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Impulsivity as a mediating factor in the association between posttraumatic

stress disorder symptoms and substance use

Article  in  Psychological Trauma Theory Research Practice and Policy · May 2020

DOI: 10.1037/tra0000588

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Impulsivity as a mechanism linking child abuse and neglect with
substance use in adolescence and adulthood

ASSAF OSHRI,a STEVE M. KOGAN,a JOSEPHINE A. KWON,a K. A. S. WICKRAMA,a

LAUREN VANDERBROEK,a ABRAHAM A. PALMER,b AND JAMES MACKILLOPa,c,d
aUniversity of Georgia; bUniversity of Chicago; cMcMaster University; and d St. Joseph’s Healthcare Hamilton

Abstract

Emerging developmental perspectives suggest that adverse rearing environments promote neurocognitive adaptations that heighten impulsivity and increase
vulnerability to risky behavior. Although studies document links between harsh rearing environments and impulsive behavior on substance use, the
developmental hypothesis that impulsivity acts as mechanism linking adverse rearing environments to downstream substance use remains to be investigated.
The present study investigated the role of impulsivity in linking child abuse and neglect with adult substance use using data from (a) a longitudinal sample of
youth (Study 1, N ¼ 9,421) and (b) a cross-sectional sample of adults (Study 2, N ¼ 1,011). In Study 1, the links between child abuse and neglect and young
adult smoking and marijuana use were mediated by increases in adolescent impulsivity. In Study 2, indirect links between child abuse and neglect and
substance use were evidenced via delayed reward discounting and impulsivity traits. Among impulsivity subcomponents, robust indirect effects connecting
childhood experiences to cigarette use emerged for negative urgency. Negative urgency, positive urgency, and sensation seeking mediated the effect of child
abuse and neglect on cannabis and alcohol use. Results suggest that child abuse and neglect increases risk for substance use in part, due to effects on
impulsivity. Individuals with adverse childhood experiences may benefit from substance use preventive intervention programs that target impulsive behaviors.

Emerging developmental perspectives on addiction suggest
that children and youth exposed to harsh and unpredictable
rearing environments are hypothesized to develop cognitive
preferences for short- versus long-term rewards (Enoch,
2011; Koob & Kreek, 2007). In the context of a stressful envi-
ronment where resources and opportunities are scarce and
their appearance unpredictable, there is little or no reinforce-
ment for delaying gratification in the hope of larger rewards in
the future. Over time, the developing child “learns” to prefer
immediate rewards, resulting in a tendency toward impulsive
decision making. Accordingly, life experience is seen as
being processed and appraised cognitively, shaping coping
behaviors and bodily responses that support neurocognitive
patterns that are calibrated to an unpredictable environment
(Del Giudice, Ellis, & Shirtcliff, 2011).

Childhood adversity poses a significant risk for substance
use problems in adolescence and young adulthood (Dube
et al., 2003; Oshri, Rogosch, & Cicchetti, 2013; Shin, Ed-
wards, & Heeren, 2009). Child abuse and neglect, in particu-

lar, represent a robust indicator of adverse rearing environ-
ments (Hussey, Chang, & Kotch, 2006; Shin et al., 2009).
Adolescents and young adults exposed to child abuse and ne-
glect report elevated the use of alcohol (Shin, Miller, & Tei-
cher, 2013), cigarettes (Anda et al., 1999), and cannabis
(Oshri, Rogosch, Burnette, & Cicchetti, 2011). Although
the influence of child abuse and neglect on substance use is
well established (Hussey et al., 2006; Shin et al., 2009),
less is known about the neurocognitive mechanism that
may underlie this link.

Early Adversity, Self-Regulation, and Impulsive
Decision Making

Self-regulatory competencies, including engaging in inten-
tional and goal-directed behaviors, are related to brain devel-
opment in the prefrontal cortex. These competencies are con-
solidated through multiple development phases and are
sensitive to the rearing environment (Morris, Silk, Steinberg,
Myers, & Robinson, 2007; Rodriguez et al., 2005). In adoles-
cence and the transition to adulthood, the emergence of self-
regulation is a critical and significant developmental land-
mark that balances and integrates propensities for reward-
seeking behavior that emerges in adolescence (Steinberg,
2005). According to the organizational model of development,
regulated behavior is affected by characteristics of rearing envi-
ronments at the family, school, and community levels (Cicchetti
& Rogosch, 2002; Evans, Gonnella, Marcynyszyn, Gentile, &
Salpekar, 2005). Children reared in stable, responsive, and

Address correspondence and reprint requests to: Assaf Oshri, Department
of Human Development and Family Science, University of Georgia, 208
Family Science Center (House A), 403 Sanford Drive, Athens, GA 30602;
E-mail: [email protected].

