ارتباط بین ویژگی های روانی اجتماعی نوظهور بزرگسالی و تغییر انگیزش نسبت به مصرف مواد در جوانان

Despite the peak prevalence of substance use and comorbid mental health problems during emerging adulthood little research has focused on understanding behavior change processes during this transitional period. This study extended Arnett's (2004) theory of the psychosocial features of emerging adulthood to explore how they may relate to treatment motivation (e.g., readiness to comply with treatment) and motivation to change (e.g., problem recognition and taking steps towards change). One hundred sixty-four youth presenting to outpatient substance abuse treatment completed questionnaires investigating problematic substance use, mental health, psychosocial features of emerging adulthood and motivation. Results of hierarchical regression analyses indicated that youth who perceived themselves as having greater responsibility towards others were more intrinsically motivated, recognized their substance use as problematic and were taking steps towards change. None of the other dimensions of emerging adulthood accounted for significant variance beyond relevant controls. Limitations, directions for future research and treatment implications are discussed.

Compared to all other age groups across the lifespan, youth in the emerging adulthood period (late teens through early twenties; also termed transition-age youth) engage in more illicit drug and alcohol use (Canadian Center on Substance Abuse, 2007 and Substance Abuse and Mental Health Services Administration (Office of Applied Studies), 2008) and have the highest rates of substance use disorders and comorbid psychiatric problems (Chan et al., 2008 and Substance Abuse and Mental Health Services Administration (Office of Applied Studies), 2008). Frequent or prolonged substance use during adolescence and young adulthood renders youth at increased risk of developing numerous long term adverse effects including chronic illness, cognitive impairment, poor general physical health, concurrent mental health disorders and substance dependence into adulthood (Merline et al., 2004, Rohde et al., 2001, Spirito et al., 2000 and Valdez et al., 2001). Although there is a large body of literature investigating the treatment efficacy and treatment seeking processes of older adults—and more recently adolescents—emerging adults with substance use problems have been largely under-investigated. When compared to adults and adolescents, emerging adults have lower motivation (DiClemente, Doyle, & Donovan, 2009) and demonstrate the poorest outcomes in response to interventions targeting substance use (Satre et al., 2003 and Smith et al., 2011). In order to offer effective services to emerging adults who struggle with their substance use and to prevent long-term substance use related consequences, research is needed to understand how the processes that underlie treatment seeking and behavior change function during this developmental period. Emerging adulthood is generally recognized as the period between the ages of 18 to 25 years old, although some consider it to extend to 30 years old (Arnett, 2000), and it is characterized by developmental markers and processes that are distinct from both adolescence and adulthood in North American youth (Arnett, 2000, Arnett, 2004 and Martin and White, 2005; cf: Hendry and Kloep, 2007 and Smith et al., 2014). During this period, emerging adults begin to make independent decisions regarding academic and/or vocational pursuits, residential arrangements (e.g., living with peers, independently, or remaining in the parental home) and begin to consolidate their own values and beliefs (Arnett, 2004). In addition, youth's primary relationships are also in transition: peers and romantic partners become more intimate and focal to youth identity formation and decision making, and parents tend to exert less power and influence on youth (Beyers and Seiffge, 2007 and Hartup and Stevens, 1997). Although for many young people, this is a period of opportunity and growth, it is also one that is accompanied by significant stress, uncertainty and instability as a result of the new pressures associated with making the transition to adulthood and navigating the world independently (Arnett, 2004, Arnett, 2005 and Martin and White, 2005). Based on qualitative data from structured interviews with emerging adults in multiple settings, Arnett (2004) posited that there are five unique psychosocial features of this developmental period. Emerging adulthood is an age of identity exploration, as youth begin to make independent decisions and discover who they are; it is an age of instability as youth plan and change plans in various areas of their lives (e.g., living arrangements, career, romantic partners); emerging adulthood is the most self-focused life stage, with decreased responsibility to parents; it is an age of feeling ‘in between’ adolescence and adulthood; and it is an age of optimism about future possibilities ( Arnett, 2004 and Arnett, 2006). Notably, Arnett (2005) further hypothesized that each of the psychosocial features of emerging adulthood renders youth at increased risk for substance use. For example, as emerging adults establish