Psychological Medicine

Original Articles

Longitudinal associations between childhood and adulthood externalizing and internalizing psychopathology and adolescent substance use

J. Miettunena1a2 c1, G. K. Murraya3a4, P. B. Jonesa3, P. Mäkia1a2, H. Ebelinga5, A. Taanilaa6a7, M. Joukamaaa8a9, J. Savolainena10, S. Törmänena1, M.-R. Järvelina6a7a11a12a13, J. Veijolaa1a2 and I. Moilanena5

a1 Department of Psychiatry, Institute of Clinical Medicine, University of Oulu, Finland

a2 Department of Psychiatry, Oulu University Hospital, Finland

a3 Department of Psychiatry, University of Cambridge and CPFT, UK

a4 Behavioural and Clinical Neuroscience Institute, University of Cambridge, UK

a5 Clinic of Child Psychiatry, University of Oulu and Oulu University Hospital, Finland

a6 Institute of Health Sciences, University of Oulu, Finland

a7 Unit of Primary Care, Oulu University Hospital, Finland

a8 Social Psychiatry Unit, School of Health Sciences, University of Tampere, Finland

a9 Department of Psychiatry, Tampere University Hospital, Finland

a10 School of Criminology and Criminal Justice, University of Nebraska at Omaha, NE, USA

a11 Department of Epidemiology and Biostatistics, MRC Health Protection Agency (HPA) Centre for Environment and Health, School of Public Health, Imperial College London, UK

a12 Biocenter Oulu, University of Oulu, Finland

a13 Lifecourse and Services Department, National Institute of Health and Welfare, Oulu, Finland


Background Emotional and behavioral problems are commonly associated with substance use in adolescence but it is unclear whether substance use precedes or follows mental health problems. The aim was to investigate longitudinal associations between externalizing and internalizing psychopathology and substance use in a prospective population study design.

Method The sample was the Northern Finland Birth Cohort 1986 Study (NFBC 1986; n = 6349; 3103 males). Externalizing and internalizing mental health problems were assessed at age 8 years (Rutter scales), substance use and externalizing and internalizing problems [Youth Self-Report (YSR)] at age 15–16 years, and hospital diagnoses for internalizing disorders (age 25) and criminal offences (age 20) from nationwide registers in adulthood.

Results Externalizing problems at age 8 were associated with later substance use. After adjustment for sociodemographic factors, parental alcohol use and psychiatric disorders, and earlier externalizing and internalizing problems, substance use predicted criminality, especially among males, with the highest odds ratio (OR) for cannabis use [adjusted OR 6.2, 95% confidence interval (CI) 3.1–12.7]. Early internalizing problems were not a risk for later substance use. Female adolescent cannabis (OR 3.2, 95% CI 1.4–7.3) and alcohol (OR 2.1, 95% CI 1.1–4.2) use predicted internalizing disorders in adulthood.

Conclusions Externalizing problems precede adolescent substance use in both genders, whereas, among boys, substance use also precedes criminal offences. Internalizing problems may follow substance use in females. These associations were robust even when taking into account previous mental health problems.

(Received January 25 2013)

(Revised July 01 2013)

(Accepted August 10 2013)

(Online publication September 13 2013)

Key words

  • Affective symptoms;
  • alcohol drinking;
  • behavioral symptoms;
  • cannabis use;
  • smoking


c1 Address for correspondence: Adjunct Professor J. Miettunen, Department of Psychiatry, PO Box 5000, 90014 University of Oulu, Finland. (Email: