalence of SUDS Occur in the Early Twenties?
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Cultural Differences
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Why Do People Tend to Mature Out of Substance Use? 366
Maturing Out in Emerging Adulthood e Higher Rates of Recovery or Decreased Onset of New Cases?
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Adult Role Attainment and Role Incompatibility Theory
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Summary
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Is Personality Change Associated with Maturing Out?
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INTRODUCTION Perhaps contrasting with popular notions, substance use disorders (SUDs) are largely disorders of young adulthood. Data from several large epidemiological studies indicate that the peak prevalence of SUDs, such as alcohol use disorders (AUDs), occurs during the early twenties and then drops precipitously with age. That is, many of the young adults who experience SUDs during young adulthood later remit (often without receiving treatment). This process of normative decline in problematic substance use is referred to as maturing out. In this chapter, empirical data depicting the rise and fall in the prevalence of SUDs in young adulthood will be summarized. Specifically, theories describing potential mechanisms that contribute to the peak substance Principles of Addiction, Volume 1 http://dx.doi.org/10.1016/B978-0-12-398336-7.00038-3
use observed during late adolescence/early adulthood will be described. In conjunction, theories that depict processes that contribute to maturing out will be covered. Finally, important considerations relevant to the phenomenon of maturing out will be highlighted.
DEFINITIONS OF SUDS Before describing maturing out in more detail, it is important to note current conceptualizations of SUDs. The Diagnostic and Statistical Manual, version IV-TR, defines two major classes of SUDs: substance dependence and substance abuse. The diagnostic criteria for dependence is defined as “a maladaptive pattern of use, leading to clinically significant impairment or distress, as manifested by three (or more) of the
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following symptoms occurring at any time in the same 12-month period: (1) tolerance; (2) withdrawal; (3) the substance is often taken in larger amounts or over a longer period than intended; (4) a persistent desire or unsuccessful efforts to cut down or control substance use; (5) a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects; (6) important social, occupational, or recreational activities are given up or reduced because of substance use; and (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance” (p 197). The DSM-IV defines substance abuse as “a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home; (2) recurrent substance use in situations in which it is physically hazardous; (3) recurrent substance-related legal problems; and (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance” (p 198). These general criteria are applied to the diagnoses for specific substances (e.g. AUDs). According to the DSM-IV’s diagnostic hierarchy, individuals who meet criteria for dependence for a given substance do not receive diagnoses for substance abuse, implying that dependence is the more severe of the two SUDs. However, for reasons that are beyond the scope of this chapter, the abuse/dependence distinction will most likely be eliminated in future versions of the DSM, resulting in the combination of the two classes of SUDs into one substance use disorder diagnosis.
DOCUMENTING MATURING OUT Several studies have documented the peak prevalence of substance use and related negative consequences that occur during the early twenties before declining with age. For example, data from the Monitoring the Future study suggest that heavy drinking (i.e. drinking five or more drinks in a row in the past 2 weeks) peaks at ages 21–22 and then decreases linearly with age. Numerous epidemiological studies have documented the rise and fall of SUDs during the third and fourth decades of life. Nationally representative data (for the United States) from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) clearly indicates that the peak prevalence of SUDs, such as AUDs, occurs during young adulthood and declines sharply with age. Notably, many of the individuals
20 18 16 14 Prevalence
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12 10
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6 4 2 0 18-20 21-24 25-29 30-39 40-49 50-59 60+ Age groups
FIGURE 38.1 Prevalence of alcohol use disorders (AUDs) and drug use disorders (DUDs) from ages 18 to 60 in NESARC data.
who recover from AUDs do not abstain from drinking but rather continue to consume alcohol at more moderate levels. Although some research suggests that heavy drinking among blacks and Hispanics may peak later compared to whites, and that the overall rates of AUDs differ among various racial-ethnic groups, the tendency for AUDs to decline with age is consistent among whites, blacks, Native Americans, Asians, and Hispanics. Similarly, NESARC data indicate that the past 12-month prevalence for drug use disorders (abuse and/or dependence for a broad range of substances including cannabis, cocaine, and heroin) is significantly higher in younger age cohorts (see Fig. 38.1). Thus, agerelated declines in prevalence seem to be robust across substances and, at least in the United States, across racial-ethnic groups.
THEORETICAL MODELS OF MATURING OUT There are two essential questions regarding the phenomenon of maturing out: why does the peak prevalence of SUDs tend to occur in the early twenties, and why is there a dramatic normative decrease in both substance use and SUDs across the third and fourth decades of life? Potential explanations that have been provided by theorists and researchers are summarized below.
WHY DOES THE PEAK PREVALENCE OF SUDS OCCUR IN THE EARLY TWENTIES? Several reasons have been proffered to explain the high rates of substance use and misuse that occur during the transition between late adolescence and adulthood.
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WHY DOES THE PEAK PREVALENCE OF SUDS OCCUR IN THE EARLY TWENTIES?
Theorist Jeffery Arnett referred to the transition from late adolescence to adulthood as emerging adulthood, and describes it as a unique developmental period in which several factors contribute to problematic substance use. According to Arnett, emerging adulthood lasts approximately from ages 18 to 25, though it can extend throughout the twenties and beyond for some individuals, depending on completion of developmental milestones such as marriage and parenthood. Arnett noted significant demographic changes over the past halfcentury in industrialized countries, such as prolonged educational pursuits and subsequent delayed entry into the workforce. This more recent focus on higher education could contribute to a later adoption of adult roles for some individuals. Indeed, compared to previous generations, both men and women are currently getting married and having children at later ages. Arnett suggests these demographic shifts result in the developmental period of emerging adulthood that is characterized by instability, self-focusing, feeling “in-between” adolescent and adult, increased optimism about the future, and identity exploration. As each one of these factors may contribute to delayed acquisition of adult roles, so too might they contribute to the increased use and misuse of substances. For example, there are various forms of instability that are evident during emerging adulthood. As documented by Arnett’s research, individuals frequently change residence, romantic partner, and educational and job status during emerging adulthood. As Arnett explains, this instability could result in anxiety and sadness, resulting in some emerging adults to use substances to “self-medicate” these negative emotions. Emerging adulthood is also a time of exceptional selffocus. As opposed to adolescents (who are governed by parents and teachers) and adults (who have commitments to work and family), emerging adults have relatively few daily obligations to other people. As described by Arnett, self-focusing results in more volatile and ephemeral social networks and friendships, which in turn creates an overall lack of imposed social control compared to other age periods. This lack of social control coupled with relatively fewer responsibilities may also explain the heightened substance use during emerging adulthood. Feeling “in-between” adolescence and adulthood is common during emerging adulthood. Arnett’s research suggests that emerging adults consider reducing substance use and associated risk behaviors (e.g. drunk driving) as crucial criteria for adulthood, even more so than the adult transitions of graduating from college and getting married. However, since emerging adults feel “in-between” adolescence and adulthood, many may consider that this age period is a time where
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substance use is relatively acceptable compared to later age periods. In line with this perception of acceptability, research suggests that perceived norms of substance use is one of the strongest correlates of substance use behaviors among emerging adults. In fact, many emerging adults overestimate rates of peer substance use compared to their own use as well as the general acceptance of substance use and related behaviors. These beliefs may explain why many people engage in substance use during emerging adulthood but not later in life. Arnett also describes emerging adulthood as the “age of possibilities,” that is, a time period when people believe that they can make dramatic changes in their life and optimism for the future is exceptionally high. This optimistic bias, according to Arnett, may result in emerging adults to discount the myriad negative consequences associated with substance use, resulting in increased substance use during this age period. Supporting this conjecture, research suggests that many emerging adults base their decision to drink on perceived positive expectancies of substance use rather than potential risks. Further, Arnett hypothesizes that many emerging adults will have a high sense of well-being and use substances based on enthusiasm, whreas some emerging adults have a lower sense of well-being and use substance to cope with negative emotions. Supporting this notion, a large body of empirical literature suggests that alcohol use is increased among individuals who endorse relatively high levels of enhancement (e.g. I drink to have fun) and coping (e.g. I drink to relieve negative moods) motives to drink compared with individuals with lower levels of these motives. Further, alcohol problems are indirectly related to enhancement motives through increased alcohol, whereas coping motives directly predict alcohol-related problems. Thus, individuals who report higher motivations to drink tend to consume higher amounts of alcohol and subsequently experience more alcohol-related problems. As Arnett describes, identity explorations may include emerging adults’ desire to have a wide range of experiences before transitioning into adulthood, including experimenting with various substances. Further, distress related to forming a stable identity may result in some emerging adults to use substances as a means of coping with identity confusion (though there is limited existing empirical evidence to support this notion). Related to identity exploration, levels of sensation seeking (i.e. the pursuit of novel and intense experiences), a significant predictor of substance use, tend to be higher during emerging adulthood compared to later ages (see section “Why do People Tend to Mature Out of Substance Use?” for further discussion). Therefore, identity explorations that are common during emerging adulthood may contribute to the high prevalence of SUDs.