their own identities, youth are interested in a wide range of novel experiences that may involve using substances. As well, emerging adults are self-focused, no longer subject to the rules and standards imposed by their parents and not yet committed to romantic partnerships, parenthood, and long term careers. Thus, these youth may be less likely to monitor their behavior to avoid social consequences of substance use. Similarly, emerging adults feel “in between”, capable of making independent decisions regarding substance use but not yet having assumed adult social roles and responsibilities. Recent evidence, however, raises questions about the hypothesized relationships between the psychosocial features of emerging adulthood and substance use for some emerging adults with longstanding substance use problems ( Smith et al., 2014). Accordingly, additional empirical work is needed to examine how features of emerging adulthood contribute to problematic substance use and poor treatment engagement and outcomes. Across varied populations with problematic substance use, studies indicate that motivation for changing problem behavior is among the strongest predictors of engagement in treatment and positive treatment outcome (Broome et al., 2001, DiClemente, 1999, DiClemente et al., 2004 and Wild et al., 2006). Two separate but related motivational constructs critical to understanding why individuals make successful changes to their substance use through treatment seeking are motivation to change ( Prochaska, DiClemente, & Norcross, 1992) and treatment motivation ( Ryan et al., 1995 and Wild et al., 2006). Motivation to change refers to one's personal intentions related to identifying substance use as problematic and taking steps towards change. Treatment motivation refers to an individual's intentions and willingness to seek support through treatment and his/her readiness to engage in that treatment program as a means to change. Several factors have been shown to impact motivation to change and treatment motivation including age, substance use severity and history, perceived substance use consequences and benefits, mental health functioning, social networks, and environmental context ( Barnett et al., 2006, Bijl et al., 2003, Breda and Helfinger, 2004, Broome et al., 2001, DiClemente, 1999, DiClemente, 2003 and DiClemente, 2005 DiClemente et al., 2009, Goodman et al., 2011, Klar, 1992 and Smith et al., 2011). Moreover, motivation to achieve abstinence from substances has been found to predict abstinence in emerging adults receiving residential treatment ( Hoeppner et al., 2014, Kelly and Greene, 2014 and Kelly et al., 2012), although studies with youth in outpatient treatment and/or harm reduction focused treatments are lacking. Accordingly, in addition to the factors described previously, it may be useful to consider the developmental aspects of emerging adulthood and how these processes might relate to substance use change and treatment seeking in this population. For example, while increased identity exploration may be associated with substance use experimentation, it may also relate to an increase in contemplation about changing substance use and other problematic behaviors as youth establish their adult identities. In addition, youth who are more self-focused may perceive fewer external controls and thus be intrinsically motivated to seek treatment. In their investigation of youth reasons for quitting substance use, Smith, Cleeland, and Dennis (2010), found that emerging adults endorsed fewer interpersonal reasons for quitting alcohol use than adolescents, a finding that was partially mediated by the number of days being in trouble with one's family. In contrast, youth who identify having a responsibility towards others may have transitioned into more mature interpersonal relationships with both family and peers and may be more likely to examine their behavior and seek treatment. The present study addresses two focal research questions in an outpatient treatment-seeking sample of youth with substance use concerns: (1) How do the psychosocial features of emerging adulthood relate to motivation to change and (2) How do the psychosocial features of emerging adulthood relate to treatment motivation? This study appears to be the first to explore these relations and no specific hypotheses were generated between the specific psychosocial features and motivation at the outset of the study. However, drawing on the literature regarding changes in substance use during the transition to adulthood, it was anticipated that youth who are farther along developmentally (i.e., closer to adulthood) would be more intrinsically motivated to change and to seek treatment overall. By investigating the developmental factors that motivate young people to seek treatment, this study's goal is to explore the possible constructs necessary to begin to build a developmentally appropriate motivational model that can inform clinical practice and research with emerging adults who present with substance use problems and mental health difficulties. This is particularly important for establishing best practices for this population, whose needs may not be met by either adolescent or adult service systems.

