alcohol and marijuana consumption and …€¦ · my special thanks goes to prof. and phd-candidate...
TRANSCRIPT
ALCOHOL AND MARIJUANA CONSUMPTION
AND PSYCHOPATHOLOGY AMONG
ADOLESCENTS IN URUGUAY A COMPARISON BETWEEN VULNERABLE AND GENERAL
POPULATION YOUTH
Word count: 14.321
Marieke Lambert Student number: 01410184
Supervisor: Prof. Dr. Wouter Vanderplasschen
A dissertation submitted to Ghent University in partial fulfilment of the requirements for the degree of
Master in Pedagogical Sciences, Orthopedagogics.
Academic year: 2016 - 2017
Abstract
Purpose: The purpose of this paper is to compare alcohol and marijuana use in relation
to psychopathology among a sample of adolescents with a vulnerable background and
adolescents from a general population in Uruguay.
Methodology: A self-report survey was administered to 30 school-going adolescents
and 30 adolescents with a vulnerable background in Canelones (Uruguay) (Mage=15.0
years, SD=1.68). A socio-demographic questionnaire, a screening instrument for alcohol
and marijuana use of the Uruguayan National Drug Board, a screening test for
problematic marijuana use (Cannabis Screening Test), a screening survey to question
adolescents’ wellbeing (Personal Wellbeing Index) and a screening instrument for
psychopathology and resilience were conducted (The Adolescent Self Report).
Findings: The vulnerable group sample has significantly higher rates of lifetime
marijuana use (Z=2.70, P<0.05) and of the following psychopathological factors
(depression-anxiety (Z=-3.5, P<0.01), antisocial and addictive behaviour (Z=-2.71,
P<0.01), disruptive and dysregulated behaviour (Z=-2.51, P<0.01) and social anxiety (Z=-
3.21, P<0.01)), in comparison with the general population sample. Additionally, lifetime
marijuana use correlates positively with addictive and antisocial behaviour within the
vulnerable sample.
Conclusion: This study supports previous findings that substance use is higher for the
vulnerable adolescent group than in a general adolescent group and that marijuana use
correlates with some factors of psychopathology.
Value: This research provides preliminary recommendations for policy makers involved
in youth affairs to focus on alcohol and marijuana prevention programmes in relation to
psychopathological effects. Informing adolescents about the consequences and risks of
these substances, especially vulnerable population groups, should be considered as
important and urgent.
Keywords: adolescents, Uruguay, marijuana use, alcohol use, psychopathology, vulnerable group.
Acknowledgements
There are several people whom I would like to thank for helping me with my research.
First and foremost, I want to express my sincerest gratitude to Prof. Dr. Wouter
Vanderplasschen, my supervisor, for his professional assistance and advice while writing
this dissertation. Communication was not easy because of my stay abroad; nevertheless
I could always count on his support and opinion.
I also want to offer my special thanks to PhD-candidate Maria Fernandez for guiding me
through the whole process. She was appointed to be my mentor during my eight-month
stay in Uruguay, but she has done way more than that. She made me feel at home.
Additionally, I am very grateful to all the people of the department of psychology of the
Universidad Catolica de Montevideo for accepting me just like I was a student of their
faculty. My special thanks goes to Prof. and PhD-candidate Daniel Costa-Ball for his help
and support with the statistical analysis and Dr. Daset Lilian for giving me the facilities
to work at the university and giving me the opportunity to improve my academic
research skills.
Furthermore, I want to thank the director of the organisation ‘Vida y Educacion’ Pablo
Monteverde and coordinator Patricia Lazaga for allowing me to perform this study at
the youth centre ‘Casa Joven’. I particularly would like to thank them and the whole
team for their assistance in setting up the actual investigation.
Last, but certainly not least, I want to thank my parents, family and friends in Uruguay
and Belgium for always supporting and encouraging me, even in the hardest moments
of my university studies.
Table of Contents 1. Introduction ...................................................................................................... 1
1.1. Substance use .................................................................................................... 3
1.1.1. Adolescence and substance use. ................................................................ 3
1.1.2. Alcohol consumption. ................................................................................. 4
1.1.3. Marijuana consumption. ............................................................................ 5
1.1.4. Substance use in Uruguay. ......................................................................... 6
1.2. Psychopathology ................................................................................................ 9
1.2.1. Psychopathology in adolescence. ............................................................... 9
1.2.2. Alcohol use and psychopathology. ........................................................... 10
1.2.3. Marijuana use and psychopathology. ...................................................... 10
1.3. Vulnerable group ............................................................................................. 11
1.3.1. Vulnerability and disadvantaged neighbourhoods. ................................. 11
1.3.2. Poverty rates in Uruguay. ......................................................................... 12
1.3.3. Vulnerable groups in Uruguay. ................................................................. 13
2. Methodology ................................................................................................... 14
2.1. Participants ...................................................................................................... 14
2.2. Procedure ......................................................................................................... 15
2.3. Questionnaires ................................................................................................. 16
2.3.1. Socio-demographic characteristics........................................................... 16
2.3.2. Psychopathology and resilience. .............................................................. 17
2.3.3. Alcohol and marijuana consumption. ...................................................... 19
2.3.4. Problematic cannabis use. ........................................................................ 19
2.3.5. Subjective wellbeing. ................................................................................ 19
2.4. Data-analysis .................................................................................................... 20
3. Results ............................................................................................................ 21
3.1. Descriptive analyses ......................................................................................... 21
3.2. Alcohol consumption among adolescents ....................................................... 23
3.3. Marijuana consumption among adolescents .................................................. 25
3.4. Alcohol and marijuana consumption in relation to psychopathology ............ 26
3.4.1. Differences in means ADA-factors............................................................ 26
3.4.2. Correlations between alcohol use and factors of the ADA. ..................... 28
3.4.3. Correlations between marijuana use and factors of the ADA ................. 29
4. Discussion ....................................................................................................... 31
5. Limitations and recommendations ................................................................... 34
6. References ...................................................................................................... 36
7. Appendix ......................................................................................................... 49
Annex 1: Informed consent parents ........................................................................... 49
Annex 2: Informed Consent adolescents .................................................................... 51
Annex 3: Indice de Nivel Socio-Economico ................................................................. 52
Annex 4: Alcohol and marijuana consumption ........................................................... 56
Annex 5: The Cannabis Abuse Screening Test ............................................................ 59
Annex 6: The Personal Wellbeing Index ..................................................................... 60
1
1. Introduction
Adolescence is an important developmental stage in which new activities are
experienced and unhealthy behaviours are established such as drinking, smoking and
illicit drug use (Kaminer, 2010). This period is a critical phase for brain development,
therefore changes in endocannabinoid activity might lead to subtle but lasting
neurobiological changes. Eventually, this can affect brain functions and behaviour
(Malone, Hill & Rubino, 2010). In this way, harmful drinking and marijuana use among
adolescents are major concerns in many countries (WHO, 2017). In South-America,
Uruguay is the country with the lowest risk perception and the highest lifetime
prevalence of alcohol use within a wide range of 15 years to 65 years old participants
(ONUDD, 2009; OEA, 2015). Additionally, alcohol is the most frequently used drug
among adolescents in Uruguay and worldwide. After alcoholic drinks, marijuana is the
second most consumed substance by students in Uruguay. More than one out of five
students ever used marijuana, while one out of six has consumed the substance in the
last year (JND, 2014). In comparison with other South-American countries, Uruguay has
the second highest rates regarding lifetime marijuana use and marijuana use in the last
year (ONUDD, 2009; OEA, 2015).
Adolescence is a sensitive period that is not only associated with substance use, also
with the onset and increase of emotional and behavioural problems and externalizing
behaviours (Mendle, Harden, Brooks-Gunn & Graber, 2010, Harden & Mendle, 2012).
Previous studies reveal a high prevalence of psychological disorders among adolescence
in Uruguay (Daset, 2002; Daset, Lopez Soler & Hidalgo, 2009; Viola, Garrido & Varela,
2007). Nevertheless, only few studies focus on adolescent alcohol and marijuana use in
relation to psychopathology in developing South-American countries like Uruguay
(ONUDD, 2009; OEA, 2015). In addition, most studies focus on marijuana and alcohol
use by adolescents and the psychopathological consequences in adulthood, not
considering the short-term effects for this age-category (McCambridge, McAlaney, &
Rowe, 2011; Renard, Krebs, Le Pen & Jay, 2014). Furthermore, the direction of the
associations between marijuana and alcohol use and psychopathological symptoms has
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not yet been fully explained (Van Gastel et al., 2011). Despite previous research, it
remains unclear whether adolescent substance use is a predictor of psychiatric disorders
in adulthood or a result of externalizing and internalizing problems in childhood (Van
Gastel et al., 2011; Miettunen et al., 2014).