This work was partially supported by NIH Grant P30 DA027827 and by NIH
Grand R01-AA024930 and Project Grant 365297 (both to J.M.). Dr. Oshri is a
mentored scientist at the Center for Translational and Prevention Science (P30
DA026285). Dr. MacKillop is the holder of the Peter Boris Chair in Addictions
Research, which partially supported his role. The authors gratefully acknowl-
edge John Acker’s assistance with data collection for the crowd-sourcing study.

Development and Psychopathology, 2017, page 1 of 19
# Cambridge University Press 2017
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sensitive home environments exhibit heightened levels of regu-
latory competence (Brody & Flor, 1997; Deater-Deckard,
2014). Exposure to adverse and chaotic rearing environments
are thought to exacerbate impulsivity through stimulation of
mesolimbic pathways (Koob & Kreek, 2007) and to undermine
the development of self-regulation via decrements in executive
functioning (McEwen, 2008). Accordingly, environmental in-
fluences such as those associated with familial experiences
are central to the development of self-regulatory capacities
and the attendant expression of impulsive decision making.

Recent perspective on stress and development suggest that
life experiences are processed and appraised cognitively,
shaping coping behaviors and accompanied by reorganiza-
tion in the developing brain (Lovallo, 2013). Neurocognitive
adaptations in response to adverse childhood experiences,
such as child abuse and neglect, include dampened stress re-
activity, a propensity to focus on short-term goals, impulsive
response selection, and emotion dysregulation with a prefer-
ence toward negative states; these are all factors that contrib-
ute to impulsive behavior (Lovallo, 2013; Lovic, Keen,
Fletcher, & Fleming, 2011). For example, reports from the
Oklahoma Family Health Patterns Project found that indi-
viduals with a history of adversity exhibited cognitive dysreg-
ulation, including problems with delaying gratification, a core
facet of impulsive decision making (Lovallo et al., 2013; Lo-
vallo, Farag, Sorocco, Cohoon, & Vincent, 2012). Using an
experimental design, Kidd, Palmeri, and Aslin (2013) found
that environmental unreliability affected children’s delay of
gratification. Similarly, a recent study documented links be-
tween child maltreatment and antisocial behaviors in children
via impulsivity (Thibodeau, Cicchetti, & Rogosch, 2015).

Although numerous studies have documented how aspects
of impulsive behavior proximally predict substance use and
abuse (Coskunpinar, Dir, & Cyders, 2013; MacKillop
et al., 2011; Verdejo-Garcı́a, rence, & Clark, 2008), the
developmental hypothesis that impulsivity acts as mechanism
linking adverse rearing environments to downstream sub-
stance abuse remains to be investigated. This gap in the litera-
ture has occurred in part due to the focus of addiction research
on conceptualizing impulsivity as a trait (Kreek, Nielsen, Bu-
telman, & LaForge, 2005), rather than a neurocognitive adap-
tation to demands of the rearing environment. In the present
study, we not only investigate the potential for impulsivity
to act as a mechanism linking adverse childhood experience
experiences to substance use but also respond to calls from re-
searchers to provide more nuanced and multidimensional
characterizations of impulsive decision making (Dick et al.,
2010). We include an examination of impulsivity using
both trait (Whiteside & Lynam, 2001) and delay discounting
(Bickel & Marsch, 2001) perspectives followed by a high-
resolution investigation of impulsivity effects on substance
use employing a multifactorial theory of impulsive behavior.