3. Results 3.1. Participant characteristics Respondents' DAST scores ranged from 0 to 20, with a mean score of 11.42, which is in the lower end of the “substantial” range (11–15: Cocco & Carey, 1998), suggesting notable drug use-related consequences experienced within the past year. Participants' AUDIT scores ranged from 0 to 40, with a mean score of 14.88 which is above the clinical cut-off for hazardous or harmful alcohol use and towards the upper limit of the “medium” risk range (8–15; Babor et al., 2001). Just under half of respondents (42.6%; n = 70) scored above 16 on the AUDIT, indicating high levels of alcohol related problems, increased likelihood for dependence, and a greater need for intensive intervention to address their alcohol use. The majority of youth (n = 135; 82.3%) indicated three or more past year internalizing mental health symptoms, suggesting clinically significant internalizing difficulties. Slightly fewer youth, 68.3% (n = 112), reported three or more past year externalizing symptoms, indicating clinically significant externalizing difficulties. With the exception of the other focused subscale, most youth (85–90%) indicated that they perceive that the features of emerging adulthood on the IDEA are characteristic of their current stage of life (‘somewhat’ or ‘strongly’ agree). In contrast, just over half of participants (58%) perceived that being other-focused was characteristic of their current life stage. With respect to treatment motivation 70% (n = 115) of the sample endorsed identified motivation (M = 5.20, SD = 1.52) while in contrast, only 14% (n = 23) of youth indicated external motivation (M = 3.05; SD = 1.32). Finally, approximately one third of respondents (34.5%, n = 57) indicated the presence of introjected motivation (e.g., shame and guilt; M = 3.05, SD = 1.51). On the SOCRATES questionnaires, participants scored in the low to very low range for both recognition (drug: M = 23.96, SD = 7.66; alcohol: M = 22.47, SD = 8.12) and taking steps (drug: M = 27.84, SD = 8.25; alcohol: M = 25.75, SD = 9.28) to change for both drug and alcohol related behaviors. 3.1.1. Intercorrelations between emerging adult variables Correlation analyses were conducted between age and the psychosocial processes associated with emerging adulthood. Interestingly, age was not significantly related to any of the emerging adult psychosocial processes (see Table 2). However, most of these processes were significantly correlated with one another. Of particular note, the experimentation/possibilities subscale was strongly and significantly related to the self focused subscale (r = .71). In addition, identity exploration was moderately and significantly correlated with all of the other psychosocial processes (r > .52) except for the other focused subscale. Although other focused was significantly related to identity exploration (r = .23) and negativity/instability (r = .19), these relationships are weak. Table 2. Bivariate correlations among all variables. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Background 1. Age – 2. Sex .13 – 3. Alcohol problems − .16⁎ .15 – 4. Drug problems − .08 .17⁎ .13 – 5. Internalizing symptoms .13 .33⁎⁎ .22⁎⁎⁎ .32⁎⁎ – 6. Externalizing symptoms .17 .09 .11 .29⁎⁎ .33⁎⁎ – Psychosocial processes 7. Identity exploration − .09 .03 .16⁎ .10 .08 .04 – 8. Experimentation/possibilities .08 .03 .16⁎ .09 .05 − .03 .62⁎⁎ – 9. Negativity/instability .01 .24⁎⁎ .08 .10 .24⁎⁎ .07 .52⁎⁎ .37⁎⁎ – 10. Other focused .11 .01 .09 .07 − .10 .03 .23⁎⁎ .18⁎ .19⁎ – 11. Self focused .09 .06 − .09 .02 − .07 − .01 .59⁎⁎ .71⁎⁎ .30⁎⁎ .42⁎⁎ – 12. In between − .13 .12 − .01 .16⁎ .04 .05 .55⁎⁎ .30⁎⁎ .48⁎⁎ .23⁎⁎ .24⁎⁎ – Motivation variables 13. Recognition alcohol .24⁎⁎ .09 .77⁎⁎ − .03 .05 − .04 .09 .10 < .01 .25⁎⁎ .11 − .05 – 14. Taking steps alcohol .21⁎⁎ .12 .50⁎⁎ .03 .07 − .09 .10 .07 .01 .25⁎⁎ .13 .10 .73⁎⁎ – 15. Recognition drug .10 .02 − .10 .64⁎⁎ .15 .11 − .01 .04 − .02 .19⁎ .06 .03 − .08 − .04 – 16. Taking steps drug .06 .02 − .10 .37⁎⁎ − .03 .03 .17⁎ .06 − .02 .34⁎⁎ .25⁎⁎ .24⁎⁎ .03 .19⁎ .48⁎⁎ – 17. External − .22⁎⁎ − .12 − .04 .12 − .10 .05 .02 − .05 .09 .04 − .10 .06 − .04 − .06 < .01 − .04 – 18. Introjected .12 .08 .19⁎ .38⁎⁎ .16⁎ .02 .11 .10 .12 .33⁎⁎ .14 .18⁎ .21⁎⁎ .22⁎⁎ .48⁎⁎ .33⁎⁎ .15 – 19. Identified .31 .23⁎⁎ .35⁎⁎ .35⁎⁎ .20⁎ .01 .13 .17⁎ .01 .29⁎⁎ .20⁎ .12 .29⁎⁎ .31⁎⁎ .50⁎⁎ .40⁎⁎ − .28⁎⁎ .63⁎⁎ – ⁎⁎⁎ p < .001. ⁎⁎ p < .01. ⁎ p < .05. Table options 3.2. Motivation Several motivation variables were significantly intercorrelated (see Table 2). Most noteworthy, identified motivation was significantly correlated with introjected motivation (r = .63); both were also related to the recognition scale of the SOCRATES (drug) in the sub-sample of youth seeking treatment for problematic drug use (r = .58 and r = .51 respectively). Despite these significant relationships, composite motivation variables were not created due to moderate effect sizes and theoretical reasons for maintaining separate constructs. 3.3. Predicting motivation to change Correlation coefficients were calculated between background variables (age, sex, substance use problems and mental health) and motivation to change (alcohol or drug) outcome variables. As illustrated in Table 2, youth who experienced more severe drug related consequences, as reflected in their higher DAST scores, were more likely to rate their substance use as problematic and indicate they are taking steps towards change on the SOCRATES-D. Youth who experienced greater alcohol related problems as measured by the AUDIT were more likely to identify their alcohol use as problematic on the SOCRATES-A, but this variable was not significantly related to taking steps to change alcohol use in this subsample. Age was the only background variable significantly related to taking steps to change alcohol use such that older youth were more likely to take steps towards change. Correlations were also calculated to explore relationships between emerging adult psychosocial process variables and motivation to change. As shown in Table 2, the other focused subscale was significantly correlated with each measure of motivation to change both alcohol and drug use. In addition, the identity exploration, self focused and in between subscales were significantly and positively correlated with taking steps towards changing drug use but were not significantly associated with any other motivation to change measures. Table 3 shows the results of the hierarchical regression analyses examining motivation to change drug and alcohol use. Each motivation model included only the predictors identified as relevant from correlation analyses. As can be seen in Table 3, background and psychosocial predictors differed based on each measure of motivation. Beta weights are presented to indicate the strength of each variable's individual contribution to the overall model. In youth with drug use concerns, adding the psychosocial process variables at step 2 of the model accounted for unique variance beyond the background variables entered at step 1 for both recognition (ΔR2 = .02, p < .05) and taking steps (ΔR2 = .13, p < .001). Beta weights presented in Table 3 reveal that the other focused subscale remained an important predictor of both recognition (β = .14, p < .05) and taking steps (β = .20, p < .05). The self focused subscale (β = .20, p < .05) was also positively related to taking steps and accounted for unique variance in the model using this subsample. Of note, the severity of participants' drug problems was the strongest predictor in each of the models (β = .64 and .39, ps < .001). In youth who identified alcohol use concerns, the other focused measure added unique variance to alcohol problem recognition (ΔR2 = .06, p < .01) and taking steps (ΔR2 = .07, p < .05) beyond the background variables entered at step 1. Severity of problematic alcohol use (β = .61, p < .001) was the strongest predictor in the recognition model. Age (β = .25, p < .05) was also found to be a significant predictor in the taking steps model for youth with alcohol use concerns. Table 3. Effects of predictors on motivation to change and treatment motivation by analysis. Type of motivation Predictors R2 ΔR2 F β Motivation to change Recognition drug Background variables (step 1) .40 93.77⁎⁎⁎ (n = 133) Drug problems .64⁎⁎⁎ Psychosocial processes (step 2) .42 .02 4.55⁎ Other focused .14⁎ Taking steps drug Background variables (step 1) .16 24.18⁎⁎⁎ (n = 133) Drug problems .39⁎⁎⁎ Psychosocial processes (step 2) .28 .13 5.76⁎⁎⁎ Identity exploration − .11 Other focused .20⁎ Self focused .20⁎ In between .17 Recognition alcohol Background variables (step 1) .37 46.31⁎⁎⁎ (n = 82) Alcohol problems .61⁎⁎⁎ Psychosocial processes (step 2) .43 .06 8.31⁎⁎ Other focused .25⁎⁎ Taking steps alcohol Background variables (step 1) .07 5.59⁎ (n = 82) Age .25⁎ Psychosocial processes (step 2) .14 .07 6.48⁎ Other focused .27⁎ Treatment motivation Identified Background variables (step 1) .29 11.47⁎⁎ Age .35⁎⁎⁎ Sex .15⁎ Alcohol problems .05 Drug problems .35 ⁎⁎⁎ Internalizing disorders − .01 Psychosocial Processes (step 2) .33 .04 2.77⁎ Other focused .17⁎ Self focused .02 Experimentation/possibilities .05 Introjected Background variables (step 1) .18 9.29⁎⁎⁎ Alcohol problems .15⁎ Drug problems .36⁎⁎⁎ Internalizing disorders − .01 Psychosocial processes (step 2) .26 .08 8.91⁎⁎⁎ Other focused .27⁎⁎ In between .05 ⁎⁎⁎ p < .001. ⁎⁎ p < .01. ⁎ p < .05. Table options 3.4. Predicting treatment motivation Correlation coefficients were first calculated between background variables (age, sex, substance use problems, and mental health issues) and treatment motivation. As indicated in Table 2, as age increased, respondents were less likely to report entering treatment in response to external pressure and were more likely to report entering treatment for ‘identified’ reasons (e.g., personal will, values in line with treatment). Also of note, severity of participants' drug problem was significantly related to both introjected and identified motivation. Although not as strong an effect, both alcohol problems and internalizing disorders were also related to both types of internal motivation. Correlation analyses were also conducted to explore whether any of the psychosocial processes of emerging adulthood related to treatment motivation (see Table 2). Youth who reported having being in a life stage with greater responsibility to others (other focused) were more likely to identify intrinsic reasons for seeking treatment (both introjected and identified). Youth with higher ratings on feeling ‘in between’ adolescence and adulthood were also more likely to report seeking treatment for introjected reasons. Finally, youth who believed this stage of their life was a time of greater self-focus and a time of experimentation reported higher identified motivation. Two hierarchical multiple regression analyses were conducted to explore the relative influence of the emerging adulthood dimensions on treatment motivation: one for identified treatment motivation and one for introjected treatment motivation. As age was the only variable related to external motivation, a regression analysis was not conducted for this variable. Only the predictors identified as relevant from the correlation analyses were included in the regression analyses and are represented in Table 3. As can be seen, adding the psychosocial process variables at step 2 accounted for unique variance (ΔR2 = .04, p < .01) in identified motivation above and beyond the contribution of significant background predictors (i.e., age, drug problem severity and sex) entered at step 1; however, being other-focused was the only significant individual psychosocial predictor. When investigating introjected motivation, the addition of the psychosocial process predictors at step 2 of the regression model accounted for additional unique variance (ΔR2 = .08, p < .01) beyond alcohol problem severity and drug problem severity entered as controls in step 1. As with identified motivation, the other focused subscale was the only significant individual psychosocial predictor of introjected motivation. Beta weights presented in Table 3 reveal that the other focused subscale was positively associated with both identified (β = .17, p < .05) and introjected (β = .27, p < .01) motivation. Also of note, the strongest predictor in both treatment motivation regression models was drug problem severity (β = . 35 and .36, ps < .001).