In addition, previous studies suggested that adolescents residing in disadvantaged urban
neighbourhoods are at higher risk of substance use and abuse, especially when
combined by limited access to health information (Volzke et al., 2006, Olumide et al.,
2014). Considering the recently changed cannabis law in Uruguay, the legalization of
marijuana could have a negative impact on the frequency and consequences of
adolescent consumption, particularly for vulnerable youth (Estoup et al., 2016).
Therefore, identification of the correlation between substance use and
psychopathological factors is necessary for the development of preventive approaches
that aim to reduce or eliminate risks of adolescent substance use, focussing on
vulnerable adolescents in Uruguay (Park & Kim, 2016). In order to meet this approach,
a study was set up concerning alcohol and marijuana consumption among adolescents,
concentrating on their mental health.
In this dissertation, I compare alcohol and marijuana consumption among a group of
adolescents from a general population and a population with a vulnerable background,
focussing on its relationship with psychopathology. The purpose of this study can be
summarized in two research questions that are divided into different assumptions:
1. Do adolescents with a vulnerable background consume more marijuana and alcohol
than adolescents from a general population in Uruguay and, if so, to what extent?
Based on the literature study, it appears that the adolescent group with a
vulnerable background consumes more marijuana and alcohol than the
general population group.
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Following previous findings, it is expected that the adolescent group with a
vulnerable background has a higher proportion of problematic substance users
than the general group.
2. To what extent are marijuana and alcohol related to psychopathology among
adolescents in Uruguay?
Following previous findings, it appears that adolescents who consume alcohol
and/ or marijuana on regular bases are more at risk to develop
psychopathological symptoms than general population adolescents.
Based on the literature study, it can be assumed that adolescents with a
vulnerable background have higher outcomes on the psychopathological
survey than adolescents of a general population.
1.1. Substance use
1.1.1. Adolescence and substance use.
Adolescence refers to the developmental time period between childhood and adulthood
and is mainly considered to contain the ages of 12–17 years (Spear, 2000; Dahl, 2004).
Emotional, cognitive and social changes occur during this critical period of development
to adulthood (Renard et al., 2014). Psychosocial capacities that improve decision making
and moderate risk taking continue to mature well into young adulthood. Accordingly,
psychosocial immaturity during adolescence may undermine what otherwise might be
competent decision making (Steinberg, 2004). Furthermore, this period is a critical
phase for brain development, characterized by neuronal maturation and rearrangement
processes. The endocannabinoid system plays an important role in fundamental brain
developmental processes, therefore changes in endocannabinoid activity might lead to
lasting neurobiological changes that can affect brain functions and behaviour (Malone
et al., 2010). In this way consuming drugs at a young age is especially harmful for the
psychological development of adolescents. Previous studies demonstrated connections
between adolescent substance use and a range of externalizing (Reef, Diamantopoulou,
van Meurs, Verhulst & van der Ende, 2012) and internalizing problems, such as
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depression (Colder et al., 2013). Early onset of alcohol use is associated not only with
higher levels of alcohol use and addiction in adulthood, but also with additional mental
health problems and social harms (McCambridge et al., 2011). Because of the vital
changes in adolescence and the little knowledge concerning substance use in relation
with psychopathology among this age –especially in South-America- this research focus
on adolescents.
1.1.2. Alcohol consumption.
1.1.2.1. Alcohol as a substance.
Alcohol is a psychoactive substance with dependence-producing properties that has
been widely used for centuries in many cultures (WHO, 2014). Its popularity is due to
the initial euphoria the substance provokes caused by the disinhibition of self-control of
the consumer (JND, 2008). The effects of alcohol depend on a variety of factors. First,
age is a determinant because alcohol consumption is especially harmful for bodies in
development. Second, the effect of alcohol is more severe among people with lower
body mass. Most women are more sensitive than men due to physiological factors.
Furthermore, aspects related to the way people consume alcohol alter the effects: the
quantity and speed of the intake will determine the level of intoxication, the
combination with soft drinks accelerates inebriation, while the simultaneous intake of
food slows absorption (JND, 2011).
1.1.2.2. Consequences of alcohol use.
Various studies have focused on the negative impact of frequent and early alcohol use
on adolescents’ mental and physical health (Jacobus & Tapert, 2013; Lisdahl, Gilbart,
Wright & Shollenbarger, 2013; Liang & Chikritzhs, 2015; Fernandez et al., 2017). Alcohol
is the world’s third largest risk factor for diseases (Rehm et al., 2009) and causes
approximately 3.3 million deaths each year with 9% of deaths in the 15 to 29 year age
group (WHO, 2013). Consequences of adolescent alcohol exposure increases inclination
for dependence and use disorders in adulthood, especially when consumed at early
onset (McCambridge et al., 2011). Furthermore, there is plenty of evidence that
5
adolescents with a history of alcohol use differ on a variety of cognitive and neural
measures from their non-alcohol-using peers (Jacobus et al., 2013; Lisdahl et al., 2013).
These differences include poor performance on an array of cognitive measures ranging
from deficits in attention, memory and visuospatial function to differences in patterns
of brain activation (Spear, 2015). Besides, alcohol can increase the risk of cancer of the
oesophagus, stomach and pancreas (WHO, 2004). Lastly, harmfully consumption can
have serious economic and social consequences for individuals other than the drinker,
such as for society in general (Sacks et al., 2013).
1.1.3. Marijuana consumption.
1.1.3.1. Marijuana as a substance.
Marijuana is the most commonly used illicit substance in the world and has a long
standing history in many cultures for its psychotropic and euphoric effects (Malone et
al., 2010; United Nations Office on Drugs and Crime, UNOCD, 2014; National Survey on
Drug Use and Health, 2015). Marijuana is a greenish-brown mixture of the dried leaves
and flowers of the Cannabis Sativa, the female hemp plant (Timberlake, 2009). The main
psychoactive chemical in this substance is delta-9-tetrahydrocannabinol (THC),
responsible for most of the intoxicating effects that people seek (Mehmedic, et al.,
2010). The main route of consumption is smoked, allowing rapid absorption by the lungs
and the effect on the central nervous system. The most frequently pursued effects of
marijuana are relaxation, disinhibition, hilarity, change in perception over time and
sensory (visual, auditory, tactile) alterations. While the unwanted effects, which are
presented in combination with the previous ones, have to do with various organic
reactions (tachycardia, sweating, increased appetite, dry mouth, bright eyes and
redness) and difficulties in functioning normally (concentration capacity, learning
processes, coordination of movements and expression, memory loss) (JND, 2011).
1.1.3.2. Consequences of marijuana consumption.
Consuming cannabis on a regular basis contains various risks. In the first place, cannabis
use may intervene with brain development (Squeglia et al., 2009, Lorenzetti et al., 2016).
6
Studies that used MRI- and PET-scans have reported reduced cortical grey matter and
increased white matter volume in adolescent cannabis users compared to users who
began using cannabis in adulthood. These results may state that cannabis consumption
can increase the probability of suffering effects that hinder the psychological and
physiological functioning of the consumer (Amen & Waugh, 1998; Wilson et al., 2000).
The study of Renard, Krebs, Le Pen & Jay (2014) suggests that chronic cannabis use
during adolescence can cause neurobiological changes that are associated with
decreased neuronal efficiency in brain regions that play an important role in learning
and memory. Moreover, chronically using cannabis before the age of 17 may cause more
cognitive consequences compared to chronic use later during adolescence, for instance
deficits in working memory (Becker, Wagner, Gouzoulis-Mayfranka, Spuentrupb,
Daumann, 2010), attention, decision-making (Dougherty et al., 2013), overall and verbal
IQ (Meier et al., 2012), executive functioning (Solowij et al., 2012), and impulsivity
(Dougherty et al., 2013). Furthermore, when marijuana is smoked with a deep inhaled,
unfiltered pattern it can lead to lung retention and it can worsen symptoms in people
suffering from hypertension or heart failure. In addition, problems in the endocrine
system (alteration of the hormones responsible for the reproductive system and sexual
maturation), as well as the reduction of the activity of the immune system can be
detected (JND, 2011).