We address these aims in two studies. Study 1 tests the in-
direct influence of impulsivity in linking childhood abuse and
neglect to substance use in young adulthood. This hypothesis
was evaluated using a national probability sample with a lon-

gitudinal design. This study permitted a proof of principle hy-
pothesis that early adversity, in the form of child abuse and
neglect, would be associated prospectively with impulsive
behavior in adolescence, which in turn would predict sub-
stance use in young adulthood. Although large, longitudinal
samples are ideal for testing broad hypotheses regarding
mechanisms and provide high levels of generalizability, these
samples, rarely, if ever, have fine-grained operationalization
of key concepts. We thus conducted a second, cross-sectional
study where we sampled 1,100 adults who completed multi-
ple measures of impulsivity, assessments of their exposure to
a range of adverse childhood experiences, and their current
substance use. In Study 2, we investigated two perspectives
on impulsivity: one using a self-report measure of impulsive
behavior and the other using a task-based assessment of delay
of gratification. We then conducted additional analyses of the
influence of specific facets of self-reported impulsivity. We
have organized the presentation of these two studies as fol-
lows. We provide an introduction to Study 1, followed by
its methods, results, and discussion. This is followed by a
similarly structured presentation for Study 2. Below we pre-
sent each study in its entirety, followed by an integrative dis-
cussion of the findings across studies.

Study 1

Alcohol, cigarettes, and cannabis are the substances most
commonly used by young people in the United States (Na-
tional Center for Health , 2007). The primary aim
of Study 1 was to evaluate the hypothesis that child abuse
and neglect would predict young adult alcohol, nicotine,
and cannabis use indirectly via impulsivity assessed in ado-
lescence. Youth who were exposed to child abuse and neglect
are expected to have “adapted” to the environment by evinc-
ing a preference for short-term gratification and attendant
difficulties with regulating impulsive behavior. These cognitive
vulnerabilities are known proximal risk factors for substance
use and abuse (Crews & Boettiger, 2009; Garavan, 2011).

In addition to our primary hypotheses, we examined the
potential for sex to modulate the paths linking child abuse
and neglect, impulsivity, and substance use. Sex differences
in self-reported impulsivity are well documented (Cross,
Copping, & Campbell, 2011). Little or no research, however,
has examined the potential for sex to moderate the associa-
tions among child abuse and neglect, impulsivity, and sub-
stance use. Studies of other youth risk behaviors, however,
suggest that sex differences may condition these paths. For
example, Black, McMahon, Potenza, Fiellin, and Rosen
(2015) found that the association between impulsivity and
sexual risk taking was higher for males than for females.
Comparable moderating effects were apparent in an investiga-
tion of the links between impulsivity and health risk behavior
(Stoltenberg, Batien, & Birgenheir, 2008). Although studies
of sex moderation on the association between child abuse
and neglect and impulsivity remain to be conducted, there
is evidence that sex interacts with childhood maltreatment

A. Oshri et al.2

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to predict mental health outcomes (Arnow, Blasey, Hunkeler,
Lee, & Hayward, 2011; Lejuez et al., 2002). Thus, in the pres-
ent study sex differences were investigated in the associations
between child abuse and neglect experiences and impulsivity
and between impulsivity and substance use.

Study hypotheses were tested with prospective data from
National Longitudinal Study of Adolescent to Adult Health
(Add Health). Given that impulsivity was measured during
adolescence at Waves 2 and 3, the Add Health data provided
a unique sample on which to test the proof-of-principle hy-
pothesis that impulsivity would link child abuse and neglect
to drug use in young adulthood. Data from young people at
age 28 permitted assessment of drug use during a time period
when the majority of young people have declined in their use.
Thus, we were able to examine the persistence of drug use
after a common developmental phase in which substance
use is elevated.

Methods

Sample. Add Health is a nationally representative sample of
adolescents in Grades 7–12 in the United States. Baseline
data were collected in 1994–1995 from 20,745 middle and
high school students from 144 schools using a stratified clus-
ter-sampling method. Parents of participating students were
also asked to complete questionnaires at baseline. Data
were collected again in 1995–1996 (Wave 2), 2001–2002
(Wave 3), and 2007–2008 (Wave 4). For inclusion in the pres-
ent study, we used data from all participants for whom Wave
4 sampling weights were calculated (n ¼ 9,421). These
weights corrected for oversampling of smaller population
groups and adjusted for attrition (Brownstein et al., 2011).
Hypotheses were tested with data from the baseline parent
questionnaire (demographics) and Waves 2–4 of the adoles-
cent/young adult interview. In the analytic sample, partici-