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In line with Arnett’s description of increased sensation seeking during emerging adulthood is a burgeoning collection of research that suggests overall mean levels of personality traits related to substance use are higher during emerging adulthood than perhaps during any other age period. For example, traits related to impulsivity (a broad construct that is related to making rash decisions and sensation seeking) and neuroticism (the tendency to experience negative emotional states) correspond to the increased use and misuse of a range of substances. For many individuals, these traits may be most pronounced during emerging adulthood and directly and indirectly relate to problematic substance involvement. For example, numerous studies have documented that individuals higher in traits related to impulsivity and neuroticism are more likely to have greater motivation to use alcohol. These motives in turn predict both alcohol use as well as alcohol-related problems. As will be described in more detail later in the chapter, changes in personality and motives across time may also influence the maturing out of substances. In summary, the peak prevalence of substance use and SUDs occurs during emerging adulthood. This age period is marked by several factors that are conducive to substance use, such as increased freedom and exploration (compared to adolescence) and decreased responsibilities (compared to adulthood). Further, compared to older age groups, personality characteristics that are linked to substance use motives, substance use, and associated negative consequences seem to be relatively high during this timeframe. These features may help explain why substance use and misuse is the highest during emerging adulthood.
WHY DO PEOPLE TEND TO MATURE OUT OF SUBSTANCE USE? As noted above, theorists and researchers have provided several explanations of the heightened use and misuse of substances that is observed during emerging adulthood. There is also a large body of work describing why there is a sharp decrease in substance use across the twenties and into the thirties. Primary findings from this literature are summarized below.
ADULT ROLE ATTAINMENT AND ROLE INCOMPATIBILITY THEORY The most prominent explanation as to why many individuals mature out of problematic substance use is the attainment of adult roles. Numerous studies have
documented that transitions into full-time employment, marriage, and parenthood are linked to decreased substance use and substance-related problems, especially alcohol use and misuse. The link between adult role attainment and reduced problematic substance involvement may reflect selection or socialization processes. That is, the link between adult roles and maturing out might reflect the tendency of SUD remitters to later adopt adult roles (i.e. selfselect). Contrastingly, adult roles may influence substance use through socialization processes, such as bringing about increased responsibilities, which result in substance use reduction for individuals who enter into these roles. Work by Denise Kandel and Kazuo Yamaguchi suggests that both role selection and role socialization processes influence substance use. For example, findings suggest that marijuana use is associated with delayed entry into marriage and parenthood (i.e. a selection effect). Marriage and parenthood are also associated with increased rates of stopping marijuana use (i.e. a socialization effect). Additionally, using a longitudinal sample of college students, Kenneth Sher and colleagues concluded that the socialization effect of marriage on later AUDs seems to be more plausible than role selection effects of AUD on later marriage. Data taken from NESARC suggest that the relation between decreased alcohol dependence and getting married and having children reflect socialization processes, whereas the effects of school and work transitions were more consistent with selection effects. Yamaguchi and Kandel proposed that the link between decreased substance involvement and adult roles could be attributed to role incompatibility, that is, adult roles associated with increased responsibility, such as marriage and parenthood, are “incompatible” with heavy substance use. For example, as Patrick O’Malley noted, marriage and parenthood result in numerous changes in social and recreational activities that are not conducive to maintaining a heavy drinking lifestyle. Specifically, compared to single individuals, those who are married attend fewer social functions that are compatible with substance use, such as parties and gatherings at bars. Increased responsibilities associated with child rearing also result in limited time for social activities involving substance use. Indeed, O’Malley noted that parenthood “is the key event” that propels men to reduce their drinking. Further, many women reduce their substance use during pregnancy because of concerns that substances such as alcohol can harm the developing fetus. Thus, many individuals seem to reduce their substance use in the presence of increased responsibilities and reduced free time that are brought about through the assumption of adult roles.
