The Development of Externalizing and Internalizing Behaviors Among

Child Psychiatry & Human Development https://doi.org/10.1007/s10578-020-01076-4

ORIGINAL ARTICLE

The Development of Externalizing and Internalizing Behaviors Among Youth With or Without a Family History of Substance Use Disorder: The Indirect Efects of Early‑Life Stress and Impulsivity

A. M. Wasserman1 · J. Wimmer1 · N. Hill‑Kapturczak1 · T. E. Karns‑Wright1 · C. W. Mathias1 · D. M. Dougherty1

Accepted: 2 October 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract Youth with a family history of substance use disorder (FH+) are more prone to have externalizing and internalizing problems compared to youth without a family history of substance use disorder (FH−), increasing the likelihood of later maladjustment. However, mechanisms for this association remain understudied. In this longitudinal study, we examined if FH+ youth are more likely to experience early-life stressors (ELS), which in turn would increase impulsivity and the expression of externalizing and internalizing behaviors. Data were collected from youth and a parent (n = 386) during a baseline assessment (age 10–12 years) and every six months when the youth was 13–16 years old. In support of the primary hypothesis, FH+ youth reported higher levels of externalizing and internalizing behaviors through ELS to impulsivity providing a developmental pathway through which FH+ youth are more prone to externalizing and internalizing problems.

Keywords At-risk youth · Early-life stress · Impulsivity · Externalizing behavior · Internalizing behavior

Introduction relationships, school, etc.). Stress has been widely acknowl- edged as a risk factor for developing externalizing and inter- Adolescence is a developmental stage when externaliz- nalizing problems [14, 15]. FH+ youth, in particular, may be ing (e.g., delinquency) and internalizing problems (e.g., more prone to experiencing ELS. A father or mother with depressed mood) typically manifest [1, 2]. Understanding a substance use disorder may be unable to efectively fulfll the development of externalizing and internalizing problems his or her role as a parent and disrupt the family system during adolescence is crucial because both are considered [16, 17]. The disruption of the family system, in turn, can transdiagnostic processes that may place youth at risk for permeate to other important developmental contexts (e.g., psychiatric disorders (e.g., substance use disorder, afective school, peer relationships [18]) leading to an accumulation disorders) later in life [3–11]. Thus, elucidating mechanisms of stressful life events that the child is unable to cope with through which youth with a family history of substance use efectively. Previous research has supported this, showing disorder (FH+) exhibit higher levels of externalizing and that FH+ youth experience a signifcant amount of stressors internalizing behaviors [12, 13] can reduce the risk for later compared to youth without a family history of substance use psychopathology. disorder (FH−) in a variety of domains [19–21]. We aim to One factor that may explain why FH+ youth display dis- apply these fndings and determine pathways from ELS to proportionately higher levels of externalizing and internal- externalizing and internalizing behaviors among a cohort of izing behaviors is early-life stress or stressors (ELS). ELS adolescents who have a father with a substance use disor- is defned broadly in the present study to include stressors der. Specifcally, in the present study, we propose that one experienced in a variety of contexts (e.g., interpersonal mechanism through which ELS may lead to externalizing and internalizing behaviors is through increased levels of impulsivity (defned as the inability to plan ahead, maintain * A. M. Wasserman attentional control, and regulate behaviors and thoughts). [email protected]

1 Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

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Familial Risk: Pathways to Maladjustment Impulsivity and Externalizing Behavior

Previous literature has examined mechanisms through Increased impulsivity may be one mechanism through which FH+ youth are predisposed to later maladjustment. which ELS may lead to externalizing behavior. Externaliz- For example, a robust fnding is that the disinhibition ing behavior captures a broad spectrum of conduct includ- phenotype [22, 23] is more common among FH+ youth ing aggression, rule breaking, and delinquency [41, 42]. than FH− youth [24–26]. In turn, the greater expression Previous research has shown that while most children dis- of disinhibitory traits has been linked to substance use and play low levels of externalizing behavior over a relatively internalizing and externalizing problems [27, 28]. Simi- stable trajectory, others maintain higher levels of these larly, Chassin et al. have also shown that exposure to a behaviors, putting them at risk for negative life outcomes higher number of stressors and negative afect are other including substance use problems [43]. Furthermore, per- mediators of the relationship between familial risk and sistent antisocial behavior, once established, may be resist- substance use [29, 30]. Thus, prior work has demonstrated ant to change in adulthood, resulting in poorer outcomes that disturbances in afective and regulatory processes are [1, 44] such as mood disorders, substance use disorders, pathways through which FH+ youth are prone to malad- and antisocial behavior [45]. Thus, it is important to study justment. We aim to extend upon prior work by utilizing a the developmental etiology of externalizing behavior dur- longitudinal cohort of FH+ and FH− youth and examine ing adolescence to prevent the life-course persistence of if ELS is related to the development of impulsivity and aggressive or antisocial behavior. externalizing and internalizing behaviors. Overall, the Theoretically, previous literature suggests that there present study aims to examine if (1) the higher number of are underlying neurobiological processes based in both ELS experienced by FH+ youth is related to higher lev- genetic and environmental variation that drive external- els of impulsivity, and that, in turn, (2) higher levels of izing behavior [46]. As proposed by Beauchaine et al. impulsivity provide a possible mechanism for the higher [47], externalizing behavior may be a manifestation of rates of externalizing and internalizing problems relative an underlying imbalance between regulatory and afec- to FH− youth. Each of these relationships are described tive processes, in particular positive emotions [48, 49]. below. Similarly, other theories have proposed a neurobehavioral- disinhibited phenotype characterized by impulsiveness and poor executive function that contributes to the develop- Early‑Life Stress and Impulsivity ment of externalizing behavior [22, 50]. Taken together, externalizing behavior may be a manifestation of an inabil- ELS is thought to increase the risk of psychopathy later in ity to regulate the latent propensity towards aggressive life because it impedes the development of brain regions or delinquent behavior. Prior research has demonstrated in the prefrontal cortex which are implicated in the con- a well-established link between measures of impulsiv- trol of impulsive behavior [31, 32]. Specifcally, as theo- ity and externalizing behavior including: aggression rized by Pechtel and Pizzagalli [33], brain regions that and delinquency during childhood [49] and adolescence are undergoing signifcant development at the time of the [50–52]. Thus, in line with theoretical models and previ- stressor or have a protracted developmental course may ous research, we examined the stable and developmental be particularly prone to the negative efects of ELS. Thus, relationships between impulsivity and externalizing behav- given that the prefrontal cortex has a prolonged period of ior during adolescence. maturation and malleability to environmental infuences, it may be vulnerable to the efects of stressful events during childhood resulting in impulsive behavior. Impulsivity and Internalizing Behavior Prior research has demonstrated a link between ELS and alterations in neurobiological functioning: youth who Although less studied than the relationship between impul- experienced signifcant ELS have altered brain structure sivity and externalizing behavior, heightened impulsiv- [34, 35] and function [36] in the prefrontal cortex which ity may also be one mechanism through which ELS may has been linked to poor self-regulation including poorer lead to internalizing behavior. Internalizing behaviors executive functioning [37, 38] and higher levels of impul- are typically defned as a syndrome of problems includ- sivity [39, 40], the focus of the present study. ing maladaptive thought patterns, feelings of depression or anxiety, withdrawn behavior, and somatic complaints without an apparent physical cause. Dissimilar to externalizing behaviors, internalizing behaviors tend to be more

