Week 6 ABCD: Substance Use Assessments

Hello I am Dr. Krista Lisdahl and I am pleased to join you today to talk about the ABCD Study substance use module so I’m going to go ahead and share my screen I believe these slides will also be shared directly with you I am at the University of Wisconsin-Milwaukee and I serve as the substance use workgroup co-chair along with Mary Heitzeg. The learning objectives for this lecture is to summarize the ABCD Study’s substance use module methods and go over the measures in some more detail so that scientists can more effectively use utilize the data in their own analyses. Part of the goals of the ABCD study is to really understand the initiation and escalation of substance use risk and resilience factors related to that and then outcomes of that substance use on multiple measures of health. We’ll get into some more specific aims next but I just want to mention that the initiation and escalation of substance use occurs in the early adolescence and then peaks in young adulthood and very little is actually known about substance use and youth younger than 12 years old in the ABCD Study started at ages 9 to 11 or so. The substance use questions that we hope to address with ABCD include what are the risk and resilience factors leading to differential substance use trajectories in tweens and teenagers? What are the gateway interactions so to speak between use of different substances? What are the effects of repeated substance use including polysubstance use, or co-use, on adolescent neurocognitive emotional and physical development? How does psychopathology alter and how is it modified by substance use patterns during these adolescent years? And what are the effects of individual genetic, behavioral, neurobiological, and environmental differences on risk profiles and substance use outcomes? Before I get going on the methods I just want to acknowledge the substance use workgroup and my wonderful colleagues throughout the United States on the ABCD Study, especially Mary Heitzeg at the University of Michigan.

We meet on a bi-monthly or monthly basis 02:50 - and we have for about five years now and there has been some changes in the workgroup over time but this is the group in 2020 for at least the next few years. I just want to thank these colleagues and if you have questions you know these are some folks that you might want to reach out to. So what are the goals to the substance use assessment? Well the first one is to provide a detailed characterization of substance use initiation, experimentation, and detailed use patterns in a large diverse sample of youth across the United States, and within this I want to say that we really wanted to measure all of the drug categories; it’s not just a study on alcohol or cannabis or nicotine alone—it’s all the substances that the youth are using over time and we really are putting a lot of effort into characterizing those patterns in great detail before they really initiate use to any sort of regular chronic level. We also want to look at youth attitudes and expectancies about substance use and then once they begin using we want to look at their motives for that continued use. We measure the subjective effects of very early meaning you know first couple of times they used alcohol nicotine or cannabis products.

And we want to look at the consequences of substance use over 04:16 - time as they start experimenting with the drugs such as alcohol or cannabis withdrawal symptoms and alcohol use disorder cannabis use disorder nicotine use disorder and drug use disorder symptom counts as well as diagnosis. We also want to look at substance use in the environment that the youth lives so we look at peer substance use, sibling substance use, family substance use currently, as well as family history of substance use disorders. We’re measuring secondhand exposure, especially to cannabis and nicotine products. The physical health workgroup measures prenatal exposure, so I won’t be going over that today but it is in the dataset. And we looked at things like perceived availability of the substances in the neighborhood, and finally, we collect biological samples which provide us with some objective measures of very recent substance use.

05:21 - This is just showing the timeline of events of the ABCD study and I’m going to be using a lot of terms such as baseline year 1, year 2 throughout the lecture so I just want to orient you that baseline is at age 9 and 10, where they’re coming in and they’re getting full neurocog testing and MRI so it’s a longer session of about six to eight hours depending on the youth. Every three to six months we do contact them at least by phone and now increasingly by apps on their phone to check in on some very basic substance use and mental health items I’m not going to spend a lot of time today on those assessments but they are available in the database and I’ll point out what file to look for. And then every even year moving forward so then year two is another year where they’re coming in for the full longer assessment year three is an “off” year where they come in for about two to three hours and they get a lot of behavioral measures—substance use, mental health measures—but not the full neurocog or neuroimaging battery. So this is a pretty busy slide and it’s just showing you pretty much the entire substance use protocol, although a couple of the parent measures are not on this, or measures that might be important for substance use such as prenatal exposure or drug policy in the environment or parental monitoring, which you can actually find in other workgroups’ assessment modules. But let’s just start over here on the left at the top of the flowchart and that’s the PLUS Form.