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IS PERSONALITY CHANGE ASSOCIATED WITH MATURING OUT?
IS PERSONALITY CHANGE ASSOCIATED WITH MATURING OUT? Although much of the research involving the maturing out of problematic substance involvement has focused on adult role obtainment, more recent work suggests that changes in personality may also be an important developmental factor. Despite personality being traditionally considered a stable, enduring construct, numerous studies have empirically documented mean level changes in personality across time and especially during emerging adulthood. These changes tend toward increased maturity, with people typically becoming less impulsive and more emotionally stable with age. This tendency has been referred to as the maturity principle. As with decreased substance use, increases in traits associated with maturity have been linked to adult role attainment and experiencing satisfaction in adult roles, such as marital and occupational satisfaction. Recent work by Andrew Littlefield, Phillip Wood, and Kenneth Sher suggests that individual differences in personality change seem to influence the tendency to mature out of alcohol-related problems. That is, despite normative trends, there seems to be significant individual differences in both the tendency to mature out of problematic substance use and to experience increased psychological maturity. Thus, not all individuals show reductions in substance use and misuse or display beneficial changes in personality. Using longitudinal data from a cohort of college students, Littlefield and colleagues demonstrated that changes in neuroticism and impulsivity were linked to changes in alcohol problems from ages 18 to 35. Findings suggested that individuals who displayed sharper declines in neuroticism and impulsivity across this period also were more likely to undergo steeper decreases in alcohol problems. Subsequent analyses suggested these relations remained significantly linked even when adjusting for the influence of marriage and parenthood, demonstrating the unique importance of personality change in addition to the adoption of adult roles. Using data from the same longitudinal sample, Littlefield and colleagues recently demonstrated that a group of individuals characterized by considerable decreases in impulsivity from ages 18 to 25 were more likely to show decreases in alcohol consumption and alcohol-related problems when compared to other groups with high and relatively stable levels of impulsivity. These findings suggest that individuals with relatively high levels of impulsivity who do not show significant decreases in that trait may be less likely to mature out of problematic alcohol involvement. These
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findings are consistent with recent longitudinal data suggesting that individuals who stopped smoking between the ages of 18 and 26 made corresponding larger increases in constraint (a construct considered to be the antithesis of impulsivity) and more pronounced decreases in negative emotionality compared to other individuals. Individual differences in personality change also seem to influence changes in drinking motives, which in turn influence the tendency to experience alcoholrelated problems. Individuals who exhibit more rapid decreases in impulsivity and neuroticism during emerging adulthood also seem to display larger decreases in coping motives to use alcohol. These reductions in coping motives predict more pronounced declines in alcohol-related problems. Thus, changes in personality and reasons for drinking seem to contribute to the maturing out of problematic alcohol involvement and most likely other substances as well. Another potential, though somewhat speculative, explanation of the decline of substance use after emerging adulthood is the ongoing cognitive neurodevelopment that occurs during this timeframe. There is significant development in the prefrontal cortex during adolescence and emerging adulthood. These changes are thought to coincide with subsequent development of several processes, including affect regulation, selfcontrol, cognitive control, and regulating behavior in general. Thus, declines in substance use after emerging adulthood, as well as the ostensibly adaptive personality changes detailed above, may be due in part to cognitive development. In summary, the normative acquisition of roles associated with adulthood seems to strongly relate to the maturing out of substance use. This relationship likely reflects both role selection and role socialization processes. Just as the relatively lower amounts of responsibility and relatively higher amounts of freedom associated with emerging adulthood are conducive to substance use and misuse, the increasing responsibilities and time demands associated with adulthood seem to be largely incompatible with a heavy substance using lifestyle. Individuals also seem to undergo changes in personality during emerging adulthood, and changes in certain personality constructs seem to relate to changes in motives to use substances and decreased substance involvement. Normative cognitive neurodevelopment may also contribute to the maturing out of substance-related problems. In reality, changes in role status, personality, substance use motives, and cognition, as well as other factors, most likely affect each other and interact to produce dynamic, complicated influences on substance use behaviors (Table 38.1).
