Children with co-occurring persistent pain and mental health symptoms face higher risk for early substance use, but the strongest predictors of whether a child starts using alcohol, tobacco or cannabis by age 14 are family environment and peer influence, a new University of Michigan study found.
The study, funded by the National Institutes of Health and National Institute on Drug Abuse, analyzed five years of data from the federally funded Adolescent Brain and Cognitive Development Study.
Researchers from the U-M School of Nursing and Michigan Medicine found that children experiencing co-occurring symptoms, such as persistent or worsening pain, anxiety and depression, were 40% more likely to initiate use of alcohol, tobacco or marijuana during early adolescence. However, the association between symptoms and use was dampened when the effect of parent rules, monitoring and peer behaviors were considered.
"The takeaway for parents and clinicians is that early intervention is key," said Terri Voepel-Lewis , professor at the U-M School of Nursing. "Recognizing and addressing the child's physical and mental health symptoms and strengthening positive parenting skills may be particularly important to prevent early substance use initiation that can lead to problematic use later on."
Key findings:
Children with moderate-to-high co-occurring, persistent symptoms (pain, depression, somatic issues) have a 40% higher risk of initiating substance use by age 14.
Children in households with no clear rules regarding substance use are 70% more likely to start using early.
A child is three times more likely to initiate use if they perceive that their peers are also using substances.
As children see parents or peers using substances, their "perceived risk" of those substances drops, making them much more likely to experiment.
Contrary to the belief that peers become the sole influence in middle school, the study found that family influence remains a powerful deterrent through at least age 14.
"A major takeaway is that the influence of parents remains strong throughout early adolescence," said Voepel-Lewis, who also has an appointment in the Department of Anesthesiology at Michigan Medicine. "The other thing that parents should know is that being available to their kids can really make a big difference in preventing their substance use onset. The longer substance use can be delayed during adolescence, the better for kids for many reasons."
She said for those parents who have had substance use problems, it's critical that they themselves are treated, and that they establish rules and close monitoring so their children know they are available to them. Making it clear that using alcohol, tobacco and marijuana is risky for kids may be important to prevent or delay use.
Voepel-Lewis and colleagues recommend that pediatricians screen young teens not only for drug use but also for the underlying physical and emotional symptoms that may precede it. Once recognized, early intervention may prevent trajectories into clinical-level symptoms and substance use into young adulthood.
"When children present to clinics with higher anxiety, depression, pain, it is essential to assess family dynamics and substance use issues," Voepel-Lewis said. "Early recognition by middle school may facilitate intervention prior to escalating symptoms and behaviors."
The researchers utilized data from 9,948 individuals in the ABCD Study , a national study involving 21 sites across the U.S., including U-M.
The study appears in the Journal of Adolescent Health. U-M co-authors include: Sarah Stoddard, Deanna Marriott, Rebecca Evans-Polce, Todd Herrenkohl, Julia Seng, Eric Scott, Lara Khadr and Carol Boyd.
Study: Social Environmental Factors Help to Explain Early Substance Use Initiation Among Youth With Comorbid Psychological and Somatic Symptom Trajectories (DOI: 10.1016/j.jadohealth.2025.10.024)
