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Keywords:

  • adolescents;
  • family relationships;
  • MDMA use;
  • peer relationships;
  • personality

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Abstract  Examination of the correlates of methylenedioxymethamphetamine (MDMA) use is crucial for the development and implementation of effective prevention programs for adolescents. The aim of the present study was therefore to identify the family, peer and individual factors that were related to MDMA use in Taiwanese adolescents. Two hundred adolescents who used MDMA and 200 who did not use MDMA were recruited into the study. The family, peer and individual factors related to MDMA use were examined using χ2 automatic interaction detection (CHAID) analysis. The results indicated that the adolescents who had more friends involved with substance use, disruptive family and attitude favoring MDMA use were more likely to use MDMA. Multiple factors of family, peer and individuals were related to MDMA use among Taiwanese adolescents. This knowledge may be helpful when designing and implementing preventive intervention programs.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Methylenedioxymethamphetamine (MDMA), commonly known as ecstasy, has potentially acute and long-term toxicity, including neurophysiological and possible neurocognitive changes.1,2 Although in some studies the MDMA-related cognitive dysfunction was attributed to the effects of polydrug use,3,4 MDMA use has been considered to have independent adverse effect on cognitive dysfunction.5,6 MDMA use has also been found to result in cognitive impairments in adolescents.7 Since 2002 MDMA has exceeded methamphetamine and become the most frequently abused illicit drug among adolescents in Taiwan. In a street outreach program to Taiwanese adolescents aged between 16 and 18 years, 14.5% of adolescents with truancy experience and 2.7% of adolescents without truancy experience had used MDMA.8 As in other countries, adolescent MDMA use has become a major public health issue in Taiwan.

Until now, the majority of research on MDMA use has covered many aspects of medical science, including molecular neurochemistry, experimental psychology, neuropharmacology, clinical psychopharmacology and toxicology.9 Research that takes an in-depth look at the correlates of MDMA use is limited,10 although this is crucial for the development and implementation of effective prevention programs for adolescents.11 Concurrent substance use, including tobacco,12–14 alcohol,12,14 marijuana,10,12–14 lysergic acid diethylamide (LSD),13 and cocaine13 are related to MDMA use in adults and college students. However, adolescent substance use is often a hidden behavior and hard to detect. The correlates of MDMA use, beyond concurrent substance use, have seldom been examined. Previous studies have found that positive attitudes towards MDMA use,11,15 friends' MDMA use,13 and spending large periods of time socializing with friends14 increases the risk of MDMA use in the adult population. However, only one study has considered family, social and individual characteristics when considering correlates of MDMA use among adolescents: adolescents who were older, male, and less supervised by their families and who had already used alcohol, marijuana, heroin and/or cocaine were more likely to use MDMA.16 Adolescent development is the result of multi-system interactions.17 The association between adolescent MDMA use and individual, family and peer characteristics needs to be evaluated in further studies.

The aim of the present study was to identify the individual, family and peer factors that were related to MDMA use in Taiwanese adolescents. The influence of family (living with parents, parents' marriage status and education level), peer (feeling part of a peer group, socializing with peers and peers' delinquent/substance-using behavior) and individual factors (age, education, personality and attitude toward ecstasy use) were examined using χ2 automatic interaction detection (CHAID).

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Study population

Taiwan's juvenile justice act requires adolescents arrested for illicit drug use to undergo a 1–2-month detoxification program at an abstinence center sponsored by the Ministry of Law. The Ministry of Justice invites psychiatrists to gather psychological, behavioral and familial information from juvenile drug users to determine the risk of relapse and, when appropriate, to intervene in the management of deviant behavior. In the present study 200 adolescent MDMA users (128 male, 72 female) were recruited consecutively from a juvenile abstinence center in southern Taiwan from September 2003 to December 2005. Those who refused an interview (n = 3) and those unable to complete all assessments at discharge (n = 4) were excluded. The protocol was approved by the Institutional Review Board of Kaohsiung Medical University.