1.1.4. Substance use in Uruguay.
1.1.4.1. Alcohol consumption among adolescents in Uruguay.
Alcohol is the most frequently used drug among adolescents in Uruguay. The latest
survey of the Junta Nacional de Drogas (JND, 2014) reported a high number of alcohol
consumption: three out of four adolescents between 13 and 17 years old has at least
once used a prevalence of alcohol during their lifetime and six out of ten during the last
year. The survey of ‘La Oficina de Naciones Unidas Contra las Drogas y el Delito’ (2009)
confirm these results: Uruguay has one of the highest rates regarding alcohol use among
students in comparison with Argentina, Bolivia, Chili, Ecuador and Peru. The country had
the highest prevalence of consumption during lifetime (80.7%) and last year (69.2%). An
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assumed explanation for these high rates of consumption could be found in the
perception of alcohol use. According to the Junta National de Drogas (2014), alcohol is
part of the culture in Uruguay, consumption is fully integrated and legitimized in all
social sectors. The legal age to purchase alcohol is 18 years, but enforcement of the legal
drinking age is weak (Fernandez et. al., 2017). The availability of alcohol as well as social
tolerance leads to alcohol consumers who are not sanctioned by their reference groups.
Other factors that increase the likelihood of drinking are lower levels of parental
supervision, exposure to a close family member who frequently drinks alcohol, positive
expectations of alcohol and having friends who consume (Bremner, Burnett, Nunney,
Ravat & Mistral, 2011). Furthermore, adolescents with a family history of drinking are at
greater risk of developing an alcohol problem (Rose, Dick, Viken & Kaprio, 2001).
Besides, easy access to alcohol has to be taken in account as well (Bremner et al., 2011).
The most frequently used way for adolescents to access alcohol in Uruguay is by buying
it themselves: six out of ten students who consumed in the last month got it at least
once in this way, despite the law that prohibits the sale of alcohol to anyone under the
age of 18 (JND, 2014).
1.1.4.2. Marijuana consumption among adolescents in Uruguay.
Marijuana is the second most consumed substance by students in Uruguay according to
the survey of the Junta National del Drogas (2014), after alcoholic drinks. More than one
out of five students ever used marijuana, while one out of six has consumed marijuana
in the last year. In comparison with Peru, Ecuador, Bolivia, Argentina and Chili, Uruguay
scores the highest prevalence of marijuana use within the last month (8.4%), and has
the second highest rates regarding lifetime marijuana use (18.3%) and consumption in
the last year (13.9%) after Chili (ONUDD, 2009). Regarding the evolution of lifetime
marijuana use, there is a growing trend noticeable: 11.9% used in 2003, while in 2011
the value increased to 16.4% and 20.1% in 2014. Observing the frequency of
consumption, it is found that among those students who report consumption in the last
12 months more than half perform experimental or occasional consumption; defined as
consuming once or a few times in the last year. Meanwhile, one out of three states that
8
they consume the substance sometimes monthly or sometimes weekly, during this
period. Finally, almost one out of ten adolescents use marijuana daily (JND, 2014).
Problematic marijuana use among adolescents in Uruguay was estimated through the
scale Cannabis Abuse Screening Test (CAST; Legleye, Karila, Beck & Reynaud, 2007). It
is found that 12.6% of students who used marijuana in the last 12 months show a high
risk of problematic use of marijuana, which represents 1.9% of the total number of
students. Meanwhile, 20.4% of consumers have a moderate risk and 66.9% a low risk of
problematic marijuana use. It can be seen, as in previous studies (JND, 2011; JND, 2003),
that the frequency of consuming is associated with the likelihood of presenting a high
risk of problematic use. Among those who consume marijuana daily or weekly, 35% have
a high risk of problematic use. Among those consumers who show a more occasional
pattern of consumption, this percentage drops to 4.7%. Another factor related to the
high risk of problematic use is the onset of marijuana. Among adolescents who started
consuming less than a year ago, there is a low proportion (2.6%), which shows a high
risk of problematic use. While among those who started consuming between one and
two years ago, the proportion is 10%, and increases to 28.2% among those who started
more than two years ago. At the same time, we should not lose sight that in most cases
students establish an experimental or occasional link with marijuana without showing a
risk of problematic use (JND, 2014).
Although the consumption rates of occasionally and problematic use are high, the risk
perception of the students is considerably low compared to other South-American
countries (ONUDD, 2009). To understand this phenomena, a few assumptions have to
be pointed out. Firstly, regarding the accessibility of marijuana, more than half of
schooling adolescents declare that it would be easy to get marijuana in Uruguay (JND,
2014; ONUDD, 2009). Furthermore, three out of ten students say that in the last year
they were offered marijuana. Also, the presence of the substance in adolescents' daily
life is shown through a significant proportion (36%), which indicates that one or more of
their friends consume marijuana regularly, meaning all weekends or even more
9
frequently (JND, 2014). Another factor that could influence the low risk perception and
high consumption of marijuana, would be its’ legalisation (Estoup, Moise-Cambell,
Varma & Stewart, 2016). By signing Law 19.172 in December 2013 Uruguay became the
first country in the world to legalize the production, sale and possession of cannabis
(Boidi, Cruz, Quierolo & Bello-Pardo, 2014). Three legal ways to obtain marijuana were
established. Self-cultivation, where each person who meets the legal conditions can
grow up to six cannabis plants per household. 'Cannabis Clubs', a joint association where
a group of 15 to 45 members can grow up to 99 cannabis plants in the same place and
at last through pharmacies, which have recently opened the registration (Walsh &
Ramsey, 2016). A recent study of 2016 (Estoup et al.) examines how marijuana
legalization has an impact on the frequency and consequences of adolescent use in a
sample of school-going participants. A significantly positive correlation is found between
legalization and marijuana-related effects: despite relatively equal use between both
groups, adolescents in the legalization group experienced increased negative
consequences and higher levels of perceived risk. At the same time, we should not lose
sight that this is only one study focussing on recreational marijuana in different states
of America, thus results in Uruguay could be different. More research about the
consequences of legalizing marijuana on Uruguayan adolescents is necessary.
1.2. Psychopathology
1.2.1. Psychopathology in adolescence.
In adolescence, an increase in the prevalence of symptoms of psychopathology is
detected. According to WHO data of 2013, a rate of 20% of mental disorders among
children and adolescents is identified, with half of these cases occurring before the age
of 14 years. In South-America, the burden of mental disorders accounts for 22.2% of the
total burden of disease, measured in disability-adjusted life years. With regard to all
neuropsychiatric disorders, the most common are the depressive disorders (13.2%) and
those caused by excessive consumption of alcohol (6.9%) (WHO, 2013).
10
Mental disorder's causes are multi-factorial, there are various elements to any given
mental disorder. A low level of subjective wellbeing is related to a lower self-esteem and
a low level of quality of life, what can influence and trigger mental disorders. (Krueger
& Markon, 2006). Therefore, in this research the subjective wellbeing and the quality of
life of both target groups will be explored.
1.2.2. Alcohol use and psychopathology.
Alcohol and mental health disorders are highly prevalent in the general population
(Merikangas & Kalaydjian, 2007), with adolescence and early adulthood the prime
periods for emergence (Kessler et al., 2005; Teesson, Slade & Mills, 2009). Mental
health and alcohol disorders cause illness to almost 184 million people, peaking in
young adults (Whiteford et al., 2013). A study of Kandel et al. (1997) found that alcohol
consumption in the previous year was associated with an elevated likelihood of
diagnosis with psychiatric disorders (i.e. anxiety, mood, or disruptive behaviour
disorders). Moreover, a number of studies have linked socio-economic factors and
comorbid alcohol and mental health disorders (Cerda, Sagdeo, Johnson & Galea,
2010; Green, Zebrak, Fothergill, Robertson & Ensminger 2012; Mulia & Zemore, 2012;
Pulkki-Raback et al., 2012). Aspects such as lower family social support (Windle and
Davies, 1999) and low personal income (Ross, 1995; Pulkki-Raback et al., 2012) have
been associated cross-nationaly with comorbid mental health and alcohol problems
in large national studies (Mulia & Zemore, 2012). Furthermore, treatment of
comorbid mental health and alcohol disorders is more complex (Tiet & Mausbach,
2007; Connolly, Suarez & Sylvester, 2011) and more costly than single disorders
(King, Gaines, Lambert, Summerfelt & Bickman, 2000), with worse projected
outcomes (Bruce et al., 2005).
1.2.3. Marijuana use and psychopathology.
A large body of evidence obtained from both animal and human studies suggests that
exposure to cannabis during adolescence increases the likelihood of developing
psychopathology in adulthood (Abush & Akirav, 2012; Malone et al., 2010; Renard,
11
Krebs, Jay & Le Pen, 2013). According to the study of Malone et al. (2010) adolescent
exposure to cannabis is associated with a range of long-term adverse effects, such as
increased addiction vulnerability, cognitive impairment, and psychosis-related illness.
Furthermore, a broad meta-analysis (Kedzior & Laeber, 2014) shows that anxiety is
significantly positively associated with the consumption and misuse of cannabis in
adolescence. It can double the risk of developing anxiety-related symptoms in
adulthood, particularly if the onset of use was initiated before the age of 15. These
results are in line with prior work that found that heavy cannabis use during adolescence
was associated with an increased risk of developing an anxiety disorder later in life, even
if that person no longer consumes in adulthood (Degenhardt et al., 2013). In addition, a
study that connected psychopathic factors and early cannabis use (Medina, Nagel, Park,
McQueeny & Tapert, 2009) suggested that cannabis use during adolescence may disrupt
white matter connections between brain regions that play a role in mood regulation.
Pre-existing genetic factors may predispose an individual to depression, and these
factors may be revealed by early cannabis use (Renard et al., 2014). Furthermore, a
study of Lynskey et al. (2004) reported that twins with an early marijuana initiation
(before the age of 17) were more likely to attempt suicide than their co-twins who didn’t
consume at an early age.
1.3. Vulnerable group
1.3.1. Vulnerability and disadvantaged neighbourhoods.
Vulnerability is the position in which an individual, organization or population is
incapable to anticipate, challenge, withstand and recover from the impact of harmful
situations. A harmful situations which contribute to vulnerability is poverty and its
different consequences (homelessness, starvation, destitution and poor housing) (WHO,
2002). Furthermore, vulnerability is considered to be an important concept in
orthopedagogy, because this study aims to support vulnerable target groups that
experience problematic situations (Broekaert, Van Hove, Bayliss & D’Oosterlinck, 2004).
12
Disadvantaged neighbourhoods can be defined as neighbourhoods with high levels of
social and economic disadvantage such as poverty, unemployment and under-
education. It can also be characterized by the observable signs of decay such as crime,
graffiti, litter, public intoxication and other incivilities (Aneshansel & Sucoff, 1996).
Although findings from research examining the effect of neighbourhood disadvantage
on substance use have been inconsistent, most studies suggest that adolescents residing
in disadvantaged urban neighbourhoods are at higher risk of substance use and abuse
(Volzke et al., 2006; Kulis, Marsiglia, Sicotte & Nieri, 2007). Poverty and instability in
disadvantaged neighbourhoods provoke significant amounts of stress that could result
in an increased inclination to use drugs, when combined by limited access to health
information (Volzke et al., 2006; United Nations Children’s Fund, 2012). Furthermore,
educationally marginalised adolescents appear predisposed to an increased risk of
consuming alcohol. In their need for support and protection from everyday privation
and isolation, social membership count as an important factor, which in turn can
increase the probability of consuming alcohol (Clement, Thirlaway, Smith & Williams,
2014).
1.3.2. Poverty rates in Uruguay.
Although Uruguay is regard to have a strong economy and the poverty rate decreased
viscously over the past dedecade, still there are regions with a low socio-economic
status (WHO, 2013). Uruguay stands out in Latin America for being an egalitarian society
with a low level of poverty and with only a small group of extreme poverty. In relative
terms, it has the largest middle class in America, representing 60% of its population.
Moderate poverty went from 32.5% in 2006 to 18.6% in 2013 and 9.7% in 2015 (The
World Bank, 2016). Although the majority of this poverty in Uruguay is not extreme, it
is still problematic. Like many other South American countries, Uruguay struggles with
alleviating extreme poverty for the poorest sections of its population. The country also
struggles with the high number of children who are born into poverty. 40% of Uruguay’s
children are born into poor families, pointing to a potentially serious problem of inter-
generational poverty (Forgét, 2013).
13
1.3.3. Vulnerable groups in Uruguay.
In this study, we consider the neighbourhood in which half of the participants reside as
disadvantaged and the group participants as vulnerable. In general terms it could be
argued that the labour situation in the disadvantaged neighbourhood of this research is
less favourable than the situation in the department of Canelones and the country in
general. It presents a slightly lower activity and employment rate. Besides, the
disadvantaged neighbourhood has a lower educational level than the rest of the
population of the department and the country in general (INE, 2011). The vulnerability
of the analyzed group is explored in two different ways. On one hand, a socio-economic
survey that inquire the socio-economic level of the participants was conducted to have
an objective view on the characteristics of the sample. On the other hand, personal
welbeing was analyzed in order to have a clear look on the perception of quality of life
and the emotional conditions of the participants.
14
2. Methodology
This research was accomplished by a cooperation between Ghent University and the
Universidad Catolica del Montevideo. During six months, support and materials were
offered to make sure we could start the research in Uruguay in the best circumstances
possible. This study is linked to the doctoral research of Maria Fernandez, a PhD-
candidate of the department of psychology, who is doing research about the risk and
protective factors of substance use of adolescents in Montevideo. The sample of the
general population was already collected by Maria Fernandez and her research team of
the department of psychology, thus the same questionnaires had to be used for the
vulnerable sample to make comparison possible.
2.1. Participants
In order to find answers to the research questions, two samples were compared: a
sample of a vulnerable population and a general population. The total sample comprises
60 youngsters between the age of 13 and 18 that was collected from the department of
Canelones, close to the capital Montevideo (Uruguay).
The first sample (N=30) was gathered from a non-governmental organisation that
supports youngsters in vulnerable situations and that is situated in a disadvantaged
urban neighbourhood in the south of Canelones. The organisation supports youngsters
with a variety of problems: most of them have economic difficulties, were raised in
complicated family situations or had a traumatized childhood. In order to increase the
life situation of these youngsters, the organisation has different aims: (a) to give
educational support to enable them to think critically about their own future, (b) to learn
adolescents more in order to provide an answer to the problems their community faces
and (c) to strengthen their relational networks and improve family ties. The total
number of participants in the non-governmental organisation is 48, of which 30 filled
out the questionnaires. It was not possible to reach a higher amount of participants
because of the lack of time and resources. No participants were excluded from the 30
15
questionnaires. The sample consisted of 15 boys and 15 girls living in the same
neighbourhood. The 30 questionnaires were collected in December 2016.
The second sample was recruited between May and June 2016 in a private high school
(secondary) in the centre of the department of Canelones. The whole sample consisted
of 390 students and the final sample included 325 participants from 12 to 18 years old
(girls 53.2%, boys 46.8%) with a mean age of 14.67 years (SD=1.62). From this sample,
30 participants were chosen with the same characteristics as the sample of the
vulnerable population according to gender and age.
2.2. Procedure
The recruitment and assessment of the vulnerable sample took place during three
different moments in December 2016 in the building of the organization. The different
dates were necessary because not all of the participants could attend to the meeting on
the same day since they had other obligations as well. Before the investigation took
place, the director and the coordinator of the organization gave their permission to start
the project. The parents of the respondents received a letter with a brief explanation of
the purpose and the aims of the study. They already signed a document to give their
approval that the youngsters could participate in every investigation that was approved
by the organization. The adolescents were informed that everything was anonymous
and the information would not be transferred to the team or their parents. They had to
fill in the questionnaires with pen and paper, because there were not enough computers
available in the building. Three youngsters were supported by the staff in completing
the questions because they had problems with writing and reading. During the
procedure, the difficulties and the aim of every questionnaire were explained to ensure
all the participants understood the questions. They could ask questions to the
supervisors who were walking around. When they finished the task, every answer was
checked before they could leave the room, to make sure the questions were filled in
properly and without mistakes. Afterwards, there was a brief conversation about the
16
task, to ensure they felt comfortable after confronting them with these personal
questions.
Data for the general population sample were collected during four days in the period
May and June 2016 by a team of the Catholic University of Montevideo. Before the
investigation took place, two researchers from the Universidad Catolica del Uruguay
organized two interviews with the head and the psychologist of the school to explain
the study and to ask permission. Afterwards the parents received a letter with a brief
explanation of the aims and the purpose of the study. Parents, tutors, students and the
institution gave their permission by signing the informed consents. The investigation
took place during academic hours in the computer lab, the only room with enough
computers available for the amount of students. The team explained how the students
could complete the questions and made clear that they could not talk while fulfilling the
task. They were available to give more information to the students if necessary. The
team checked the answers and made sure every question was complete before the
student could leave the room. Afterwards the team organized a brief conversation and
game to thank the participants.