pant mean age was 15.2 years, (SD ¼ 1.56) at baseline,
16.2 years (SD ¼ 1.63) at Wave 2, 21.2 years (SD ¼ 1.63)
at Wave 3, and 28.8 years (SD ¼ 1.59) at Wave 4. The sample
was 55.6% female, and the ethnic composition was
Caucasian (56.6%), Hispanic (14.9%), African American
(21.3%), and 7.3% Asian (7.3%). Most adolescents’ parents
(75.5%) had at least a high school diploma. The median fam-
ily income at baseline (1995) was $40,000. The University of
Georgia Institutional Review Board approved analyses of this
secondary data resource.

Measures.

Child abuse and neglect. Exposure to child abuse and ne-
glect was operationalized as a latent construct using four
items obtained from youth at Wave 3. The items asked the fre-
quency of specific child maltreatment experiences prior to
Grade 6. These experiences included supervisory neglect
(“How often were you left home alone?”), physical needs ne-
glect (“not taken care of basic needs”), child physical abuse
(“How often . . . slapped, hit, or kicked you?”), and child sex-
ual abuse (“How often . . . touched you in a sexual way . . .”).
The items were scaled from 0 (never) to 5 (more than 10
times). These items have been used in previous research
and are sensitive to substance use outcomes (Fang & Corso,
2007; Ouyang, Fang, Mercy, Perou, & Grosse, 2008).

Impulsivity. Impulsivity was operationalized as a latent
construct at Waves 2 and 3 using three items. The items
were “I rely on my gut feelings,” “I like to live without think-
ing about the future,” and “I like to take risks.” All items were
assessed on a range from 1 (strongly disagree) to 5 (strongly
agree). To evaluate the dimensionality of the items, confir-
matory factor analysis was performed and is reported in the
Results section (Table 1).

Table 1. Study 1 measurement model estimates of early adversity and impulsivity

Measurement Estimates l SE 95% CI R2

Child abuse & neglect
Supervisory neglect 0.57 19.73 [0.36, 0.46]*** .16***
Physical neglect 0.41 17.55 [0.51, 0.63]*** .36***
Physical abuse 0.46 20.99 [0.42, 0.50]*** .19***
Sexual abuse 0.49 12.23 [0.41, 0.57]*** .28***

Impulsivity Wave 2
Like to take risks 0.38 14.92 [0.33, 0.43]*** .13***
Rely on gut feeling 0.59 24.90 [0.55, 0.64]*** .40***
Lack of future thinking 0.51 24.08 [0.47, 0.56]*** .23***

Impulsivity Wave 3
Like to take risks 0.37 17.03 [0.33, 0.41]*** .12***
Rely on gut feeling 0.62 29.32 [0.58, 0.67]*** .46***
Lack of future thinking 0.56 32.03 [0.52, 0.69]*** .27***

Note: Model fit for Study 1 measurement model: x2 (28) ¼ 113.71, p , .01, root mean square error of approx-
imation ¼ 0.02, comparative fit index ¼ 0.97, standardized root mean square residual ¼ 0.02.
***p , .01.

Adversity, impulsivity, and drug use 3

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Substance use. Substance use was assessed via youth re-
port at Waves 3 and 4. Alcohol, cigarette, and cannabis use
items evaluated past month’s usage: “How many days in the
past 30 days have you used [substance]?” Alcohol and canna-
bis usage was scaled from 0 (none) to 6 (every day or almost
every day), whereas cigarette usage was the number of days in
the last month that the participant smoked at all (0–30).

Covariates. Targets’ age, gender, race/ethnicity (Cauca-
sian, African American/Black, Latino, or Asian American)
and primary caregivers’ education level (0 ¼ , high school
diploma, 1 ¼ high school diploma or GED, 2 ¼ some college
and above) were assessed. Because our primary interest is in
how child abuse and neglect constitutes a chronically harsh
and unpredictable rearing environment, we used posttrau-
matic stress disorder (PTSD) as a proxy to control for acute
trauma. At Wave 1 and Wave 2, participants were asked if
they had ever been diagnosed with PTSD (0 ¼ never diag-
nosed, 1 ¼ has been diagnosed). To accommodate the devel-
opmental timing in the model, a binary indicator was created
based on age at diagnosis of PTSD such that 0 ¼ individuals
who were never diagnosed with PTSD or diagnosed after age
at Wave 2, and 1 ¼ individuals who were diagnosed with
PTSD prior to age at Wave 2.