For comparison purposes, 243 students who reported that they had never used MDMA were randomly selected from six classes of a senior high school and a vocational school in southern Taiwan. We confirmed MDMA use/non-use in two ways. First, we delivered a questionnaire to parents to confirm their child's MDMA use. A total of 221 parents of students returned the questionnaire and confirmed that their child had never used MDMA. Second, after providing written informed consent, the 221 students underwent a urine test to determine their MDMA use. Urine drug screening was performed using the Microgenics CEDIA amphetamine/Ecstasy assay (Microgenics, CA, USA.) on an Hitachi 717 autoanalyzer (Hitachi, Tokyo, Japan). Concentrations of the cut-off calibrators for the immunoassays is 500 ng/mL. Positive samples were confirmed, extracted by solid phase extraction and heptafluorobutyric anhydride (HFBA) derivation. The result of urine screening indicated that only one student had an equivocally positive reaction. Although further examination confirmed that the result was negative for MDMA use, this student was excluded. Finally, a total of 200 adolescents (128 male, 72 female), matched with the MDMA use group by gender, were randomly selected from these 220 students. No difference in age (16.8 ± 1.1 vs 16.9 ± 0.7 years, t = 0.508, P > 0.05) or educational level (9.4 ± 0.7 vs 9.5 ± 0.5 years, t = 1.582, P > 0.05) was found between MDMA use and non-use groups.

Assessment

Adolescent Family and Social Life Questionnaire

The family dimension of the Adolescent Family and Social Life Questionnaire (AFSLQ) examined whether adolescents lived with their parents, whether the parents' marriage was intact and whether the parents' education level was >9 years.18 The social life dimension consisted of four subscales: adolescent's rank within and subjective perception of their peer group; active interaction with peers; peers' delinquent behavior; and peers' substance-use behavior,18 with a Cronbach's alpha ranging from 0.65 to 0.75. Higher scores on the social life dimension indicate higher rank within and increased satisfaction with status in the peer group, more active interaction with peers, fewer peers with delinquent behavior and fewer peers with substance-use behavior.

Tridimensional Personality Questionnaire

The Chinese version of the Tridimensional Personality Questionnaire (TPQ) contains 100 self-administered true–false questions designed to measure novelty seeking (NS), harm avoidance (HA) and reward dependence (RD) dimensions of personality.19,20 Each dimension has four subscales. Higher scores indicate higher NS, HA and RD tendencies. The 1-month test–retest reliability was 0.62–0.76. It also had acceptable construct validity.21

Questionnaire on Attitudes toward Ecstasy Use

The Questionnaire on Attitudes toward Ecstasy Use (QAE) was modified from a questionnaire originally used for examining attitudes toward methamphetamine use.22 The QAE contained 30 four-point items that assessed the attitudes of subjects toward MDMA use, with a Cronbach's alpha of 0.84. Higher QAE scores indicated that the subjects had an attitude favoring MDMA use.

We ascertained participants' salient sociodemographic factors, including sex, age and education. We also assessed the characteristics of MDMA use for the participants who had previously used MDMA, including age at first exposure, average expenditure and frequency of use.

Procedure and statistical analysis

Written informed consent was obtained from all participants prior to study commencement. All participants completed all questionnaires based on the explanations of the research assistants and under their direction. Stepwise CHAID using Answer Tree 3.1 software (SPSS, Chicago, IL, USA) was used to detect mutually exclusive subgroups of the sample that differed markedly in regard to rate of MDMA use. The analysis selected the best predictors of the outcome and divided the sample into subgroups based on that variable while merging non-significant categories. This process was repeated within each subgroup until no further predictors could significantly contribute to the analysis. Compared with the logistic regression analysis, the CHAID analysis directly considers the interaction between variables. The continuous variables were transformed into dummy variables by their median scores. Because this is an exploratory procedure we investigated the replicability of the resulting subgroup categories by conducting the analysis on three-quarters of the sample (training sample) and by examining the replication with the remaining one-quarter (testing sample). P < 0.05 was considered statistically significant.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Among the 400 adolescents surveyed, 256 (64%) were male, the mean age was 16.8 ± 0.9 years (range 14–19 years) and the mean education level was 9.4 ± 0.6 years (range 7–12 years).