1 3 Child Psychiatry & Human Development inwardly focused and less outwardly expressed and dis- study sampled a group of youth who had a family history of ruptive. Developmentally, internalizing behaviors reach a substance use disorder and a similar group of youth who did peak around ages 10–12 and remain stable thereafter [53]. not have this have this risk factor. Consistent with previous Importantly, internalizing behaviors have been linked to research, we hypothesized that family history status (i.e., maladjustment during adolescence and adulthood includ- whether or not the youth had a family history of substance ing substance use [5, 6], poor academic achievement [54], use disorder) would directly predict a higher number of ELS and psychiatric disorders [4]. Therefore, understanding [19], the impulsivity growth factors (i.e., mean levels, rate possible mechanisms that might explain individual difer- of change [26]), and the externalizing [63] and internal- ences in the stability and change in internalizing behavior izing behavior growth factors [28]. More importantly, we could prevent long-term maladjustment. sought to extend prior work by elucidating mechanisms While impulsivity has been typically applied to the study through which FH status is related to externalizing and inter- of externalizing behavior, the construct may have implica- nalizing behaviors during adolescence. Three possible mech- tions for internalizing behavior as well, although the pos- anisms through which FH status relates to externalizing and sibility has received less attention. Theoretically, a rapid internalizing behaviors were tested: through ELS, through reaction to negative emotions, particularly to sadness, may the impulsivity growth factors, or through ELS to the impul- increase the risk of internalizing problems in a similar way sivity growth factors. Based on theory and prior research that a rapid reaction to anger or frustration may increase the linking ELS to later neurobehavioral dysfunction [32, 33], risk of externalizing problems [55]. That is, highly impulsive we hypothesized that ELS would predict the growth fac- individuals may have a refexive response to negative emo- tors for impulsivity, which in turn would predict the growth tions and may be unable to override the initial maladaptive factors for externalizing and internalizing behavior. Thus, response, leading to internalizing problems. Likewise, Beau- FH+ youth are expected to have increased rates of external- chaine’s model posits that externalizing behavior is the result izing and internalizing behaviors because they experienced a of a reduced capacity for self-regulation of emotion-based higher number of ELS, which in turn will be related to high processes, could also further our understanding of internal- levels of impulsivity during adolescence. izing behavior as well. Specifcally, internalizing pathology may be due to an imbalance of regulatory and afective processes, in particular avoidant behavior or negative emotions. Method Aspects of poor self-regulation, including impulsivity, that have been traditionally applied to the study of exter- Participants nalizing problems have been shown to predict internalizing problems as well. For example, poor executive function has A community sample of 386 youth ages 10–12 years old been shown to predict high levels of both externalizing and who had not initiated substance use and their parent(s) were internalizing problems [56], poor behavioral inhibition has recruited through various media advertisements (e.g., radio). been related to negative afect [57], and impulsivity has been From the original sample, 305 (79.02%) adolescents had a linked to major depressive disorder [58, 59] and a higher father with a substance use disorder (FH+) and 81 adoles- number of suicide attempts [60, 61]. In summary, while cents had no such family history in their parents or grand- impulsivity clearly has implications for the development of parents (FH−). See Ryan et al. [64] for more details regard- externalizing behavior, the low perseverance and poor regu- ing the study sample. Children were excluded from study lation indicative of impulsive behavior may generalize to entry if they met any of the following criteria: a positive maladaptive cognitive processes, suggesting impulsivity has pregnancy test, urine drug screening, or breath alcohol con- implications for the development of internalizing behavior centration; a diagnosis of a substance use disorder or other as well [62]. psychiatric disorder (with the exception of disorders that are likely comorbid with the development of a substance use The Present Study disorder, for example, attention defcit/hyperactivity disorder); an IQ < 70; or any other signifcant disability. Children In the present study, we examined the relationships between with psychiatric disorders such as ADHD were not excluded ELS, mean levels of and growth in impulsivity ages 13–16, because they typically co-occur with the development of and means levels of and growth in externalizing and inter- substance use problems. Thus, excluding these youth would nalizing behaviors ages 13–16, comparing FH+ youth to have limited the practicality of the study and the data may FH− youth. The overall aim of the present study was to not have been representative of youth with a family history test for possible developmental processes through which of substance use disorder. The prevalence of ADHD across FH+ youth have higher levels of and/or accelerated growth the study period was 29.4%. Participants and their data in externalizing and internalizing behaviors. The present are protected by a Certifcate of Confdentiality from the