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TABLE 38.1 Factors Potentially Contributing to Peak SUDs during Emerging Adulthood and Factors Potentially Contributing to Maturing Out Factors potentially contributing to heightened substance use during emerging adulthood
Factors potentially contributing to declining substance use during early adulthood
• Increased freedom/relatively less responsibilities
• Adult role attainment/ increasing responsibilities
• Instability in roles, residence
• Role incompatibility
• Increased self-focus, decreased social demands
• Increased social demands
• Feeling “in-between” adolescence and adulthood
• Neurocognitive development
• Decreased focus on negative outcomes
• Decreased motives to use substances
• Identity exploration
• Identifying as an adult
• Social acceptance of substance use
• Decreased social acceptance of substance use
• Heightened levels of risky personality traits
• Decreases in risky personality traits
MATURING OUT: NORMATIVE BUT NOT UNIVERSAL As described briefly above, there is considerable variability in the developmental course of SUDs. That is, although the normative trend is for rates of substance use and misuse to peak during the early twenties before declining with age, many individuals do not follow this typical pattern. For example, even among substance users, many individuals are not diagnosed with an SUD during emerging adulthood or later in life. Other individuals do not undergo normative decreases in problematic substance use but rather display chronic patterns of heavy use and SUDs across their lifespan. Still others experience SUDs and problematic substance use off and on at various intervals during their life. Thus, although the maturing out of substance use seems to be the norm (at least in the United States and other industrialized countries – see section “Cultural Differences” for further discussion), it by no means reflects the developmental course of substance use for all individuals.
ADULT ROLES DO NOT ALWAYS LEAD TO DECREASED SUBSTANCE INVOLVEMENT Although transitions into adult roles seem to be a crucial element of maturing out, not all individuals
who engage in adult roles reduce problematic substance involvement. Despite the harms associated with substance use during pregnancy, not all women quit (or even reduce) substance use habits when carrying a child; therefore, parenthood does result in reduced substance use in everyone. NESARC data suggest that entry into marriage is significantly associated with nonabstinent recovery (i.e. low-risk drinking) from alcohol dependence for many people. However, some individuals remained dependent after getting married and these individuals were less likely to subsequently recover from alcohol dependence. Additionally, though becoming a parent doubled the likelihood of becoming abstinent (i.e. eliminating alcohol use), this influence of parenthood was decreased among individuals who remained dependent after three or more years of starting full-time work. Therefore, not all individuals seem to mature out of SUDs after undergoing adult role transitions. There are several reasons why adult role transitions may not always lead to reductions in substance involvement. Some occupations may be more conducive to substance use and misuse than others, and thus occupational obtainment may not always lead to decreased substance use. Occupational obtainment may also result in increased stress, which may result in increased substance use to cope with job-related stress. Positive assortative mating (the tendency for individuals to marry individuals with similar characteristics) may result in couples comprised of individuals who both engage in problematic substance use. Such relationships may not facilitate reduced substance use and, in some cases, may promote it. For example, Kenneth Lenoard and his colleague Gregory Homish found that individuals with antisocial characteristics, a family history of alcoholism, higher levels of negative affect, and positive alcohol expectancies were more likely to engage in postmarital drinking. Drinking after marriage was influenced by partner drinking for both men and women. Decreased relationship quality (which may or may not be related to substance use) also seemed to predict later alcohol problems. The social network of the married couple may also moderate the influence of marriage on subsequent substance involvement. Leonard and Homish showed that the number of “drinking buddies” (i.e. social contacts that primarily involve activities associated with alcohol consumption) for both husbands and wives were longitudinally linked to both heavy drinking and alcohol problems. Taken together, these findings suggest that the characteristics of the individuals entering into marriage, as well as the nature of the marital relationship, moderate the protective influence of marriage on substance use. There is also some evidence that the protective influence associated with adult role transitions may be
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limited to certain age periods. Results from a meta-analysis of several studies suggested that never marrying was significantly related to increased alcohol consumption for men aged 18–39 but not older men. Findings also suggested that marriage/divorce was related to decreased/increased alcohol consumption in young but not older women. Thus, the specific age period in which adult transitions occur may alter the influence of adult roles on substance use.