The instruments and informed consents (Annex 1 and 2) used for both samples were
approved by the Ethical Board of the Catholic University of Uruguay. The questionnaires
were anonymized and kept confidential and sealed. Neither the participants nor the
organisations received any kind of monetary compensation.
2.3. Questionnaires
2.3.1. Socio-demographic characteristics.
The reduced version of the Indice de Nivel Socio-Economico (INSE_RED) (Annex 3) was
used to analyse the socio- economic status of the participants (Llamb & Piñeiro, 2012).
The questionnaire seeks to classify households according to their consumption or
expenditure capacity and consisted of questions regarding individual, family, school and
environment characteristics. Although it reduces the scales precision, the reduced index
17
of 10 variables (instead of 41 variables) was obtained respecting the complete index.
The choice of using the reduced version is based on two main reasons. At first, the
limitation of time the participants had to complete the survey resulted in a decreased
amount of questions. Also, considering the age and the concentration ability of the
group, a longer survey would lead to random answers and indifference towards the
questions.
2.3.2. Psychopathology and resilience.
To investigate the psychopathological and resilience characteristics presented in the
target group, the participants had to fill in ‘The Adolescent Self Report’ (ADA) (Daset et
al., 2015). The reduced version exists of 82 items instead of 118 and is scored using a 5-
point Likert scale (0-4). The reasons to use the reduced version of the ADA are the same
as for the INSE. The ADA contains both positive factors (social desirability, life planning)
as psychopathological symptoms (emotional and behavioural problems). The survey is
based on the studies of Achenback and Edelbrock (1978); Lemos, Fidalgo, Calvo and
Menendez (1992) and Lopez-Soler et al., (1998). In the following part, a description is
made of the six factors of the ADA (Daset, Fernández-Pintos, Costa-Ball, López-Soler &
Vanderplasschen, 2015).
2.3.2.1. F1: Depression- Anxiety.
Depression is a common medical illness that evokes feelings of sadness and a loss of
interest in activities once enjoyed. It can lead to a range of emotional and physical
problems and can decrease a person’s ability to function at work and at home (Parekh,
2017).
2.3.2.2. F2: Antisocial and Addictive behaviour.
Antisocial behaviours are disruptive acts characterized by open or hidden hostility and
intentional aggression towards others. It can include repeated violations of social rules,
disobedience of authority and reckless disregard for others and one self (Reid, Patterson
& Snyder, 2002). An addictive behaviour is a stimulus related to a behaviour that is both
18
rewarding and reinforcing, hence it is associated with the development of an addiction.
Being addicted is a brain disorder characterized by compulsive engagement in rewarding
stimuli, despite adverse consequences (Volkow, Koob & McLellan, 2016).
2.3.2.3. F3: Disruptive and Dysregulated behaviour.
Disruptive mood dysregulation disorder (DMDD) is a group of behavioural disorders
defined by continuous patterns of hostile and provocative behaviours that adolescents
direct towards any type of authority figure. It is a childhood condition of extreme
irascibility, anger and intense temper outbursts that requires clinical attention because
they experience severe aggravation (Pagliaccio et al., 2017).
2.3.2.4. F4: Social Anxiety.
Social anxiety can be described as the constant fear of social situations in which the
person is exposed to unfamiliar people or to possible circumstances that will be
embarrassing and humiliating. The avoidance, anxious preoccupations or anguish in the
feared social hinder significantly with their normal routine, relationships or social
activities (APA, 2013).
2.3.2.5. F5: Resilience- Prosociality.
Resilience is the ability to endure and rebound from crises or permanent challenges such
as stressful situations, trauma and difficult experiences (Argosy University, 2014).
Prosocial behaviour is characterized by being empathic about the feelings, rights and
health of others in order to help or enhance them (Wadsworth & Santiago, 2008).
2.3.2.6. F6: Obsessive-compulsive
Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have
periodical, undesired thoughts, ideas or sensations that make them feel driven to do
things repetitively. The repetitive behaviours can significantly obstruct with a person’s
daily live and his social interactions (APA, 2013).
19
2.3.3. Alcohol and marijuana consumption.
To analyse adolescents’ alcohol and marijuana use, a survey (JND, 2011) (Annex 4) was
organised. The survey determined (a) the lifetime prevalence of alcohol use (yes/no),
(b) the prevalence of alcohol use during the last 12 months (yes/no) and (c) the age of
first alcohol use. Besides alcohol use, the questionnaire also focused on marijuana use.
The lifetime prevalence of marijuana use (yes/no), the prevalence of marijuana use
during the last 12 months and the age of first marijuana use was investigated. The onset
of alcohol use was conceptualized as the first use of alcohol in any context, not
considering the number of drinks.
2.3.4. Problematic cannabis use.
The Cannabis Abuse Screening Test (CAST) (Annex 5) questionnaire is a 6-item scale
screening for problematic patterns of cannabis use. This scale, specifically designed for
its application with adolescents and young people, was validated by the European
Observatory of Drugs through its application in 17 countries in the study (JND, 2014).
This screening scale aims at identifying patterns of cannabis use leading to negative
consequences on a health or social level for the user himself/ hetself or others (Legleye
et al., 2007). All items are measured with a 5-point scale (0 “never”, 1 “rarely”, 2 “from
time to time”, 3 “quite often”, 4 “very often”). Once the values assumed by each of these
six indicators are dichotomized, a simple summation index ranging from 0 to 6 is
constructed and, finally, the ranges that account for the differential risks of consumption
can identify a drug problem (Hibell et al., 2009).
2.3.5. Subjective wellbeing.
Participants were asked to what extent they felt satisfied with different aspects of their
lives with the Personal Wellbeing Index scale (PWI, Cummins at al., 2003) (Annex 6). The
PWI comprises 7 items relating to satisfaction which correspond to one of the following
areas of life: standard of living, health, life achievements, relationships with other
people, present security, relationships with the community and future security. Items
are scored on a Likert-type scale from 0 (completely dissatisfied) to 10 (completely
20
satisfied), in accordance with Cummins and Gullone (2000). The final score is obtained
by calculating the mean score for the items and adjusting this to a scale of 0 to 100.
2.4. Data-analysis
Test results and answers from the questionnaires were digitalised in Excel 2013 and
afterwards imported in the statistic computer programme SPSS Statistics 23. This
programme was used to perform statistical analyses with the variables described above.
The first set of analyses calculated the descriptive statistics of the two samples regarding
demographic characteristics, the prevalence of alcohol and marihuana use and the
different items of psychopathology and resilience. Using the Pearson’s correlation
coefficient, the second set of analyses explored the relationship between the six ADA-
items mutually and its correlation to the items of the Personal Wellbeing Index (PWI)
and alcohol and marijuana consumption between the two groups. Additionally, a
comparison was made to analyse if alcohol and marijuana consumption of the
vulnerable sample differed significantly from the general population sample and with
the national sample of Uruguay (JND, 2014). Moreover, the Shapiro-Wilk test was used
to examine if the different variables were normally distributed (Sampieri, Callado &
Lucio, 2006). The different factors of the ADA; F1, F2, F3, F4, F5 and the PWI are not-
normally distributed because they are significant on a 0.01 scale (p<.01). For the
variables that were not normally distributed, a Mann-Whitney U test was conducted.
This test analyses the mean of two independent groups with non-parametric data and
shows if there is a significant difference (Sampieri et. al., 2006). To test the significance
of the normally distributed variable F6, we conducted an independent sample T-test.
The independent-samples t-test compares the means between two unrelated groups on
the same dependent variable (Sampieri et al., 2006).
21
3. Results
3.1. Descriptive analyses
The descriptive analyses were conducted to have a clear view on the different variables
and their percentages and frequencies of both samples. Table 1 provides characteristics
of the two samples. Both samples have the same amount of boys (50%) and girls (50%).
The samples are also equal regarding age: 46.7% are 13-14 years old, 23.3% 15-16 years
old and 30.0% are 17-18 years old. The average age is 15.0 years (SD=1.68). Focussing
on the socioeconomic status, there is a difference noticeable between both samples.