Whenever youth come in to a session that includes either neurocog 07:26 - or MRI they fill out a PLUS Form which is just a quick medication form looking at recent (meaning past 24-hour use) of caffeine, prescription medications, or over-the- counter medications, nicotine use, and so the youth fills that out and then the parent fills out the recent medication use. So those plus forms are filled out by both and it’ll give you a sense for what medications or caffeine or nicotine levels they might have in their system when they’re at the session. Moving on, the beginning of the substance use protocol for the first three years (baseline, year one follow-up, and year two follow-up), we asked some questions to the youth on whether or not they’ve heard of substances such as alcohol, nicotine products, caffeine, cannabis products, inhalants, prescription drugs, and then if they’ve heard of any other drugs that make people feel high. The thinking here again is that they’re very young at baseline they’re nine to just short of 11 years old there’s very few studies—no large-scale national studies that that start that young—and there was a Texas State study that showed that at that young a lot of the youth hadn’t even heard of these drugs so we didn’t want to be asking them half an hour battery worth of questions about drugs that they’ve never heard of. So in those first few years they are asked if they’ve heard of this drug and if they have not heard of the drug then they do not get any more questions about it.

So for example, if they’ve never heard of marijuana or cannabis or any of the other 09:14 - names for it then they’re not going to get any further questions about cannabis. So that’s very important to keep in mind when you’re looking at baseline year one and year two data as you’ll see in the NDA the first three years of NDA releases. If they say they’ve heard of it at any time they do continue to get those questions. So at baseline we actually ask them all the substance use categories that they’ve heard of whether or not they’ve used them in their lifetime. If they have used them then we’ve gotten the age of their first use, their age of any sort of regular onset (which at that point was described as weekly use), their maximum dose, and then the last time they used.

09:59 - At years one, two, three, and forward, we don’t ask lifetime use anymore we ask since their last assessment. So we say, “since our last assessment (and we have the date), have you used alcohol?” If they have used alcohol, they’ll say, “was that the first time you used alcohol?” and we get an estimated date. We ask that for all the drug categories. If they’ve reported using alcohol, then we administer a low-level use inventory that looks at three drug categories you’re going to see this a lot throughout the substance use interview: we look at alcohol sipping, we look at very early kind of first puff of nicotine products or chewing tobacco, and first puff or taste of any cannabis product. And so those are our low-level use inventories, and for the most part for baseline, year one, and year two, that’s the only place that most of the youth will report any substance use. So for example—and don’t quote me on this, I’m just throwing out some numbers—about 22 percent or so have had alcohol sipping at baseline, less than one percent have engaged in any sort of nicotine use or cannabis use, so it’s very rare for any of the other substances, but if you’re looking for any substance use in those early years, again the cohort is only between ages 9 to 12-13 in the first three years of the study, so this is before most of our other large-scale like Monitoring The Future Studies—this is younger than those studies usually start, so you want to look at that low- level use first.

If they’ve used 11:45 - more than just a sip or a tiny puff of something, then we actually launched the Timeline Follow Back which is a much more detailed calendar interview that you can find lots of literature out if you’re interested in learning more, but we use a web-based calendar format along with standard unit pictures to really orient the youth to the substances such as alcohol—what we mean by one standard drink of alcohol—and we go month by month in a detailed semi-structured interview to get at their patterns of use. If they’ve used drugs such as cigarettes, electronic nicotine device (END), cannabis products, cocaine, methamphetamine, and heroin, we do have some follow-up questions that are getting at things like route of administration or product type for cannabis, how high they get when they use cannabis, whether or not they smoke cigarettes with flavoring and some other routes of administration follow-up questions for cocaine, methamphetamine, and heroin, I can give you some examples for later. Once that’s complete they get some questions about their recent caffeine intake, and then we move on to substance use attitudes, as well as peer use and sibling use, and I’ll go a little bit more detail later into that. They also fill out starting at one year for most of them and then also some were added in three-year related specifically to ENDs expectancies and vaping expectancies, so we look at these youth beliefs and expectancies about the most common substances and those are administered every other year. If they’ve used at least one alcohol drink in the past year, they fill out an Acute Subjective Response scale.

If they’ve used at least two alcohol drinks in the past year, 13:49 - then they fill out Hangover Symptoms questionnaire and the RAPI which which which looks at the number of AUD symptoms. Later on, starting at year four and then every other year forward, they’ll also fill out a drinking motives questionnaire. If they’ve used nicotine products, they fill out the Acute Subjective Response scale that relates to cigarettes, ENDs use, and chewing tobacco, nicotine dependence symptoms based on the PATH Study, and then starting at years four later they’ll also fill out Tobacco Motives questionnaire which looks specifically at cigarette motives and then a couple measures looking at reasons for and motives for ENDs usage. If they’ve used any sort of cannabis product, they fill out the Acute Subjective Response, a measure looking at cannabis use disorder symptoms—the MAPI, as well as again motives moving forward in years four forward. Starting at year three, they fill out a cannabis withdrawal scale, and it’s also notable that we measure other drug symptoms for any other drugs besides alcohol, nicotine, and cannabis.

I won’t be talking about the KSADS in this lecture but if they’ve used 15:08 - two or more then that triggers giving them the KSADS alcohol use disorder or appropriate substance use disorder module to look at diagnosis for a substance use disorder. Okay so these are the measures—what they’re called and what they measure—that we gave at baseline. So I don’t have to go into a lot of detail here because most of this was just described, but again they get that PLUS survey for both the participants and their parents. If they’ve heard of the substance then we go into that lifetime drug interview—the Timeline Follow Back—which is looking at quantity and frequency of all substances, we measure peer group deviance—so how much do they think that their peer group is using substances, intention to use—which is about curiosity or susceptibility to using substances in the near future, we get that caffeine intake, we get those low-level use measures for alcohol, cannabis, and nicotine, as well as their subjective effects the first couple times that they’ve used those drugs. If they’ve used at least two or more times in the past six months at baseline then they’re going to get those consequence measures such as alcohol hangover/withdrawal symptoms or a symptom count for alcohol use disorder, nicotine, or marijuana use disorder.

16:49 - On the parent side, the parents measure, as I mentioned previously, they fill out a family history for substance use disorder which you can find in the mental health workgroup, as well as prenatal drug exposure which I believe is also now with the mental health group. Starting at years two and forward we also measure house I’m sorry that’s I take that back—this is the Household Substance Use Rules, we measure that at baseline. So this is basically what rules do they have for substance use for their youth in their own home. These are the year one measures and I’ve written in red here any changes from baseline, so everything else is consistent from baseline with some notable changes. In the substance use initial patterns interview, instead of lifetime use we’re looking at use since last session, we also at that point updated some of our electronic nicotine device wording, we switched our caffeine use measure from measuring for the past six months to measuring the past month just because we were starting to see a little bit more confusion about how to get average six month use so we narrowed it down to the past month and then we added some more attitudes measures: we’re looking at peer tolerance of use—that’s friends attitude about the youth’s use, perceived harm from the Monitoring The Future Study—which is the youth’s opinions about the harms of drugs, we added three expectancies measures looking at alcohol, cigarettes, and marijuana expectancies and then for the consequences, the gating for that instead of using the past six months which is hard to judge because we typically see them every year we expanded that to two uses in the past year, but the measures for consequences remain the same.

18:58 - Looking at year two, again everything from baseline and year one pretty much came forward and continued in the same way with a few slight changes. In year two, we added this question about “was that the first time you used the substance?” just because we felt that might be easier to track if we just did that every year. On that drug use interview as well as a Timeline Follow Back, we added cannabidiol or CBD questions specifically and we clarified that when we’re talking about marijuana products such as marijuana edibles, tinctures, or smoking products, we’re not talking about CBD alone so we did kind of pull that out and clarify that in our interview and this is mostly due to the just extreme proliferation of CBD used throughout the country at that time. We also added for the Timeline Follow Back an estimated portion to cover missed sessions—so if someone came in at baseline and then they didn’t come in at year one at year two we could do the past 12 months detailed Timeline Follow Back, and then we’ll also have an interview that continues to go back further but this is in a much more kind of estimated average use way instead of the the full details that we get with the last 12 months. We also implemented some changes in summer 2020 that separated out smoking from vaping marijuana flower or marijuana concentrate and this is due to the findings from the Monitoring The Future Study that came out in early 2020 showing a huge increase in vaping specifically, so we wanted to dig in a little bit with more detail and really measure those vaping patterns as well as expectancies and motives moving forward.

21:05 - The rest of the interview—the substance use patterns interview—remained the same. We did start to ask the youth about their perceived availability of substances in the environment. We continue to collect that from their parent as well so those can be compared. And for the parent, we added a substance use household density measure which looks at—I’ll show you in some more detail later in the lecture—but household density of substance use as well as secondhand exposure focusing primarily on nicotine and cannabis, and then how the parents are storing drugs and alcohol in their house. I also want to note that for some of our two-year interviews they were disrupted due to the COVID-19 pandemic, so for two-year and three-year interviews and we’re looking most likely for four-year interviews, part of the interview or all of the interview might have been administered remotely.

22:06 - When this occurred we added some questions to the substance use interview as well as the timeline follow-back interview specifically to know whether it was a hybrid session a completely in-person or completely virtual session and how exactly did they fill it out and whether or not the roROAa was confident about confidentiality and privacy. So we are still digging into what the effects of that might be but just to keep in mind for releases. It’ll probably be primarily release 4.0 that’ll have data that was administered remotely, but just wanted to put that note there. Going into year 3 follow-up, which will primarily come out in NDA 3.0 which I believe is coming out any week now, this is where we did a really deep audit to make sure that all of our language regarding ENDs use was consistent throughout the whole battery, and this was based on input from the Monitoring The Future Study as well as the PATH Study we added an ENDs expectancies measure as well as a vaping expectancies measure, we added a sibling substance use measure that looks at extent of sibling use and whether or not they’ve seen their sibling use it or whether or not their sibling has given them drugs directly.

23:40 - The other main addition there was adding the cannabis withdrawal scale, so that’s at year three moving forward. All of these other updates in red are really about separating out vaping from smoking in our Timeline Follow Back and just making sure that our vaping language is consistent throughout the battery. This is the drug toxicology measures that we use in the ABCD study. Our main purpose for using drug toxicology is to try and have an objective measure of a very recent adolescent substance use as well as to try and ensure that they’re not entering the scanner or neurocognitive testing while they’re still under the influence of drugs and alcohol. So we chose the Dräger saliva test because it’s got a much more narrow detection window for that toxicology and we can look at amphetamines, benzodiazepine, cannabis with THC specifically, cocaine, MDMA, methadone, and methamphetamine with a fairly narrow detection window.

So we advise our participants that they can’t use 24:55 - substances the day before—at least 24 hours before their evaluations. We expect as the study progresses into later adolescence that we’ll have more and more substance use and and this will become a very important issue to make sure that they aren’t undergoing fMRI testing or cognitive testing while they still are under the influence of a substance. So at baseline about ten percent of the sample is randomized into this testing, at two year we’re increasing that to 15 percent, at three year we’re increasing it another 20 percent, and plus if there’s anyone who has reported any substance use in the past they will also automatically get the Dräger. I’m going to come back to that last four-year message. If they get a positive on the Dräger we do repeat it to make sure that it’s two positives so that it’s not a false positive, the youth also provide some urine for a NicAlert test to look at Cotinine levels which is the metabolite of nicotine.

26:00 - The detection window is about one to three days kind of depending on the study and how heavy of a smoker they are, and it follows pretty much the same percentage of random testing as the Dräger plus anyone who reported previous nicotine use. We also give them a blood alcohol test that follows about the same randomization, although it increases to 50 percent in year four. We collect hair and we’re able to collect it successfully on about 70 percent of the participants. Hair can allow us to detect substance use that occurred within about one to three months depending on how long or how much hair we get. We can look at markers that suggest heavy alcohol exposure, methamphetamine, or MDMA which is ecstasy, amphetamine, cocaine, PCP, opiates, benzo, THC metabolite, as well as THC and cannabidiol we select a small number of people to actually get it analyzed these are our highest risk youth and at baseline we analyzed about 400+ folks, at year one 134, at year two 153.

70 percent is 27:27 - collected and banked and we’re actually trying to pursue funding to get more hair analysis. Starting in year four, we’re rolling out the Abbott iCup which is analyzed at Redwood Toxicology. This allows us to get a pretty quick drug screen for the major drug categories at a much cheaper rate than the Dräger. The problem is the detection window is much longer, so if we really want to make sure that they haven’t used in the past 24 hours, which could drive decisions about sending the teen home or continuing the session, then we need to follow up any positive tests with the Dräger to see was it within that about 24-hour window. I wanted to just give you some highlights for what we plan in year four, which is currently being piloted so I have to say this might change but in case people are looking for things that they think are missing from the substance use battery, the main thing that we’re going to be adding is motives measures.

So if the youth already is using alcohol, cigarettes, and/or cannabis, or vaping 28:38 - any products then they will fill out these motives measures. Everything else is remaining the same and just another note that for any four-year data watch for any COVID related notes on whether or not the protocol was administered virtually, hybrid, or completely in-person I’ve gone through the battery for baseline all the way to year four including the toxicology, and I wanted to map that on a little bit more clearly to where you find the files in the NDA releases. So the baseline NDA files and Release 2.0 are labeled as such and i’m not i’m not going to necessarily go through each one because you guys can read them, but I tried to give the title of it as well as the abbreviation—so for example the PLUS form that I talked about that looks at very recent medication use from the parents, that’s ABCD parent participant last year’s survey day ‘plus01’ is the variable name. So there’s different files for the PLUS forms as well as the alcohol BAC test, the NicAlert test, the Dräger toxicology test, the hair results, as well as details about the hair samples themselves, parent rules on substance use, parent community risk and protective factors—that is the availability of substances in the environment, and then at baseline there’s a large file that’s called Y_Substance Use Interview—that includes data related to the lifetime substance use patterns: that age of first and maximum use, last time they use the drug, and then any sort of drug follow-up questions from the Timeline Follow-Back. I have to say there’s very little substance use at baseline so don’t be surprised if you open that and it’s a lot of zeros or blanks.

The other thing to keep 30:49 - in mind is that at baseline a lot of youth didn’t even hear of most of the substances, so you’re not going to be going into baseline and finding hundreds of inhalant users; there’s really very minimal substance use. But that same file has the data for the low-level alcohol use, nicotine and marijuana use, that caffeine intake—which about 70 percent or so have used caffeine at baseline so there’s quite a bit of data there, as well as their substance use attitudes—so peer use, intention to use, and then those alcohol, nicotine, and cannabis measures, although there’s very little data on those consequence measures at baseline as well as one year. The Timeline Follow Back calendar scores is its own file and again that’s only for the youth who actually engaged in significant substance use, so there’s only going to be about 12-14 subjects or so with any data there. At year one and moving forward, we did some rearranging in REDCap and that ended up splitting the files into more sections for the NDA release, so when you’re looking at the longitudinal data year one two three and moving forward, it’s organized in this way. You’re gonna start seeing the youth mid- year phone interview files that looks at whether or not they’ve used the major categories of drugs in the past six months—that’s their phone interview, not their in-person.

We have those PLUS forms, 32:25 - we have the toxicology—so the blood alcohol, the NicAlert, the Dräger, the hair samples—there’s a file alone that’s on the parent rules and the parent availability, and then there’s a youth substance use intro and use patterns, and that goes into the use since the last session, age of first use, that low-level alcohol, nicotine, marijuana use and caffeine intake. Note that we tried to add whenever we could “calc scores” which add in zeros for non-users so the assumption there is if we ask the youth have you heard of nicotine products and they said no, that they haven’t used any of those nicotine products and in those cases we would add in zeros. The Timeline Follow Back calendar scores habits has its own file, as well as substance use attitudes—so you’ll find peer use, intention to use, peer tolerance and perceived harm there, and then it’s separated by the youth alcohol, nicotine, and marijuana measures. In those files you’ll find the expectancy data, subjective effects, and consequence—whether it’s symptoms of alcohol use disorder in the case of the RAPI symptoms of hangover or alcohol withdrawal with the HSS. There is a summary score file that we plan on adding to over time and in the end, the 2.

0 release they have some like caffeine total scores as well as 34:04 - some total scores related to the subjective effects of alcohol, tobacco, and marijuana. Some of the newer measures like the sibling substance use and household density, youth availability, vaping and ENDs expectancies, and cannabis withdrawal will be in the NDA 3.0 release and those motive inventories will be launched at the four-year interview and the first time they’ll be available will be NDA 4.0. So this is again just going back to that whole picture of the substance use interview, it’s flow—which is indicated by the arrows, and some gating notes that are really important for you to keep in mind. Again, baseline through two-year we ask those “heard of” questions—they only receive it once, and so we don’t re-give it if they heard of it previously then we assume they continue to know what it is and we tried to produce these “calc” variables to put in zeros if they didn’t hear of it.

So, this isn’t true for attitude questions because we can’t assume their 35:19 - attitudes, but if they say “I’ve never heard of alcohol” we’re assuming that they haven’t been drinking alcohol in the past year. And I just want to say we give all sorts of names for the substance, we don’t just say alcohol—so most youth would recognize at least one of the terms used. Users may need to put in zeros for other measures like consequences—so for example, the RAPI scores, one could assume if they’ve never used alcohol and therefore didn’t receive the RAPI, that a score of zero would be appropriate. So users need to decide when or when not to add in zeros to some of these variables. We have a bunch of summary variables that we’ll have in release 4.

0, which 36:10 - will have new Timeline Follow Back variables such as combining all the tobacco use days or cannabis product use days, and users can do this on their own, calculating these variables, but for our next release our goal is to create a lot more summary variables that the whole community can use. The rest I’ve already mentioned, so just keep in mind that gating and if you say “well why is this missing on 6,000 subjects?“—it’s because they said they didn’t hear of it or they said they never used it. This is just going through some examples of showing you the substance use interview in REDCap, so that again you can get a better sense for some of these gating issues. So for example, we asked them if they’ve used a sip of alcohol—if they say yes to that then we ask them about a full drink, but if they say no then we don’t ask them about a full drink. If they did have a sip of alcohol, we asked them those low-level use questions on the iSip, which gets at how many sips they’ve had since they saw you, was it part of a religious event, whether or not it was the first time they tried it, you know and of course if they say “no it’s it’s not the first time” they tried it then that we’re not going to populate the question about the date.

So we use gating a lot in the interview, primarily 37:45 - for one thing avoid overexposing substance use questions to the youth, and the second to save time because the ABCD protocol is quite long. In some kids it can take up to eight hours and we really need to figure out ways to reduce the time as much as possible. This is just showing a little bit more of that iSip—if they had already filled out the iSip at baseline for example, these follow-up questions about did they continue to finish the drink, what type of drink was it, who did they get the drink from, are not asked again and instead we just asked them how many sips they’ve had since the last session. Similar for low-level use of tobacco, if they’ve already filled it out then we only ask them the number of puffs that they’ve had since the last session, but we don’t ask them again what product type it was the first time they tried, or how old they were, or did they continue to use the product, was it flavored or any of these follow-up questions—those are just asked once. Same thing for low-level marijuana use—here i’m just showing you some of the example questions, if they’ve already filled it out then we only answer that number one about how many times have they used since we last saw you so we kind of get the number of puffs, and that’s really only relevant for these very low users.

Once they’re using it more than just that sit 39:22 - down and have one little puff then we’re actually launching the Timeline Follow Back and getting at their more detailed patterns of use. But here we ask about age that they first tried it, did they continue to use it after their first puff, what type of product, and at years two and three we separated out smoking flower from vaping flower and smoking concentrate from vaping concentrate. We asked them how high they got in that first experience, and then who did the marijuana belong to, and we also added some more items to that—if you want those details you can find them always in the data dictionary. So as there’s changes made at each follow-up year, you’ll see exactly what the item options are for that data release. Just a note again on that Timeline Follow Back, it’s not so relevant now but moving forward you’ll have to decide whether you want to use the detailed and the estimated substance use in between time points or just one of them.

40:37 - So to make it really clear the detailed Timeline Follow Back is the current date back 12 months or shorter—so if there was only nine months in between in-person sessions then that time period would only be nine months but if, it was 15 months then the detailed portion would only go back 12 months. The primary rationale for that is to save time, and that lots of studies really looking at reliability and validity of the Timeline Follow Back only go back 12 months and there’s not a lot of data going too far back, but we wanted to capitalize on the interview type and the rapport and the information that we had so far with the subject to go ahead and cover those remaining months. For the remaining months, we’ll look at the general pattern, and from that we can get the total dose such as the total number of standard alcohol drinks, or the number of days used during that period, average dose per occasion if that’s appropriate, but we won’t get as much detailed information about weekend or weekday, we wouldn’t be able to really trust the number of co-use days or maximum dose—things like that—that we are trying to target on the detailed Timeline Follow Back. I’m not going to read this whole thing but this is just showing you the REDCap Timeline Follow Back instructions. Again, this is a semi-structured interview, we’re really developing rapport and talking through substance use patterns and showing the youth pictures so we really understand what they’re using and how they’re using it and get at their kind of month by month patterns.

42:22 - So in order to do that, the RA opens up the Timeline Follow Back report, puts in what session it is, we kind of get this timeline for when they’ve been coming in and how many months are we going to be capturing here, and then you click on which substances they’ve used, and here’s my opportunity to highlight all the drugs that we are measuring for these detailed patterns—because you’ve heard a lot about alcohol, nicotine products, and cannabis products, and some of our other attitude questions do have questions about inhalants, other substances, and prescription drug misuse, the Timeline Follow Back is an opportunity to separately measure patterns of alcohol, cigarette, electronic nicotine device, cigars, hookah, pipe tobacco, smokeless tobacco, nicotine replacement items, smoked marijuana flower, marijuana blunts, vaped marijuana flower, vaped marijuana oil, smoked marijuana oil, such as concentrates, dabs etc., edible marijuana such as cannabis brownies, marijuana infused alcohol, which is becoming increasingly popular at least in young adults, marijuana tinctures, synthetic marijuana such as k2, cannabidiol non-medical use—so meaning that they’re they’re smoking cannabidiol joints or vaping cannabidiol on their own without their parent or physician knowing it, psilocybin or magic mushrooms, salvia, cocaine, prescription stimulants such as adderall, cathinones or bath salts, methamphetamine, ecstasy, ketamine, GHB, prescription sedatives, heroin, prescription opiates such as oxycontin, cough or cold medicine used to get high not as their parent or doctor instructed them, other hallucinogens such as LSD, PCP, inhalants, steroids, a fake drug that we ask a few different times just to see if they’re kind of being socially desirable and saying yes to stuff and then other substances. So on the calendar we double click and an event comes up and we have a couple different options: we can answer just one incident, so you know that last Friday I had two alcohol drinks, whereas over here maybe I’m a very regular user and I use every day of the week, or maybe that’s only true for this month but there’s flexibility there, so you can either just put in one episode or you can put in a repeated episode. And for the calendar whatever drug that they touch on, the correct standard unit—in this case electronic nicotine device—we measure a number of distinct occasions during the day, so they use twice and then in this case alcohol it’s two standard drinks. And again there’s slides that come with this that really explain the different substances and how we measure them.

This results in it automatically populating on the calendar 45:35 - and the RA goes month-by-month throughout the year. We do have follow-up questions again getting at things like route of administration—whether you typically smoke cigarettes with flavor, and here are some examples of them although it’s not all of the follow-up questions you can find those in the data dictionary, but for in the case of ENDs devices we look at like how much liquid do they typically smoke in their electronic cigarette (this is the baseline wording and it’s actually been updated, but I just wanted to show you how it looked at baseline), how often did it contain nicotine, whether or not they used a disposable or rechargeable ENDs device, we did add Juul to that, we’ve also added some questions at year two about how often they specifically use a Juul device and whether they’ve ever tried dripping—which is dropping the kind of e-cigarette juice directly onto the hot coils. For marijuana—smoked marijuana in this case—and at year twos and three, we kind of separate out this first question into smoked marijuana flower versus vaped marijuana flower, but we look at their primary way that they used it, if they know of their strain of marijuana (they don’t have to know it, they can say “don’t know” for all of these actually), how strong or potent they think their marijuana typically is, how often they smoke very potent marijuana, how high they typically get, and then we ask some similar questions about concentrates—so their type of concentrate they use, how they use it, how strong or potent they think it is, and how often they smoke very potent concentrates. For cocaine and heroin and methamphetamine, we ask some route of administration questions specifically to get at whether they’re injecting these substances and whether or not they use clean needles. This is an example of the caffeine intake inventory.