DEVELOPMENTALLY LIMITED SUDS CAN STILL BE DESTRUCTIVE Research documenting the phenomenon of maturing out suggests that many, if not most, individuals with SUDs during late adolescence and emerging adulthood later recover. Notably, this does not suggest developmentally limited SUDs are somehow benign. Extreme substance use, especially in the case of alcohol, is strongly linked to many of the injuries and deaths that occur during emerging adulthood. Many of the crimes that occur during this time period, such as vandalism, assault, and rape, are also alcohol related. SUDs that occur during emerging adulthood may also have detrimental influences on subsequent occupational and relational obtainment for the individual. Thus, though many individuals recover from SUDs, developmentally limited forms of pathological substance use still result in many negative consequences for societies, families, and individuals.
CULTURAL DIFFERENCES Although most of the research described in this chapter is based largely on US samples, a meta-analysis of studies from ten different countries has suggested an international presence of maturing out. This pattern was consistent across most countries studied, indicating the cultural robustness of this normative trend. However, it should be noted that the countries included in this study (e.g. Germany, Poland, Switzerland, United Kingdom) are similar to the United States in their levels of Westernization/industrialization; thus, caution should be used when generalizing to other countries and cultures. Just as legal drinking ages and drinking customs vary among regions, so too does the manner in which people develop and “grow out” of problematic use. For example, in countries with strict religious affiliations, often any amount of substance use is seen as destructive, whereas other regions that view drinking as an intrinsic part of the culture and heritage may have a more lenient stance on alcohol use. Thus, cultural and regional differences may affect the manner in which people mature
out. Lastly, there is marked variability in the developmental course of SUDs in most, if not all, countries, with many people and subcultures not necessarily following the patterns and trends discussed throughout this chapter.
MATURING OUT IN EMERGING ADULTHOOD – HIGHER RATES OF RECOVERY OR DECREASED ONSET OF NEW CASES? Throughout this chapter, the rapid decrease in prevalence of SUDs that occurs during the third decade of life has been discussed in terms of the high rates of recovery experienced by many emerging adults. However, intriguing new analyses from the NESARC data suggest that much of the rapid decline in the past 12-month prevalence of AUDs may be primarily attributable to a decrease in the rates of new onsets (i.e. new cases of AUDs) rather than increased offsets (i.e. recovery from AUDs) that occur during this time period. These findings suggest that SUDs, such as AUDs, may not be highly stable at any age; that is, recovery from SUDs is not limited to emerging adulthood. Rather, decreases in new cases of AUDs seem to occur more frequently in emerging adulthood than any other age group. Notably, these findings still suggest that AUD diagnoses are less persistent (i.e. a larger percentage of individuals with an AUD diagnosis later recover) during emerging adulthood than in other age periods. Overall, these results highlight the importance of understanding the many factors that contribute to acquisition, persistence, and recovery from SUDs during various age periods.
SUMMARY For many individuals, emerging adulthood represents a time of peak use and misuse of various substances. Substance use during the time period relates to myriad negative consequences that could detrimentally influence life course. Fortunately, many, if not most, of these individuals later mature out of problematic substance use. Notably, these decreases in use typically do not occur in the presence of treatment. Importantly, many individuals continue to use certain substances, such as alcohol, though heavy consumption and negative consequences largely abate. These beneficial decreases are linked to adult role attainment as well as changes in certain personality traits. Despite these normative trends, there is considerable variability in the developmental course of substance use and associated outcomes. Getting older is not a panacea
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for problematic substance involvement. Unfortunately, some individuals continue to engage in risky patterns of consumption and experience negative consequences from substance use throughout their lives. Thus, understanding the contributing factors to risky and potentially chronic patterns of use at all life stages is of paramount importance.