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Department of Health and Human Services, and both parents them in terms of their subjective stress (1 = Minimally stress- and adolescents gave their informed consent/assent. All pro- ful to 4 = Extremely stressful). Trained research assistants cedures were approved by the Institutional Review Board. collected further details regarding the event(s) in a subse- The participants who did not meet any exclusionary cri- quent semi-structured interview. Then, the interviewer and teria frst completed assessments at baseline, with follow-up at least three research assistants would meet as a group and appointments occurring roughly every six months thereafter. present each event in a standardized manner. Each research The baseline assessment was about six hours in length, and assistant would provide an objective stress rating (1 = Mini- subsequent appointments averaged about four hours long. At mally stressful to 4 = Extremely stressful). If the group did baseline, both the parent and child were compensated $120, not provide the same rating, the event was discussed in more and at following assessments, the parent received $75 and detail until a consensus rating was reached. In line with past the child received $120. Participants were given opportuni- research [14, 68], the present study used the total number ties to take breaks and given lunch during their appoint- of events as the measure of ELS instead of the subjective or ments. Measurements taken at each time-point included objective rating. Thus, higher values refect a higher number interviews, behavioral tasks, and various self-report forms. of ELS. See Ryan et al. [64] for a description of all study measures. Measurements and variables pertinent to the present study Impulsivity are described below, all of which were screened for skewness and multicollinearity. Adolescents completed the Barratt Impulsiveness Scale Participants were included in the analytic sample if they (BIS; [69]), a self-report measure containing 30 items meas- had data for ELS at baseline and data for the time-varying uring the frequency of impulsive behavior. Questions vary assessments (i.e., impulsivity, externalizing behavior, and from “I am self-controlled” to “I do things without think- internalizing behavior) between the ages of 13–16 for at least ing”, and participants answer on a scale from 1 = Rarely/ one time-point. For the seven longitudinal assessments, the never to 4 = Almost always/always. Per recommendations percentage of available data from the study sample between from Steinberg and colleagues [70], rather than a total score, the ages of 13 to 16 at six-month intervals were as follows: we used the sum of the eight items from the BIS-Brief. The 90%, 83%, 82%, 78%, 69%, 66%, and 59%, respectively. The BIS-Brief has been demonstrated to be a unidimensional median number of time-points completed by the participants construct that is valid and reliable among youth with or was six. without a family history of substance use disorder [71] with higher scores refecting higher levels of impulsivity. Measures The BIS-11 was collected approximately every six months between the ages of 13–16 for a total of seven assessments. Family History Status Cronbach’s alpha to assess reliability ranged from 0.77 to 0.81. Participants were categorized by their family history status based on whether or not the adolescent’s biological father Externalizing and Internalizing Behaviors was diagnosed with a substance use disorder. This was determined based on the parent’s response to the Family The Childhood Behavioral Checklist (CBCL; [72]) was History Assessment Module [65, 66]. Adolescents with a completed by the parent and contains 113 items concerning family history of substance use disorders were classifed their child’s behavior problems that occurred over the past as FH+ (coded as 1), and those without were classifed as six months. Response options ranged from 0 = Not True (as FH− (coded as 0). far as you know) to 2 = Very True or Often True. Externaliz- ing behavior (35 items total) was measured by summing the Early‑Life Stress 17-item Rule Breaking subscale (e.g., “Lying and cheating”) and the 18-item Aggressive Behavior subscale (e.g., “Gets The Stressful Life Events Schedule (SLES; [67]) contains in many fghts”). Internalizing behavior (32 items total) was over 80 items assessing the occurrence of stressful life measured by summing the 13-item Anxious/Depressed sub- events over several categories including education (e.g., scale (e.g., “Nervous, high strung, or tense), 8-item With- getting a bad grade), housing (e.g., changing residences), drawn/Depressed subscale (e.g., “Too shy or timid), and the crime (e.g., victim of a crime), health (e.g., hospitalization), 11-item Somatic Complaints subscale (e.g., “Overtired with- fnances (e.g., fnancial difculties), and interpersonal rela- out a good reason”). The raw scores for the Externalizing tionships (e.g., falling out with a friend). At the baseline Behavior and Internalizing Behavior scales were collected assessment, participants retrospectively documented each approximately every six months between the ages of 13–16 stressful life event that occurred during childhood and rated for a total of seven assessment time-points. Due to positive

1 3 Child Psychiatry & Human Development skewness (range = 1.45–2.70 for externalizing behaviors and Within-variable covariances between the intercept and slope 1.80–2.53 for internalizing behavior), we added the constant factors were freely estimated. one and log-transformed the scores for externalizing and Given that the intercept factors for impulsivity and exter- internalizing behaviors similar to previous studies [73, 74]. nalizing and internalizing behaviors were conditional at age After the transformation, skewness ranged from 0.01 to 0.18 13, we also conducted additional analyses in which they for externalizing behavior and 0.02 to 0.23 for internalizing were reentered at later ages sequentially (i.e., age 13.5, 14, behavior. etc.). These additional analyses were conducted to demon- strate that the results were due to stable between-person Analytic Plan diferences rather than strictly conditional at age 13. Any substantive diference in the fndings when the intercept Descriptive Statistics factor is conditional at later ages compared to when it is conditional at age 13 is discussed in detail. Otherwise, it will To describe the unconditional relationships between each be stated that there was no diference in the results. Lastly, of the variables, bivariate correlations and means are frst pseudo-R2 [75] were computed which describe the amount reported. Note these descriptive analyses were conducted of between-person variance explained by the predictors in with raw total scores rather than transformed scores to make the conditional model for the intercept and slope factors in them more translatable and interpretable to other research comparison to the total amount of between-person variance that have used the same measures. in the unconditional model. All analyses were conducted in Mplus v. 8.1 [76]. Full- Unconditional Growth Models information maximum likelihood (FIML) estimation with robust standard errors was used for all models to account Prior to testing the main study hypotheses, two uncondi- for missing data. The confrmatory ft index (CFI) and root tional growth curve models (i.e., there were no exogenous mean error of approximation (RMSEA) were used to evalu- predictors and model parameters only depended on time) ate model ft with a CFI > 0.90 and RMSEA of < 0.10 indi- were estimated: one model that included the seven assess- cating acceptable ft [77] and CFI > 0.95 and RMSEA < 0.05 ments of impulsivity and externalizing behavior between the indicating excellent ft [78]. Indirect efects were estimated ages of 13–16 and the other that included the seven assess- via MODEL INDIRECT in Mplus with N = 1000 boot- ments of impulsivity and internalizing behavior between the strapped samples to account for the tendency of standard ages of 13–16. These preliminary analyses were conducted errors of indirect efects to be non-normal. Per MacKin- to describe the average rate of change in impulsivity, exter- non et al. [79], the indirect efects were determined to be nalizing, and internalizing behavior and between-person dif- signifcant if both the lower and upper bounds of the 95% ferences in their levels of and average rate of change. confdence interval did not contain zero.