The results of stepwise CHAID for the training sample are shown in Fig. 1 (ϕ = 0.706; agreement coefficient, 0.853; κ = 0.705; P < 0.001). The results indicated that the first and the most significant variable selected was the number of peers who used substances. Altogether, 84.18% of the adolescents who had many friends using substances (median ≥4.57) had used MDMA, whereas 13.48% of the adolescents who had few friends using substances (median <4.57) had used MDMA (χ2(d.f. = 1) = 149.022, P < 0.001). Among the adolescents who had many friends using substances, disruptive family was another discriminating factor: 98.41% of those whose parents' marriages had broken up used MDMA versus 74.74% of those whose parents' marriages were intact (χ2(d.f. = 1) = 15.942, P < 0.001). In contrast, among the adolescents who had few friends using substances, attitude toward MDMA use had an influencing effect: 22% had used MDMA of those who tended to favor MDMA use (median >38) versus 8.79% of those who tended to reject MDMA use (median ≤38; χ2(d.f. = 1) = 4.829, P < 0.05). Other factors, including age, education, personality, living with parents, parents' education level, feeling part of the peer group, socializing with peers and peers' delinquent behavior, were not significantly related to MDMA use on CHAID.

image

Figure 1. Stepwise χ2 automatic interaction detection of factors related to ecstasy use in the training sample of adolescents (n = 299). MDMA, methylenedioxymethamphetamine.

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The results of stepwise CHAID for the testing sample are shown in Fig. 2 (ϕ = 0.646; agreement coefficient, 0.822; κ = 0.644, P < 0.001). As with the results of the training sample, the number of friends using substances (χ2(d.f. = 1) = 149.022, P < 0.001), disruptive family (χ2(d.f. = 1) = 4.829, P < 0.001) and the adolescent's attitude toward ecstasy use (χ2(d.f. = 1) = 15.942, P < 0.05) were the factors related to MDMA use in the testing sample. This indicated that the results of the CHAID analysis were replicable.

image

Figure 2. Stepwise χ2 automatic interaction detection of factors related to ecstasy use in the testing sample of adolescents (n = 101). MDMA, methylenedioxymethamphetamine.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The results of the present study indicate that the number of friends using substances, disruptive family and the adolescent's attitude toward MDMA use are the factors significantly related to MDMA use in Taiwanese adolescents. These factors can be split into two groups: modifiable and unchangeable.16 In the present study disruptive family was the factor that was unchangeable, and having friends who used substances and attitude toward MDMA use were potentially modifiable. Programs planned and implemented to prevent MDMA use should focus on correctable risk factors. Meanwhile, adolescents' families and teachers should closely monitor those who are in the high-risk group.16

The number of peers who use substances was the most significant factor related to MDMA use in Taiwanese adolescents. It has consistently been found that substance use among peers is the strongest predictor of substance use in the young.22,23 However, Bauman and Ennett have suggested that the association between individual and peer substance use may primarily be due to the tendency for adolescent users to select similarly inclined companions, projecting their own drug use when assessing their peers.24 However, this causal relationship could not be confirmed by the present cross-sectional study. Nevertheless, preventing adolescents from having contact with substance-using peers and teaching them the skills necessary to refuse an invitation to use MDMA may reduce the risk of temptation.

The present study also found that disrupted family was a powerful family factor. Of the many forces that influence adolescent mental health, the most fundamental are the social contexts in which adolescents are embedded,25 and the family contexts are among the most critical.26 Disruptive family may reduce family support and monitoring, deepening family conflict and so increase the risk of MDMA use.