The sample of the vulnerable population includes 30% low class, 70% middle class and
no high class participants. The sample of the general population includes no participants
of low class, 43.4% of middle class and 56.7% high class. Although a large middle class is
shown for the vulnerable sample, the numbers should be put into perspective. It could
be that the participants filled out the questionnaires in a desirable way or presented
their situation more optimistic because they felt ashamed.
22
Table 1
Socio-demographic characteristics of the sample of the vulnerable sample (n=30) and general
population sample (n=30)
Vulnerable sample General sample
Variables N % N ´%
Gender
Male 15 50.0 15 50.0
Female 15 50.0 15 50.0
Frequency of age
13-14 14 46.7 14 46.7
15-16 7 23.3 7 23.3
17-18 9 30.0 9 30.0
Socioeconomic status
Low 9 30.0 0 0.0
Medium 21 70.0 13 43.4
High 0 0.0 17 56.7
Mean age 15.0 15.0
In order to collect more information about the emotional wellbeing, questions regarding
the different feelings they had and situations that happened in the last year where
asked. More participants from the general population sample felt joy and more
participants of the vulnerable sample felt anger, shame and fear within the last year.
Furthermore, we examined the different situations the participants were confronted
within the last year. The situations that happened most frequently among the
vulnerable sample, in order of highest to lowest frequency, were the following: death of
someone close (46,7%), break-up (40%), accident with material injury (20%), moving out
(13.3%), divorce of parents (10%) and physical maltreatment (6.7%). For the adolescents
of the general population sample, the results were the following: death of someone
close (16.6%), break-up (13.3%), moving out (13.3%), violent robbery (10%) and divorce
of parents (3.3%).
To summarize the descriptive results, it is noticeable that the vulnerable population
group does not include high class participants and the general population group low
class participants. In addition, the participants of the vulnerable sample have two times
23
more shame, anger and sadness then the general sample. Furthermore, within the last
year, three times more deaths of someone close, break up with boy- or girlfriend and
divorce of parents had happened for the vulnerable sample. Moreover, the perception
of their quality of life is lower than the general population sample. These results gave
an indication of the objective and subjective wellbeing of the adolescents that is lower
in the vulnerable group.
3.2. Alcohol consumption among adolescents
Table 2 describes the alcohol and marijuana use prevalence for both samples. Regarding
alcohol consumption among the vulnerable sample, almost 77% consumed alcohol in
their lifetime and 70% has consumed in the last year. Looking at the general sample,
60% ever consumed alcohol and 53.3% has consumed in the last year. The average age
for first alcohol use for the vulnerable sample is 12 years old (SD=3.0). Due to the missing
data of the average age of the first onset of alcohol use in the general population sample,
no number can be presented.
24
Table 2
Alcohol and Marijuana use prevalence of the vulnerable (n=30) and general population sample
(n=30).
Vulnerable sample General sample
Variables N % N %
Alcohol consumption
Alcohol use once in lifetime: yes 23 76.7 18 60.0
Alcohol use last 12 months: yes 21 70.0 16 53.3
Marijuana consumption
Marijuana use once in lifetime: yes 12 40.0 3 10.0
Marijuana use last 12 months: yes 10 33.3 3 10.0
Friends who use Marijuana 19 63.3 14 46.7
CAST
Low risk 20 66.6 30 100.0
Medium risk 7 23.3 0 0.0
High risk 3 10.0 0 0.0
Mean age of first marijuana use 13.5 15.7
In order to find a significant difference between the percentages alcohol use, we
compared the vulnerable sample with the general sample and the national sample of
Uruguay (JND,2014). The Z-score for the different variables had to be between -1.96 and
1.96 according to the 0,05 significance scale. The results of the comparison between the
vulnerable and general population sample are the following: there was no significant
difference for alcohol use during the last year (Z=1.4, p>.05) for both groups, neither for
alcohol use in a lifetime (Z= 1.2, p>.05). Looking at the percentages of the vulnerable
sample and the sample of Uruguay (JND, 2014), there were no significant differences
between alcohol consumption last year (Z=1.1, p>.05) and alcohol consumption in a
lifetime (Z=0.25, p>.05) on a 0.05 significance scale. Although the prevalence of alcohol
consumption is higher for the vulnerable sample in comparison with the general
population sample and the national sample, this difference is not significant.
25
3.3. Marijuana consumption among adolescents
Considering the characteristics of marijuana consumption for both samples, the average
age of first marijuana use for the vulnerable sample is 13.5 years (SD=1.5), for the
general sample 15,7 years (SD=1.5). 40% of the participants of the vulnerable sample
had ever used marijuana, four times more than the general population sample (10%)
and 33.3% used in the last year, three times more than the general population sample
(10%). The majority of the vulnerable sample has friends who use marijuana (63.3%),
while not even half of the general population sample has such friends. Observing the
CAST, the vulnerable sample includes participants with a low risk (66.6%), a medium risk
(23.3%) and a high risk (10,0%) regarding problematic marihuana use. The general
population sample includes only participants with a low risk (100%) of problematic
marihuana use. The knowledge of the participants about the consequences of marijuana
use were observed as well. Approximately 20% of the adolescents of the vulnerable
sample think that frequently using marihuana does not include any risks and 10% do not
know if it leads to any bad consequences.
In order to find a difference between the percentages of marijuana use, we compared
the vulnerable sample with the general sample and the national sample of Uruguay
(JND, 2014) (Table 3). There was no significant difference for marijuana use last year
(Z=1.82, p>.05) for the general sample, however for marijuana use during lifetime there
was a significant difference within both groups (Z=2.70, p<.05). Looking at the
percentages of the vulnerable sample and the national sample of Uruguay (JND, 2014)
a significant difference is noticeable between marijuana use during last year (Z=2.38,
p<.05) and between marijuana use in a lifetime (Z=5.5, p<.05) on the 0.05 scale.
26
Table 3
Comparison between the percentages of alcohol and marijuana consumption between the
vulnerable and general population sample and the vulnerable and national sample on a 0.05
significance scale.
General sample Z-score National sample Z-score
Alcohol last year 1.4 1.1
Alcohol lifetime 1.2 0.3
Marijuana last year 1.8 2.4
Marijuana lifetime 2.7 5.5
Note: significant on a 0.05 significance scale if the Z-score is > than 1.96 or < than -1.96.
It can be concluded that adolescents of the vulnerable sample start consuming
marijuana on average more than two years earlier than the adolescents of the general
sample. Furthermore, more than 30% of the participants of the vulnerable sample have
users with a medium or high risk of addiction, compared to 0% of the general sample.
Moreover, the vulnerable sample has four times more marijuana users than the general
sample, and this difference is significant. In comparison with the national sample, the
vulnerable sample has significantly more marijuana users during last year and in a
lifetime.
3.4. Alcohol and marijuana consumption in relation to psychopathology
3.4.1. Differences in means ADA-factors.
If we compare the means of the samples of the vulnerable and the general group, we
can demonstrate a significance for the following ADA-factors: F1 (Z=-3.50, p=.00), F2 (Z=-
2.71, p=.01), F3 (Z=-2.51, p=.01) and F4 (Z=-3.21, p=.00) (Table 4). There is no significant
difference for F5 (Z=-1.03, p=.30) and personal wellbeing (Z=-.60, p=.55). There is also
no significant difference between the means of F6 behaviour for the two samples
(t(29)=1.60, p=.11).
27
Table 4
Distribution of the ADA factors and PWI: Vulnerable (n=30) and general population sample
(n=30).
Vulnerable sample General sample
Variables M (SD) M (SD) Z p
ADA
F1: Depression- Anxiety 27.9 (23.7) 11.7 (11.6) -3.50 .000
F2: Antisocial and Addictive
behaviour
3.7 (2.7) 1.9 (2.0) -2.71 .010
F3: Disruptive and Dysregulated
behaviour
17.1 (11.2) 9.9 (6.9) -2.51 .010
F4: Social Anxiety 16.7 (13.5) 7.0 (5.2) -3.21 .000
F5: Resilience- Prosociality 37.7 (11.1) 41.2 (6.4) -1.03 .300
F6: Obsessive-compulsive 14.8 (5.7) 12.8 (4.1) 1.60 .110
Personal Wellbeing Index
PWI 75.1 (22.8) 83.6 (8.0) -0.60 .55
Beside the general population sample, a comparison between the original ADA- sample
(Daset et al., 2015) and the vulnerable sample was conducted with the Mann-Whitney
Test (Table 5). A significant difference between the means is shown for the following
ADA-factors: F1 (Z=-3.60, p<.001), F2 (Z=-3.09, p=.002), F3 (Z=-3.69, p<.001), F4 (Z=-3.69,
p<.001) and F6 (Z=-5.78, p<.001). There is no significant difference for F5 (Z=-1.33,
p=.183).
28
Table 5
Distribution of the ADA factors: Vulnerable sample (n=30) and original study of ADA (n=335).
Vulnerable
sample
Original ADA
Variables M (SD) M (SD) Z p
ADA
F1: Depression- Anxiety 27.9 (23.7) 14.1 (12.4) -3.60 .000
F2: Antisocial and Addictive
behaviour
3.7 (2.7) 2.2 (2.4) -3.09 .002
F3: Disruptive and Dysregulated
behaviour
17.1 (11.2) 9.6 (8.1) -3.69 .000
F4: Social Anxiety 16.7 (13.5) 8.8 (7.2) -3.39 .001
F5: Resilience- Prosociality 37.7 (11.1) 36.0 (8.7) -1.33 .183
F6: Obsessive- compulsive 14.8 (5.7) 8.2 (4.7) -5.78 .000
In conclusion, the vulnerable sample consists significantly more participants with
psychopathological problems regarding depression-anxiety, antisocial with addictive
behaviour, disruptive and dysregulated behaviour and social anxiety than the general
population sample. Furthermore, The vulnerable sample has more participants with
psychopathological problems regarding depression-anxiety, antisocial with addictive
behaviour, disruptive and dysregulated behaviour, social anxiety and obsessive-
compulsive behaviour than the original ADA-sample and this difference is also
significant.
3.4.2. Correlations between alcohol use and factors of the ADA.
Pearson’s correlations were conducted to measure the strength and direction of the
association that exists between two variables, in this case the different factors of the
ADA and lifetime alcohol use and last year use (Sampieri et al., 2006). If we compare
lifetime alcohol use (Table 6) with the different factors of the ADA for the vulnerable
sample, it is shown that there is a weak positive correlation (.39) with F3 and a weak
negative correlation (-.39) with F5 on the 0.05 significance level. Alcohol consumption
last year correlates positively (.38) with F3 on the 0.05 significance level. There are no
significant correlation between the ADA factors and alcohol consumption for the general
population sample. If we compare alcohol consumption with the PWI, the different
29
feelings or the different situations, there are no significant correlations within both
samples.
Table 6
Correlations alcohol with the ADA factors for the vulnerable sample (n=30) and the general
population sample (n=30).
1 2 3 4 5 6 7 8
1. F1 1 .36 .32 .74** -.13 .41* -.18 -.13
2. F2 .35 1 .11 .49** -.08 .24 -.09 -.10
3. F3 .65**
.58**
1 .10 -.17 .27 -.10 -.17
4. F4 .95** .34 .70** 1 -.16 .29 -.17 -.14
5. F5 -.48** -.39* -.32 -.39* 1 .28 -.05 .00
6. F6 .236 -.04 .16 .58 .25 1 -.27 -.20
7. Alcohol in lifetime .25 .23 .39* .20 -.39* .05 1 .87**
8. Alcohol last year .32 .15 .38* .27 -.28 -.03 .84** 1
The correlations between the participants of the vulnerable sample (n=30) are presented under the
diagonal and the correlations between the participants of the general population sample (n=30) are
presented above the diagonal.
** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed).
Only correlations between alcohol use and the ADA-factors were found in the vulnerable
sample. When participants score high on lifetime alcohol use, on average, they will also
score high on disruptive and dysregulated behaviour and score low on resilience-
prosociality. Furthermore, If participants score high on alcohol consumption last year,
on average, they will also score high on disruptive and dysregulated behaviour.
3.4.3. Correlations between marijuana use and factors of the ADA.
If we compare lifetime marijuana use and marijuana use last year with the ADA-factors
for the vulnerable sample (Table 7), it is noticeable that there is a weak positive
correlation (.37) between F2 and marihuana last year on a 0.05 significance level.
Participants who score high on marihuana last year, will also have a high score, on
average, on antisocial with addictive behaviour. There are no significant correlations
between marijuana consumption last year and the ADA factors for the general
population sample, nor lifetime marijuana use for both samples. If we compare
30
marihuana consumption with the PWI, the different feelings or the different situations,
there are no significant correlations within both samples.
Table 7
Correlations marijuana with the ADA factors for the vulnerable (n=30) and the general
population sample (n=30).
1 2 3 4 5 6 7 8
1. F1 1 .36 .32 .74** -.13 .41* -.08 -.08
2. F2 .35 1 .11 .49** -.08 .24 -.03 -.03
3. F3 .65**
.58**
1 .10 -.17 .27 .00 .00
4. F4 .95** .34 .70** 1 -.16 .29 -.05 -.05
5. F5 -.48** -.39* -.32 -.39* 1 .28 .06 .06
6. F6 .236 -.04 .16 .58 .25 1 .02 .02
7. Marihuana in
lifetime
.02 .35 .18 -.10 -.22 -.15 1 1.0**
8. Marihuana last year .13 .37* .22 .02 -.30 -.02 .87** 1
The correlations between the participants of the vulnerable sample (n=30) are presented under the
diagonal and the correlations between the participants of the general population sample (n=30) are
presented above the diagonal.
** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed).
31
4. Discussion
The aim of this study was to assess the use of alcohol and marijuana in relationship with
psychopathological factors in a sample of school-going boys and girls and a sample of
adolescents with a vulnerable background in Canelones (Uruguay). Two samples (N=30)
with the same amount of boys (50%) and girls (50%) and with the same age
characteristics were selected in order to find an answer on the research questions. The
vulnerable sample was conducted from an organisation who works with adolescents
residing in a disadvantaged neighbourhood. The participants had a lower economic
level, quality of life perception and subjective wellbeing than the general population
sample. Two hypothesis were tested: ‘do adolescents with a vulnerable background
consume more marijuana and alcohol than adolescents from a general population in
Uruguay and, if so, to what extent?’ and ‘to what extent are marijuana and alcohol
related to psychopathology among adolescents in Uruguay?’.
In line with prior work that state that adolescents residing in disadvantaged urban
neighbourhoods are at higher risk of substance abuse (Olumide et al., 2014; United
Nations Children’s Fund, 2012; Volzke et al., 2006), we found that adolescents of the
vulnerable sample score higher on the CAST for medium and high risk marijuana use
than the general population sample. Furthermore, the vulnerable sample has a
significantly higher percentage of participants that ever used marihuana compared to
the general population group and to the most recent sample of the Junta National (JND,
2015). According to literature, poverty and instability in disadvantaged neighbourhoods
provoke significant amounts of stress that could result in an increased inclination to use
drugs, when combined by limited access to health information (Olumide et al., 2014;
United Nations Children’s Fund, 2012; Volzke et al., 2006). The low result on subjective
wellbeing that occurred for the vulnerable sample could be an indication of a source of
stress, that could cause an inclination of marijuana use. Combined with the limited
knowledge of marijuana consumption (approximately 20% of the adolescents of the
vulnerable sample think that frequently using marijuana does not include any risks and
10% do not know if it leads to any bad consequences), this research supports prior work
32
that state that a focus on prevention and informative lessons about marijuana
consumption in schools, especially in disadvantaged neighbourhoods, is necessary
(Clement et al., 2014; Olumide et al., 2014).
This study supports previous research that has indicated a high prevalence of
psychological disorders in adolescents (Daset 2002; Daset et al 2009; Viola, Garrido &
Varela, 2007). Above all, depression-anxiety has high rates for both samples, what
affirms the findings of the World Health Organisation (2013), who declares that
depression is the most common neuropsychiatric disorder in South-America.
Furthermore, a significantly higher amount of participants of the vulnerable sample
have psychopathological characteristics such as depression-anxiety, antisocial with
addictive behaviour, disruptive and dysregulated behaviour and social anxiety in
comparison with the general population sample and the original sample of the ADA.
These findings are in line with former work (de Graaf et al., 2002; Gilman et al., 2003;
Melchior, Moffitt, Milne, Poulton & Caspi, 2007; Cerda et al., 2010) that reported
associations between socio-economic disadvantage and depression and anxiety.
Although the vulnerable group has more psychopathological problems, their resilience-
prosociality is almost the same as the general population sample. Results identify that
this group could have the ability to endure and rebound from their problems by
themselves, if they get enough support from their surroundings (Wadsworth & Santiago,
2008).