Conditional Growth Models Results To test the main hypotheses, multivariate growth curves were conducted to account for between-person diferences Descriptive Statistics in stability and rate of change for the variables assessed over time. The time-invariant predictors included FH status and Means, standard deviations, and bivariate correlations the number of ELS. The time-varying outcomes included between all study variables are reported in Table 1. The impulsivity, externalizing behavior, and internalizing behav- means for impulsivity tended to decline over time whereas ior. Discrete age categories between 13–16 years old at the means for externalizing and internalizing behaviors six-month intervals were used as the metric of time (seven tended to remain stable. Regarding the bivariate correla- time-points total). A latent variable framework was used to tions between the study variables, as can be seen in the conduct the growth models by estimating an intercept fac- bolded values, FH+ youth tended to report a higher number tor and slope factor. The intercept factor was estimated by of ELS, higher levels of impulsivity, and higher levels of fxing each of the loadings for each of the seven time-points externalizing and internalizing behaviors. ELS also tended to 1. The slope factor was estimated by fxing the loading at to be positively associated with impulsivity, externalizing age 13 to 0, the loading at age 16 to 1, and freely estimating behavior (except at age 16.0), and internalizing behavior the loadings at the intermediate time-points. Consequently, (except at age 15.5). For the time-varying outcomes, con- the intercept factor represents between-person diferences at current correlations as noted with underlined values in age 13 whereas the slope factor represents between-person Table 1 are reported. There was a concurrent positive asso- diferences in rate of change from ages 13–16 years old. ciation between impulsivity and externalizing behavior and

1 3 Child Psychiatry & Human Development .24 22 .18 .20 21 .11 .23 .74 20 .18 .22 .76 .63 19 .16 .24 .79 .72 .66 18 .17 .21 .74 .68 .67 .49 17 .14 .22 .82 .72 .68 .65 .47 16 .20 .24 .69 .68 .66 .64 .68 .56 15 .13 .27 .27 .27 .24 .30 .29 .31 .59 14 .16 .26 .82 .33 .25 .28 .23 .29 .33 .39 13 .19 .25 .80 .36 .69 .34 .29 .36 .36 .38 .49 12 .14 .26 .83 .46 .72 .36 .66 .36 .38 .46 .44 .55 11 .12 .28 .83 .45 .79 .40 .73 .35 .60 .27 .35 .50 .54 10 .13 .28 .81 .48 .81 .45 .76 .39 .67 .33 .62 .29 .37 .57 9 .22 .30 .74 .38 .73 .35 .74 .39 .70 .35 .62 .34 .56 .33 .52 8 .24 .22 .24 .19 .23 .18 .23 .23 .22 .30 .21 .28 .28 .21 .20 .24 7 .79 .19 .22 .17 .26 .23 .17 .19 .14 .19 .14 .19 .19 .18 .17 .25 .20 6 .75 .80 .25 .18 .26 .20 .23 .21 .24 .19 .20 .17 .22 .21 .21 .20 .22 .23 5 .73 .72 .78 .25 .21 .17 .15 .16 .18 .20 .18 .18 .14 .18 .16 .16 .16 .18 .16 4 .67 .71 .73 .76 .25 .15 .19 .19 .15 .17 .19 .16 .13 .18 .20 .15 .20 .16 .21 .19 3 .62 .61 .66 .70 .23 .75 .14 .09 .16 .13 .13 .08 .19 .09 .12 .11 .18 .21 .13 .22 .14 2 .52 .54 .62 .62 .23 .67 .74 .15 .12 .16 .18 .24 .26 .14 .22 .16 .15 .18 .21 .21 .28 .18 1 7.31 4.16 4.32 4.16 4.31 7.98 4.39 4.35 4.34 7.69 7.09 6.14 6.35 8.48 7.92 7.55 6.22 N/A 6.72 9.35 6.72 8.19 7.79 SD .05. Underlined estimates represent inter-variable concurrent correlations inter-variable represent estimates .05. Underlined < 6.79 15.62 15.65 15.74 15.93 15.37 16.03 16.15 16.26 6.61 6.44 6.10 5.85 6.63 6.07 6.74 5.80 N/A 5.89 6.99 6.07 6.71 6.45 M Descriptive statistics and bivariate correlations and bivariate statistics Descriptive variables of study 8. Age 13.0 8. Age 7. Age 16.0 7. Age 6. Age 15.5 6. Age 5. Age 15.0 5. Age 4. Age 14.5 4. Age 23. Early-life stress 23. Early-life 3. Age 14.0 3. Age 2. Age 13.5 2. Age 1. Age 13.0 1. Age 21. Age 16.0 21. Age 19. Age 15.0 19. Age 15. Age 13.0 15. Age 17. Age 14.0 17. Age 13. Age 15.5 13. Age 11. Age 14.5 11. Age 9. Age 13.5 9. Age 20. Age 15.5 20. Age 22. Family history status 22. Family 18. Age 14.5 18. Age 14. Age 16.0 14. Age 16. Age 13.5 16. Age 12. Age 15.0 12. Age 10. Age 14.0 10. Age Externalizing behavior (CBCL) Externalizing behavior Impulsivity (BIS) Impulsivity Internalizing behavior (CBCL) Internalizing behavior 1 Table Estimates in bold are signifcant at p in bold are Estimates

1 3 Child Psychiatry & Human Development internalizing behavior. Lastly, externalizing behavior positively correlated with internalizing behavior concurrently.