In the present study the parents' level of education did not independently influence adolescent MDMA use. However, the results of previous studies on this association came to different conclusions. For example, Turkish mothers who have a higher level of education have more chance of securing a job, which may result in less time to monitor their child's MDMA-using behavior.16 Whereas Italian fathers with a lower level of education may not have adequate skills and knowledge to prevent their offspring from using MDMA.27 It is necessary to take social contexts into consideration when examining the influence of parents' education on adolescent MDMA use.

The present study found that a positive attitude toward MDMA use was associated with MDMA-using behavior, which further supported the results of previous studies.11,15 In Taiwan MDMA is known colloquially as ‘head-rocking pills’ or ‘happy pills’, and the users expect MDMA use to induce a euphoric mood and close feelings for others. These simplistic expectations may thus increase the risk of recidivism. If the anticipated consequences are evaluated as being positive and, at the same time, the negative consequences are evaluated as not apparent, people are more likely to start and continue using specific substances.28 Development of strategies to improve adolescent attitudes to and knowledge of the consequences of MDMA use may prevent initiation and habituation of MDMA use.

NS is thought to reflect the brain's incentive, or behavior activation system and is associated with the dopamine system.29 People with high NS readily engage in new interests and activities.19 HA is thought to reflect variation in the brain's punishment or behavior inhibition system. Those with low HA are confident, optimistic, carefree, uninhibited, and energetic.19 RD is thought to reflect variations in the brain system that facilitates acquisition of conditioned signals or reward or relief from punishment.19 Adolescents with low RD are impaired in responsiveness to verbal approval and social reinforcement and have poor persistence.19 Thus, previous studies have reported that high NS,21,30–33 low HA32–34 and low RD21,33 on the TPQ are associated with adolescent substance abuse. However, in the present study personality on the TPQ did not significantly influence MDMA use. We further compared the scores on the subscales in each dimension between MDMA use and non-use groups and found that scores on the subscales in the NS and HA dimensions were not in the same direction. For example, while MDMA users had higher score on the NS subscale of extravagance versus reserve than MDMA non-users (3.7 ± 1.6 vs 3.1 ± 1.7), MDMA non-users had higher score on the NS subscale of disorderliness versus regimentation than MDMA users (5.8 ± 1.6 vs 4.2 ± 1.9). While the score on the HA subscale of fear of uncertainty versus confidence was higher in MDMA users than in MDMA non-users (5.1 ± 1.7 vs 4.4 ± 1.9), the score on the HA subscale of fatigability and asthenia versus vigor was higher in MDMA non-users than in MDMA users (4.1 ± 2.6 vs 3.4 ± 2.4). These results indicated that the factor structure of the TPQ in the present participants was not the same as in the original study of Cloninger,19 which may account for the present result that personality on the TPQ was not significantly related to MDMA use.

The present results must be interpreted in light of several limitations. First, although determining the causal relationship between MDMA use and the associated factors was not the main objective, the cross-sectional nature of the present study has limited the ability to draw conclusions about the causal relationship of MDMA use with attitudes toward MDMA use and the number of friends using substances. Second, despite examination of various individual and environmental factors, some factors that may affect MDMA use among adolescents remained unmeasured. For example, adolescent psychopathology was not explicitly assessed in the present study. Third, although we confirmed non-user status by urine tests and parents' observation, underreporting of MDMA use by the MDMA users was still a possibility.

In the present study multiple factors of family, peer and individuals were found to influence MDMA use among Taiwanese adolescents. The factors identified may be helpful when designing and implementing preventive intervention programs. Preventing adolescents from having contact with substance-using peers and teaching them the skills necessary to refuse an invitation to use MDMA may reduce the risk of temptation. Strategies to improve adolescents' attitudes toward MDMA use should be implemented both on school campuses and in the community as early as possible, and in such a way that will capture the adolescents' attention and persuade them to avoid MDMA use. Although it is impossible to change family background, early monitoring of the possibility of involvement with MDMA use should be commenced for adolescents with disrupted family.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

This study was supported by a grant from the Chi-Mei Medical Center and Kaohsiung Medical University Research Foundation (94-CM-KMU-16).

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
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