Again we’re looking at kind of 47:57 - their typical number of standard drinks for each category that they had per week in the past month. And we have instructions there for how to describe this and this kind of tells you the typical serving size, and so if someone always has 16 ounces and that’s two serving sizes okay so the RA does have to do some calculations here, and we also have some summary variables showing you the total sum of caffeine, average caffeine used per week in the past month. That substance use attitudes subsection that looks at peer tolerance—so that’s a self-report of their friends’ attitudes about their own substance use, and friends are people that are around their age. Peer group deviance is measuring their friends’ use of alcohol, nicotine, marijuana, inhalants, and other drugs. The PATH inventory intention to use measure looks at the youth’s curiosity about and intention to use alcohol, nicotine, and marijuana in the near future.

And Perceived Harm is opinions about how much others risk harming themselves by taking 49:12 - drugs. I think I’ve described these for the most part already but for the alcohol expectancy questionnaire—it measures thoughts, feelings, and beliefs about the effects of alcohol use, and looks at the child’s opinions about how much others risk harming themselves by taking drugs. One note about Acute Subjective Response—we get their Acute Subjective Response to alcohol following the first five times they ever drink and then more recently in the past three months and then over their heaviest periods, so that one portions of that are repeated over time. For nicotine, we also have an expectancies measure that’s specific to cigarettes, and later we added in the expectancies specific to ENDs use, Acute Subjective Response, and then the nicotine-dependent scale from the PATH Study. Similar measures for marijuana, with the MEEQ, Acute Subjective Response to marijuana, and the MAPI— which is getting at a symptom checklist of marijuana-related problems.

We also do that for other drug-related problems with the DAPI. I wanted to just at least highlight a couple of these newer measures that you might not see in other studies—so this is substance use density, and we chose to have the parent fill out an estimate of the number of either adults or youth in the household that use all these different drug categories. So scientists can choose to you know specifically look at alcohol exposure and kind of add up the number of adults versus youth or total that have used alcohol in the household and get an idea for how much substance use is in their direct environment. It can be filled out for up to three households, and I should note there are some questions for the other households about how confident the reporter feels because most of the time it’s going to be the mother filling out about a household like with the youth’s father or co-parent in which case they may or may not be very familiar with what’s going on in that household, so you do have to pay attention to those follow-up questions. We also ask questions about in their own household as well as the other households, where do they store the drugs and alcohol.

Again, you might want to only use the primary household 51:50 - or you might want to create a summary score and see if there’s differential impact. The Sibling Substance Use Scale was adapted from Matt McGue’s lab at Minnesota, and asked “do you have any older siblings or siblings younger by no more than one and a half years—for example if you’re around age 15 they’re around 12 and a half.” So this is looking at older siblings or siblings that are very close in age, and we ask them whether those siblings use substances in the past year. We ask about alcohol, cigarettes, ENDs, marijuana, inhalants, prescription drugs, and other drugs. And then we ask a couple follow-up questions if they did use those substances —”how many times have you seen them use it” and then “how often do the sibling give you the substance” And again, just to re-emphasize that the alcohol use or drug use modules on the KSADS are launched as part of the KSADS interview if the youth has reported substance use.

53:06 - So just final note on the substance use module, when you’re starting to do data analysis you have to consider the gating, and again if they hadn’t heard of the drug then they don’t have those questions about use or attitudes answered. I would suggest that you use the calculated variables with the zeros added back in if it’s a use question, but I would not suggest that for any of the attitude questions because we really can’t assume what their attitudes or beliefs are before they’ve formed. For the PLUS form, you will have to look at the date administered or the type of session if you want to say control for the effects of very recent caffeine on cognition you need to make sure that you’re using the PLUS form report for that neurocog date or session—so there is some kind of coding and calculation involved there. The expectancies and motives are administered every other year to save time. In the future as the youth start to really escalate their substance use, as we’re seeing in about year three and we expect in year four and five, we’ll be calculating a lot more co-use and combined product type variables from the Timeline Follow Back.

54:24 - Right now you can also do that on your own—there are very few substance users in release 1.0 or 2.0 as well as even 3.0 although it’s starting to increase a little bit more. And again, final note about COVID-19, thus far batteries two-year and three-year batteries that were administered anywhere between March 2020 and now could have been administered completely virtually—that might impact the substance use battery reporting. We’re currently examining its impact to see if there’s differential reporting based on type of battery administration but so just keep that in mind as you’re analyzing data that might include 2020 to 2021 and hopefully not beyond that. Well that’s all I had today and hope it was informative and look forward to answering questions. Thank you have a great day bye .