Unconditional Growth Models

The unconditional growth model for externalizing behav- 2 ior and impulsivity had excellent ft, = 108.76, df = 93, p < 0.01; CFI = 1.00; RMSEA [90% CI] 0.02 [0.00, 0.04]. Externalizing behavior did not signifcantly change over time on average. Impulsivity signifcantly decreased over time on average; however, there was no signifcant change between ages 13.0 and 13.5 years old. For both externalizing behavior and impulsivity, there was signifcant between-person variability in both the initial mean levels (i.e., at age 13) and the rate of change from ages 13–16. The unconditional growth model for impulsivity and internalizing behavior also 2 had excellent ft, = 140.73, df = 93, p < 0.01; CFI = 0.98; RMSEA [90% CI] 0.04 [0.02, 0.05]. Similar to externalizing behavior, internalizing behavior did not change on average; however, there was signifcant between-person variability in both the initial mean levels and rate of change. For a plot of the predicted trajectories for impulsivity and externalizing and internalizing behaviors by family history status, see Fig. 1. Consistent with the bivariate correlations, FH+ youth had higher levels of impulsivity and externalizing and internalizing behaviors compared to FH− youth that was stable between the ages of 13 to 16 years old.

Conditional Growth Models

Next, to test the study hypotheses, separate conditional growth curve models were estimated for externalizing and internalizing behavior as the primary outcomes. In these models, FH status directly predicted ELS and the growth factors (i.e., intercept, slope) for both impulsivity and externalizing or internalizing behavior. ELS also directly predicted the growth factors for both impulsivity and externalizing or internalizing behavior, and the growth factors for impulsivity directly predicted the growth factors for externalizing Fig. 1 Trajectories for the time-varing outcomes by family history or internalizing behavior. Thus, FH status could indirectly status. Plotted trajectories shown for impulsivity (a), externalizing predict the growth factors for externalizing or internalizing behavior (b), and internalizing behavior (c) by family history status. Gray, shaded areas represent 95% confdence intervals for the growth behavior through three possible mechanisms: (1) through trajectories ELS; (2) through the impulsivity growth factors; and/or (3) through ELS to the impulsivity growth factors. ELS could only indirectly predict the growth factors for externalizing outcomes of impulsivity and externalizing behavior assessed or internalizing behavior through the impulsivity growth between the ages of 13–16. factors. Direct Efects Externalizing Behavior First, the direct efects are reported to test the hypothesis that See Fig. 2 and Table 2 for the model results that tested the FH status would be positively related to ELS, the impulsiv- direct and indirect relationships between the time-invariant ity growth factors, and the externalizing behavior growth 2 predictors of FH status and ELS, and the time-varying factors. Overall, the model had excellent ft, = 136.08,

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Fig. 2 Conditional growth model results for externalizing behav- relationships. Heavier, thicker solid lines indicate a signifcant indi- ior. Standardized estimates shown. Thinner, solid lines indicate sig- rect efect. Double-arrowed lines indicate covariances. For family his- nifcant relationships at p < .05, dashed lines indicate non-signifcant tory status, 0 = negative, 1 = positive df = 113, p < 0.01; CFI = 0.99; RMSEA [90% CI] 0.02 [0.00, growth factors through ELS, the impulsivity growth factors, 0.04]. As can be seen in Fig. 2, any solid black line (both and/or ELS to the impulsivity growth factors. As can be seen thinner and thicker) indicates a signifcant direct efect. in Fig. 2, following the thicker, solid black lines, FH status As expected, FH status directly predicted a higher num- had three signifcant indirect efects predicting higher levels ber of ELS. As shown in the Efects for the Intercept Fac- of externalizing behavior: through a higher number of ELS tor section in Table 2 (one column for impulsivity as the (β = 0.06 [0.01, 0.13]), through higher levels of impulsiv- outcome and the other for externalizing behavior), both FH ity (β = 0.09 [0.03, 0.18]), and through a higher number of status and a higher number of ELS predicted higher initial ELS to higher levels of impulsivity (β = 0.03 [0.01, 0.06]). mean levels of impulsivity and higher initial mean levels of Neither FH status nor ELS directly predicted the impulsivity externalizing behavior. Additionally, higher mean levels of slope factor; thus, no indirect efect was possible. The results impulsivity predicted higher mean levels of externalizing were replicated when the intercept factors for impulsivity behavior. As shown in the Efects for the Slope Factor sec- and externalizing behavior were reentered at later ages, sug- tion in Table 2, a slower rate of decline in impulsivity was gesting that these relationships were stable and not strictly related to a positive rate of change in externalizing behavior conditional at age 13. from ages 13–16. In other words, there was a positive association between the impulsivity and externalizing behavior Internalizing Behavior slope factors. There was no support that FH status or ELS were related to the rate of change in impulsivity or external- See Fig. 3 and Table 3 for the model results that tested the izing behavior. Based on pseudo-R2 computations, the model direct and indirect relationships between the time-invariant explained 10.8% and 0.4% of the between-person variability predictors of FH status and ELS, and the time-varying out- for the impulsivity intercept and slope factor (which were comes of impulsivity and internalizing behavior assessed modeled to be predicted by FH status and ELS), respectively. between the ages of 13–16. The model explained 20.5% and 17.8% of the between-person variability for the externalizing behavior intercept and Direct Efects slope factor (which were modeled to be predicted by FH status, ELS, and the impulsivity intercept and slope factor), First, the direct efects are reported to test the hypothesis that respectively. FH status would be positvely related to ELS, the impulsivity growth factors, and the internalizing behavior growth 2 Indirect Efects factors. Overall, the model had excellent ft, = 162.70, df = 113, p < 0.01; CFI = 0.98; RMSEA [90% CI] 0.03 [0.02, Next, indirect efects are reported to test the hypothesis that 0.05]. As can be seen in Fig. 3, any solid black line (both FH status would indirectly predict the externalizing behavior thinner and thicker) indicates a signifcant direct efect.