SEE ALSO Alcohol Use Disorders, Impulsivity, Disinhibition, and Risk Taking in Addiction, Interpersonal Factors and Addictive Disorders, Self-Medication, Adolescent Substance Use: Symptoms and Course, Symptoms and Course: Alcohol Use Disorder in Adulthood, Cultural Influences on Youth Alcohol and Drug Use, Costs and Consequences (Morbidity and Mortality) Associated with Adolescent and College Drinking and Related Problems
List of Abbreviations AUDs NESARC SUDs
alcohol use disorders National Epidemiologic Study on Alcohol and Related Conditions substance use disorders
Glossary Constraint a personality trait characterized by the tendency to reflect and deliberate before acting, and avoiding risky behaviors. Broadly, the opposite of impulsivity. Emerging adulthood the transition from late adolescence to adulthood (roughly ages 18–25) that is marked by transitions, increased freedom, and identity explorations and in which peak rates of substance use and substance disorders are observed. Epidemiological a scientific study that focuses on the causes, distribution, and spread of diseases or epidemics within a population. Impulsivity a broad construct of personality that is characterized by the tendency of individuals to engage in behavior without adequate forethought about the plausible negative consequences of their actions. Broadly, the opposite of constraint. Individual differences observed differences in individual characteristics and behaviors. For example, the fact that some people abstain from alcohol, whereas others drink heavily reflect individual differences in alcohol consumption. Maturing out the process of a normative decline in peak problematic substance use that typically occurs across the mid- to late twenties. Maturity principle the theory that people tend to undergo personality changes associated with increased maturity, such as becoming less impulsive and neurotic, thought to develop with the ability to handle the demands of adult roles. Neuroticism a personality trait characterized by the enduring tendency to experience negative emotions and emotional states. Often translated to experiences of anger, guilt, anxiety, and depressed mood. Substance use disorder use of alcohol or other drugs despite problems related to use of the substance. Substance abuse and substance dependence are the primary categories of substance use disorders.
Substance use motives an individual’s reasons for using substances (drugs or alcohol). These include both positively reinforcing (e.g. drinking to enhance positive mood) and negatively reinforcing motives (e.g. drinking to cope with negative moods). Role incompatibility theory a theory that describes the phenomenon when an individual’s societal role (e.g. mother) is not compatible with that individual’s behaviors (e.g. frequent drinking at bars). Role selection the process in which individual differences influence the likelihood of assuming a specific role (e.g. emerging adult marijuana users are less likely to subsequently get married). Role socialization the process in which the assumption of specific roles influence behaviors or other individual characteristics (e.g. marriage tends to result in decreased substance use).
Further Reading Arnett, J.J., 2005. The developmental context of substance use in emerging adulthood. Journal of Drug Issues 35, 235–253. Bachman, J.G., Wadsworth, K.N., O’Malley, P.M., et al., 1997. Smoking, Drinking, and Drug Use in Young Adulthood: The Impact of New Freedoms and New Responsibilities. Lawrence Erlbaum Associates, Mahwah, NJ. Dawson, D.A., Grant, B.F., Stinson, F.S., et al., 2006. Maturing out of alcohol dependence: the impact of transitional life events. Journal of Studies on Alcohol 67, 195–203. Jackson, K.M., Sher, K.J., Schulenberg, J., 2008. Conjoint developmental trajectories of young adult substance use. Alcoholism: Clinical and Experimental Research 32, 723–737. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., 2004. Monitoring the Future: National Survey Results on Drug Use. 1975–2003. In: College Students and Adults Ages 19–45, vol. II. National Institute on Drug Abuse, Bethesda, MD. NIH Pub No. 04-45508. Johnstone, B.M., Leino, E.V., Ager, C.R., Ferrer, H., Fillmore, K.M., 1996. Determinants of life-course variation in the frequency of alcohol consumption: meta-analysis of studies from the Collaborative Alcohol-Related Longitudinal Project. Journal of Studies on Alcohol 57, 494–506. Littlefield, A., Sher, K.J., Wood, P.K., 2010. Do changes in drinking motives mediate the relation between personality change and “maturing out” of problem drinking? Journal of Abnormal Psychology 119, 93–105. O’Malley, P.M., 2004–2005. Maturing out of problematic alcohol use. Alcohol Research and Health 82, 202–204. Raskin White, H., Jackson, K., 2004–2005. Social and psychological influences on emerging adult drinking behavior. Alcohol Research and Health 82, 182–190. Sher, K.J., Gotham, H., 1999. Pathological alcohol involvement: a developmental disorder of young adulthood. Development and Psychopathology 11, 933–956. Sobell, L.C., Ellingstand, T.P., Sobell, M.B., 2002. Natural recovery from alcohol and drug problems: methodological review of the research with suggestions for future readings. Addiction 95, 749–764. Yamaguchi, K., Kandel, D.B., 1985. On the resolution of role incompatibility: life event history analysis of family roles and marijuana use. American Journal of Sociology 90, 1284–1325.
Relevant Websites http://www.jeffreyarnett.com/ – Jeffrey Arnett’s website – detailed discussion of “emerging adulthood.” http://www.niaaa.nih.gov – National Institute of Health – National Institute on Alcohol Abuse and Alcoholism, which includes a list of publications using NESARC data.
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