Data analytic strategy. Hypotheses were tested with struc-
tural equation modeling using maximum likelihood estima-
tion as implemented in Mplus 7.31 (Muthén & Muthén,
2015). To account for the lack of independence in the data
due to cluster sampling within schools, we used the TYPE¼
COMPLEX command (Muthén & Muthén, 2015). A confir-
matory factor analysis was first executed to evaluate the mea-
surement model for impulsivity and child abuse and neglect.
We examined metric and scalar measurement invariance for
the impulsivity construct at Waves 2 and 3, assessing model
fit changes with criteria of change in comparative factor index
(CFI) . 0.01 (Cheung & Rensvold, 2002) and change in
Tucker–Lewis index . 0.02 (Vandenberg & Lance, 2000).
We then specified an indirect effect model where impulsivity
at Wave 3 mediated the influence of child abuse and neglect
on each substance use variable at Wave 4; Wave 2 impulsivity
and Wave 3 substance use were included as covariates. The
standard errors of indirect effects from child abuse and ne-
glect to substance use in adulthood were estimated using
bootstrapping with 5,000 sample replicates (Preacher &
Hayes, 2008). In a final step, we used multiple group analyses
to examine if gender moderated the paths linking child abuse
and neglect, impulsivity, and substance use.

Results of Study 1

Table 2 presents descriptive statistics and bivariate correla-
tions among Study 1 variables. Confirmatory factor analysis
supported the measurement model which fit the data as fol-
lows: x2 (28) ¼ 113.70, p , .001; CFI ¼ 0.97, root mean
square error of approximation (RMSEA) ¼ 0.02, standard

root mean square residual ¼ 0.02. As shown in Table 1, factor
loadings were significant, in the correct direction, and ex-
ceeded 0.36 for the impulsivity and child abuse and neglect fac-
tors. No offending estimates emerged (e.g., negative residual
variances or correlations greater than one). In a second anal-
ysis, we tested for metric and scalar invariance across time in
the impulsivity construct. Results show no significant differ-
ences on the CFI and Tucker–Lewis index across time, con-
firming measurement invariance from Waves 2 to 3.

We next tested the pathway from child abuse and neglect
to each form of substance use at Wave 4 in early adulthood
(controlling for Wave 3) via changes in impulsivity from
Wave 2 to Wave 3. Participants’ age at Wave 1, PTSD diag-
nosis, gender, race, parents’ education level, and family
yearly income were included in the model as covariates.
Among the control variables, male sex predicted elevated
levels of impulsivity (B ¼ –0.03, p , .01), cigarette use
(B ¼ –0.15, p , .05), and cannabis use (B ¼ –0.12, p ,
.01). Age was associated positively with cannabis use (B ¼
–0.02, p , .05). Parental education was positively (B ¼
0.01, p , .05) associated with cannabis use, and negatively
(B ¼ –0.03, p , .05) associated with cigarette use. Parental
education (B ¼ –0.004, p , .001) and household income
(B ¼ –0.005, p , .001) were negatively associated with im-
pulsivity at Wave 3. Diagnosis of PTSD was not significantly
associated with impulsivity at Wave 3.

Modification indices suggested estimating cross-lagged
paths between Waves 3 and 4 measures of cannabis and ciga-
rette use, and eliminating the alcohol use outcome, which was
not significantly predicted by impulsivity. In addition, earlier
levels of substance use (Wave 2) did not significantly predict
impulsivity in Wave 3. Therefore Wave 2 substance use was
trimmed from the structural model. The final model and fit in-
dices are presented in Figure 1, with parameter estimates
shown in Table 3. Child abuse and neglect positively pre-
dicted impulsivity at Wave 3 (B ¼ 0.10, p , .001). In turn, im-
pulsivity at Wave 3 significantly predicted cigarette use at
Wave 4 (B …