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Table 2 Growth model results for early-life stress, impulsivity, and externalizing behavior Efects for early-life stress EST SE STD p <

FH status 4.59 0.84 0.24 .01 Efects for intercept factor Impulsivity Externalizing behavior EST SE STD p < EST SE STD p <

Intercept Factor Intercept Factor Mean 13.18 0.53 – .01 −0.03 0.22 – .91 Intercept Factor Variance 13.82 1.26 0.89 .01 0.68 0.05 0.80 .01 Efects of Time-invariant predictors FH status 1.83 0.49 0.19 .01 0.67 0.11 0.30 .01 Early-life stress 0.11 0.03 0.23 .01 0.01 0.01 0.12 .02 Relations between outcomes IMP Intercept – – – – 0.05 0.02 0.22 .01 IMP Slope – – – – 0.01 0.02 0.03 .74 Random Efect Covariances Within-variable covariance with slope − 4.28 0.98 − 0.40 .01 − 0.07 0.04 − 0.18 .09 Efects for slope factor Impulsivity Externalizing behavior EST SE STD p < EST SE STD p <

Slope factor Slope factor mean − 0.44 0.51 – .38 0.00 0.20 – .99 Slope factor variance 8.47 1.57 1.00 .01 0.23 0.08 0.85 .01 Age 13.0 loading 0.00 – – – 0.00 – – – Age 13.5 loading 0.19 0.08 – .03 − 0.12 0.12 – .33 Age 14.0 loading 0.46 0.10 – .01 0.18 0.14 – .18 Age 14.5 loading 0.69 0.08 – .01 0.30 0.23 – .20 Age 15.0 loading 0.80 0.07 – .01 0.50 0.11 – .01 Age 15.5 loading 0.99 0.07 – .01 0.83 0.12 – .01 Age 16.0 loading 1.00 – – – 1.00 – – – Efects of time-invariant predictors FH status 0.11 0.48 0.02 .81 − 0.02 0.11 − 0.02 .83 Early-life stress − 0.02 0.03 − 0.04 .60 0.01 0.01 0.08 .47 Relations between outcomes IMP intercept – – – – − 0.01 0.01 − 0.04 .72 IMP slope – – – – 0.07 0.02 0.38 .01

EST unstandardized estimate, SE standard error, STD standardized estimate, FH family history (0 = negative, 1 = positive), IMP impulsivity

Similar to the model for externalizing behavior, FH status impulsivity or internalizing behavior. The model explained directly predicted a higher number of ELS. As shown in 16.4% and 19.9% of the between-person variability for the the Efects for the Intercept Factor section in Table 3 (one internalizing behavior intercept and slope factor (which were column for impulsivity as the outcome and the other for modeled to be predicted by FH status, ELS, and the impul- internalizing behavior), both FH status and ELS directly pre- sivity intercept and slope factor), respectively. dicted higher initial mean levels of impulsivity and higher initial mean levels of internalizing behavior. Additionally, Indirect Efects higher levels of impulsivity directly predicted higher levels of internalizing behavior. As shown in the Efects for the Next, indirect efects are reported to test the hypothesis that Slope Factor section in Table 3, a slower rate of decline in FH status would indirectly predict the internalizing behavior impulsivity was related to a positive rate of change in inter- growth factors through ELS, the impulsivity growth factors, nalizing behavior from ages 13–16. There was no support and/or ELS to the impulsivity growth factors. As can be seen that FH status or ELS were related to the rate of change in in Fig. 3, following the thicker, solid black lines, FH status

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Fig. 3 Conditional growth model results for internalizing behav- relationships. Heavier, thicker solid lines indicate a signifcant indi- ior. Standardized estimates shown. Thinner, solid lines indicate sig- rect efect. Double-arrowed lines indicate covariances. For family his- nifcant relationships at p < .05, dashed lines indicate non-signifcant tory status, 0 = negative, 1 = positive had three signifcant indirect efects predicting higher levels 13–16 for externalizing behavior whereas impulsivity was of internalizing behavior: through a higher number of ELS no longer related to internalizing behavior at age 16. This (β = 0.06 [0.01, 0.12]), through higher levels of impulsivity pattern suggests that the efects for externalizing behavior (β = 0.07 [0.02, 0.15]), and through a higher number of ELS are stable across time, whereas the efects for internaliz- to higher levels of impulsivity (β = 0.02 [0.01, 0.05]). When ing behavior may weaken over time. There was no evidence the intercept factors were recentered at later ages, the results that FH status or ELS were related to the rate of change in were still signifcant except at age 16 because the impulsiv- impulsivity and externalizing and internalizing behaviors. ity intercept factor was no longer related to the internalizing FH status and ELS explained 10.8% of the between-person behavior intercept factor. variance in levels of impulsivity but a negligible percent of variance in the rate of change. FH status, ELS, and the impulsivity growth factors explained 20.5% and 16.4% of Discussion the between-person variance in levels of externalizing and internalizing behaviors, respectively, and 17.8% and 19.9% FH+ youth display higher levels of externalizing and inter- of variance in the rate of change, respectively. Overall, our nalizing behaviors [28, 63] during adolescence compared fndings provide support that FH+ youth display higher to FH− youth, although developmental processes underly- levels of externalizing and internalizing behaviors in part ing this association remain understudied. In an extension of because they experience a higher number of ELS, which in prior work [12, 13], we explored if ELS and the development turn was related to higher levels of impulsivity. of impulsivity could explain the diference in the expression of externalizing and internalizing behaviors between Early‑Life Stress and Impulsivity FH+ and FH− youth. Our main fndings were as follows: (1) FH+ youth experienced a higher number of ELS; (2) The neurobehavioral disinhibition phenotype [22, 51, 80] both FH status and a higher number of ELS predicted higher has been shown to be more common among FH+ youth [81]. levels of impulsivity and higher levels of externalizing and However, a gap in the literature is elucidating the possi- internalizing behaviors; (3) higher levels of impulsivity ble environmental risk factors that are responsible for the predicted higher levels of externalizing and internalizing association between this phenotype and family history sta- behaviors and a slower rate of decline in impulsivity pre- tus. The results of the present study address this gap and dicted a positive rate of increase in externalizing and inter- found that the diferences in levels of impulsivity between nalizing behaviors from age 13 to 16 years old; (4) FH status FH+ and FH− youth during adolescence may, in part, have predicted higher levels of externalizing and internalizing their origin in childhood. Specifcally, FH+ youth are espe- behaviors through a higher number of ELS to higher levels cially likely to experience stressful events during child- of impulsivity. The results were stable between the ages of hood [19, 82], which can impede the development of the

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Table 3 Growth model results for early-life stress, impulsivity, and internalizing behavior Efects for early-life stress EST SE STD p <

FH status 4.59 0.86 0.24 .01 Efects for intercept factor Impulsivity Internalizing behavior EST SE STD p < EST SE STD p <

Intercept factor Intercept factor mean 13.18 0.51 – .01 0.33 0.20 – .10 Intercept factor variance 13.88 1.27 0.89 .01 0.53 0.04 0.84 .01 Efects of time-invariant predictors FH status 1.83 0.50 0.19 .01 0.46 0.10 0.24 .01 Early-life stress 0.11 0.03 0.23 .01 0.01 0.01 0.14 .02 Relations between outcomes IMP intercept – – – – 0.04 0.01 0.20 .01 IMP slope – – – – 0.01 0.02 0.04 .68 Random efect covariances Within-variable covariance with slope − 4.32 0.94 − 0.40 .01 − 0.06 0.03 − 0.20 .06 Efects for slope factor Impulsivity Internalizing behavior EST SE STD p < EST SE STD p <

Slope factor Slope factor mean − 0.45 0.48 – .35 0.12 0.19 – .52 Slope factor variance 8.42 1.48 1.00 .01 0.18 0.07 0.87 .02 Age 13.0 loading 0.00 – – – 0.00 – – – Age 13.5 loading 0.19 0.09 – .03 − 0.08 0.62 – .90 Age 14.0 loading 0.47 0.10 – .01 − 0.11 0.75 – .88 Age 14.5 loading 0.70 0.09 – .01 0.18 0.95 – .85 Age 15.0 loading 0.81 0.07 – .01 0.72 0.62 – .25 Age 15.5 loading 1.00 0.08 – .01 0.69 0.43 – .11 Age 16.0 loading 1.00 – – – 1.00 – – – Efects of time-invariant predictors FH status 0.09 0.46 0.01 .84 0.07 0.09 0.07 .40 Early-life stress − 0.01 0.03 − 0.04 .64 0.00 0.00 0.01 .94 Relations between outcomes IMP intercept – – – – − 0.01 0.01 − 0.08 .53 IMP slope – – – – 0.05 0.03 0.33 .04

EST unstandardized estimate, SE standard error, STD standardized estimate, FH family history (0 = negative, 1 = positive), IMP impulsivity prefrontal regions implicated in the regulation of impulsive A Common Framework for Understanding the Role behavior [33]. Consequently, ELS can have lasting neurobe- of Impulsivity on Externalizing and Internalizing havioral efects observed well beyond childhood [36, 83] Behaviors and FH+ youth may be ill prepared for adolescence because they are lagging behind in cognitive development, leading A main fnding from the present study was that impulsivity to heightened impulsivity. This is an especially problematic shared a stable and developmental relationship with both scenario given that limbic regions implicated in emotion externalizing and internalizing behavior, illustrating that processing (e.g., amygdala, ventral striatum) undergo rapid, the two behavior problems may be rooted in common pro- non-linear development and are fully mature during early cesses. We surmise that the neurobehavioral disinhibition adolescence [84, 85]. Thus, youth who experience signif- phenotype provides a unifying theoretical framework for cant ELS may be less able to regulate these afective changes understanding why impulsivity is related to both external- during adolescence because of higher, trait-like levels of izing and internalizing behavior. Central to the phenotype impulsivity, increasing the risk of psychopathology. is an inability to inhibit impulsive tendencies; accordingly,

1 3 Child Psychiatry & Human Development disinhibited youth may have a more rapid reaction to afec- Implications tive processes leading to an increased expression of externalizing and internalizing behaviors [86]. Disinhibited One implication of the present study is that it provides a youth may have a rapid reaction in the context of positive possible mechanism by which ELS is related to adolescent emotions (e.g., surgency) or negative emotions (e.g., sad- maladjustment. Theoretical models suggest that ELS has ness, anger/frustration) and externalize or internalize as a long-term negative efects resulting in impulsiveness, but result. Indeed, research has previously applied the disinhi- consequences of the heightened impulsivity due to ELS bition phenotype to the etiology of externalizing problems remain understudied. Behavioral studies have begun to [87], although recent work has also demonstrated that the link ELS to maladaptive outcomes through its efects on phenotype has implications for the etiology of internal- impulsivity. For example, through its efects on impulsiv- izing problems as well [88, 89]. As suggested earlier, this ity, ELS has been shown to predict later alcohol use and is particularly relevant given that the developmental peak dependence [98, 99], tobacco use [100], and externalizing in afective processing occurs during adolescence. In sum, behaviors such as aggression [101]. However, prior work the neurobehavioral disinhibition phenotype can provide has largely relied on cross-sectional data to test the indi- a common framework for the shared role of impulsivity rect efects of ELS on maladjustment through impulsivity as it pertains to externalizing and internalizing problems. and have focused on adulthood. We extended prior work Another explanation for impulsivity as a common risk by examining longitudinal relationships as well as the factor for externalizing and internalizing behaviors is that efects of ELS on impulsivity during adolescence. they have similar neurobiological underpinnings, particu- Another implication is that perhaps one explanation of larly in regards to dysfunction within the prefrontal cortex the high rates of comorbidity between externalizing and [90–92]. Importantly, while the expression of external- internalizing behavior [102] is that they share common izing and internalizing problems may share common def- risk factors. Specifcally, the present study illustrated that cits within prefrontal regions, the underlying subcortical both ELS and mean levels of impulsivity predicted mean regions that contribute to the expression of externalizing levels of externalizing and internalizing behaviors and that and internalizing may be diferent. Beauchaine et al. [47] growth in impulsivity predicted growth in externalizing theorized that externalizing behavior is due to an inability and internalizing behaviors. While there are shared predic- of the prefrontal regions to regulate subcortical regions tors of externalizing and internalizing behavior, we also implicated in the expression of positive emotions. In an acknowledge there are important sources of divergence extension of Beauchaine’s theory, internalizing behavior between the two as well such as the underlying afective may be a manifestation of the inability of the prefrontal processes. Regardless, the present study implies that one cortex to regulate brain regions implicated in the expres- possible explanation for shared variance between external- sion of negative emotions [93–95]. Thus, the similarity in izing and internalizing behavior is that they have a com- fndings between externalizing and internalizing behav- mon etiology. iors may be due to the underlying dysregulation within the prefrontal cortex shared by both behaviors, which is cap- tured by our measure of impulsivity. However, externalizing problems may be indicative of an inability to regulate Limitations positive emotions whereas internalizing problems may be indicative of an inability to regulate negative emotions. One limitation of the present study is that the measure of To summarize, the neurobehavioral disinhibition ELS was retrospective, introducing a potential bias to the phenotype and/or defcits in prefrontal cortex function- variable. For example, the ELS measure may be biased ing could be possible explanations for the shared role of by participant’s ability to recall stressful events. Plausi- impulsivity in relation to externalizing and internalizing bly, more extreme life events (e.g., a parent dying) are behaviors. We do note, however, that these two explana- more likely to be recalled than less extreme stressful life tions are likely not mutually exclusive considering that events (e.g., temporal family fnancial difculties). How- defcits in prefrontal cortex functioning are fundamental to ever, many studies that include measures of ELS often rely disinhibition phenotype [96, 97]. To be exact, the reduced on retrospective reports (e.g., [40, 99]) considering the functioning within the prefrontal cortex that is indicative difculty of longitudinally assessing stressful life events of the disinhibition phenotype may perturb the capacity to as they occur. Similarly, another limitation is that the regulate subcortical regions implicated in the expression measures in the present study were all self-reported; thus, of positive and negative afect, providing a possible neuro- the relationships between the variables could be infated biological mechanism for the development of externalizing due to a shared method efect. Notably, externalizing and and internalizing problems.

1 3 Child Psychiatry & Human Development internalizing behaviors were assessed with parent reports behaviors. The present study conducted a series of multi- whereas impulsivity was assessed with adolescent reports, variate growth curve analyses to examine if family history reducing the likelihood of a method efect. status was related to mean levels of or growth in external- Another limitation is that impulsivity is a multifaceted izing and internalizing behaviors through ELS and/or mean construct and other aspects of impulsivity or poor regulation levels of or growth in impulsivity. Our results revealed that could share diferent relationships with the study variables. FH+ youth experienced a higher number of ELS, which in We decided to assess the construct of impulsivity with the turn was related to higher levels of impulsivity. The efects Barratt Impulsiveness Scale because it represents a general of ELS on impulsivity were linked to higher levels of exter- propensity for impulsivity including behavioral (e.g., “I act nalizing and internalizing behaviors. In support of the pri- on spur of the moment”) and cognitive processes (e.g., “I mary hypothesis, FH+ youth were exposed to more ELS have racing thoughts”) that likely have implications for both which reduced their ability to regulate impulsive tendencies externalizing and internalizing behaviors. Notably, however, and subsequently increased the expression of externalizing other aspects of impulsivity or related constructs such as the and internalizing behaviors. Importantly, externalizing and capacity to regulate positive or negative emotions may dif- internalizing behaviors serve as transdiagnostic factors that ferentiate between externalizing and internalizing behavior, can increase the likelihood of psychopathology; thus, under- respectively. In other words, while impulsivity, as assessed standing their developmental etiology can inform prevention by the Barratt Impulsiveness Scale, may generalize to both eforts. externalizing and internalizing behaviors, other aspects of regulation (or lack thereof) such as emotion regulation may Acknowledgements Research reported in this publication was supported by NIDA of the National Institutes of Health under Award diferentiate between the two. While we acknowledge this Numbers R01-DA026868 and T32-DA031115. Dr. Dougherty is also limitation, the purpose of our study was to examine the role supported by the William and Marguerite Wurzbach Distinguished of the general inability to regulate impulses as it relates to Professorship. The funding entities had no role in the study design, externalizing and internalizing problems. Lastly, including collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. youth with ADHD has implications for the interpretation of the data. Specifcally, ADHD has been linked to trait impul- Compliance with Ethical Standards sivity [103, 104]. Thus, the relationships between impulsivity and the other study variables could be more pronounced Conflict of interest There are no confict of interests to report. in the study sample compared to other populations that have lower rates of ADHD. We choose to include individuals with Ethical Approval All study procedures were approved by the institu- ADHD to enhance the generalizability of the study fnd- tional review board at the University of Texas Health Science Center at San Antonio. ings, acknowledging this limitation. In conclusion, despite these limitations, the present study extends the literature by Informed Consent Informed consent was obtained from parents of the demonstrating that youth with a family history of substance youth and informed assent was obtained from the youth. A Certifcate use disorder may be more likely to exhibit externalizing and of Confdentiality was obtained from both parents and youth. internalizing problems because they have a higher number of ELS.

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