Furthermore, alcohol consumption of the vulnerable sample correlates positively with
disruptive and dysregulated behaviour, what could correspond to studies that have
linked socio-economic factors with comorbid alcohol and mental health disorders
(Cerda et al., 2010; Green et al., 2012; Mulia et al., 2012; Pulkki-Raback et al.,
2012). Nevertheless, it remains unclear in what way these associations differ from single
disorders (Cerda et al., 2010). In addition to the results of alcohol consumption,
marijuana use last year correlates positively to antisocial and addictive behaviour in the
vulnerable sample. The study of Malone et al. (2010) agrees with these findings,
33
adolescent exposure to cannabis is associated with a range of long-term adverse effects,
such as increased addiction vulnerability and psychosis-related illness.
Although numerous studies describe the relation between substance use and
psychopathology in general (Kessler et al., 2005; Teesson et al., 2009), this study
cannot be added to it. No significant results could be found. Reasons could be the small
research groups we worked with that made comparison difficult and other variables that
were not taken into account in this study. Nevertheless, the high results of both
marijuana and alcohol use and psychopathological characteristics should give a clear
sign that prevention and information transfer is needed, especially for vulnerable
groups. Considering the recently changed cannabis law in Uruguay, the legalization of
marijuana could have a negative impact on the frequency and consequences of
adolescent consumption, such as their mental health (Estoup et al., 2016). Therefore,
future research should focus on the relation between substance use and
psychopathological factors with a larger and more representative sample of a vulnerable
and a general adolescent population in Uruguay.
34
5. Limitations and recommendations
The current findings reflect a first step in identifying the variables that influence the
differences of a vulnerable and a general population youth according to alcohol and
marihuana use and psychopathology. There are, however, some limitations of the
current study that should be noted. First and above all, the generalization of the study
results should be limited to the organization and the school where the intervention took
place. It requires replication with a larger and more representative sample in order to
examine if these results also count for other samples of a vulnerable and a general
population. Future studies should be based on probabilistic sampling methods and
includes schools nationwide. Second, self- reported questionnaires were used, which
can increase the probability of social desirable answers. It cannot be excluded that the
youngsters based there answers on desirable situations and not on the real situation.
However, self-reported questionnaires have been a valid and extensively used method
to obtain information regarding youngsters’ perspectives (Rescorla, Ginzburg,
Achenback, Ivanova, Almqvist & Verhulst, 2013). Also, the questions about their
socioeconomic level could give a wrong image because feelings of shame and loyalty to
their parents could influence the answering. It is also necessary to mention that three
youngsters needed support from a supervisor, which leads to a bigger chance of
desirably answering. In addition, it is important to know that no professional researcher
set up the procedure and analysed the results. Although support was arranged while
organising the investigation with the vulnerable group, difficulties occurred due to the
unfamiliar Spanish language the participants spoke and the lack of experience I had.
Despite the fact that the results were analysed together with the professor of statistics
of the Universidad Catolica de Montevideo, different expectations could result in small
mistakes in the results. Also, it is important to mention that my mother tongue is Dutch,
thus grammatical and spelling mistakes can occur in this dissertation. Furthermore, only
quantitative research was used to investigate the two groups. During the first stage,
interviews with ten youngsters were conducted in order to get more information about
their patterns and ideas of alcohol and marihuana use. The data was excluded because
there was no value in adding the information to this research. The youngsters responded
35
in a short and desirable way that made the data unusable. It could be valuable to include
qualitative research as well by interviewing the youngsters or organising focus groups
to get a closer look on their experiences with alcohol and marihuana use, but this should
be done by an unknown researcher who is familiar with the language.
36
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7. Appendix Annex 1: Informed consent parents
Estimados padres o tutores
La Facultad de Psicología de la Universidad Católica del Uruguay realizando la validación
un instrumento de evaluación para adolescentes denominado Autoinforme de
Adolescentes (ADA). Por esta vía, solicitamos autorice para que su hijo/a participe en
esta investigación respondiendo a las preguntas de los cuestionarios.
El trabajo solicita una autovaloración a partir de la autopercepción y para ello se le
ofrece al adolescente un punto de comparación con sus pares. El instrumento se
fundamenta en los hallasgos de Achenbach y Edelbrock (1978) con el Youth Self Report,
adaptado a España (Lemos, Fidalgo, Calvo, Menéndez, 1992) y a Uruguay (Daset, 1998).
El ADA consta de tres secciones: la primera sección recoge datos sociodemográficos de
orden general, la segunda encuesta aspectos prosociales, fortalezas, estilos de
afrontamiento y proyecto de vida; y una última sección explora aspectos desadaptativos
o que suponen, muchos de ellos, sufrimiento psíquico.
En el marco de este trabajo, se administrarán los cuestionarios en una única vez y en
forma grupal, en un tiempo estimado de 60 minutos, con un intervalo de descanso. La
administración se realizará dentro del colegio San Isidro durante el horario curricular.
Con respecto a la posible inclusión de su hijo/a en esta investigación, hacemos constar
que la no participación de la/el joven no acarreará ningún tipo de consecuencias
negativas para él/ella. Al mismo tiempo es pertinente aclarar que los resultados
individuales obtenidos y todos los datos personales serán mantenidos bajo estricta
confidencialidad, a través de un sistema identificatorio de doble vía.
En caso de que usted autorice la participación de su hijo/a en esta investigación, le
agradecemos que nos haga llegar el talón adjunto firmado.
50
Los saluda atentamente,
Equipo de Investigación en la Línea de Niñez y Adolescencia
Por favor complete el siguiente talón y marque según corresponda
-------------------------------------------------------------------------------------------------------------------
AUTORIZO
NO AUTORIZO
A QUE MI HIJO/A PARTICIPE DE LA INVESTIGACIÓN ADA
Fecha: …………………............. Nombre del alumno: …………………………………….
Firma de padre, madre o tutor: …....................................
Aclaración de firma:……………………………………………………
Por cualquier información adicional sobre la investigación comunicarse con la Dra. G.5
Lilian. R. Daset (2487.2717 interno 337)
FACULTAD DE PSICOLOGÌA
UNIVERSIDAD CATÓLICA DEL URUGUAY
CONSENTIMIENTO INFORMADO INSTITUCIONAL
51
Annex 2: Informed Consent adolescents
Facultad de Psicología
Universidad Católica del Uruguay
Consentimiento para Participantes de la Investigación con el Autoinforme de
Adolescentes (ADA)
Yo,……………………………………………………………………………………., por voluntad propia, doy mi
consentimiento a participar en este proceso de investigación psicológica, sabiendo que,
• Se me han explicado los fines del estudio y para ello debo responder a
todos los cuestionarios que me serán provistos por los investigadores.
• Que tengo el derecho a suspender mi participación informando a los
investigadores en cualquier momento del estudio, sin que ello implique
ninguna consecuencia negativa para mi persona.
• He comprendido la información suministrada y he podido formular
preguntas.
Montevideo,…………de 2016
Firma del participante:………………………………
Aclaración de firma……………………………………
Quedando a vuestra grata disposición les saludamos cordialmente
Prof. G. 5 Dra. Lilian R. Daset
52
Annex 3: Indice de Nivel Socio-Economico
A continuación encontrarás una serie de preguntas. En cada una deberás indicar la
opción que corresponda y en otros casos escribir una palabra o frase, o colocar un
número, según lo indique la pregunta. Es importante que respondas honestamente, ya
que utilizaremos la información para ayudar a otros jóvenes como tú. Si bien debes
colocar tu nombre, toda la información que obtenemos del cuestionario es confidencial.
1. Número que te han asignado:
2. Sexo:
Femenino/ masculino
3. Fecha de nacimiento:
4. Año que cursas:
5. País de nacimiento:
6. Departamento en el que vives:
7. Barrio en el que vives:
8. Cuál es la principal persona que sostiene económicamente el hogar:
o Madre
o Padre
o Hermano/a
o Tío/a
o Otro (escribe quien)
9. ¿cuál es el maximo nivel de estudios completó esa persona?
o No tiene estudios
o Escuela – primaria
o Liceo –secundaria
o Enseñanza técnica (UTU o similar)
o Estudios tercearios (universidad, magisterio, profesorado)
o Estudios de posgrado
10. ¿qué atención médica recibe el principal sostenedor del hogar?
53
o Salud pública
o Mutualistas (Española, Médica Uruguaya, SMI…)
o Seguro médico privado (SUMMUM, Británico, MP)
o Hospital Militar/Policial
11. ¿tienen empleada doméstico?
o No
o Si, por hora (viene algunos días)
o Si, por día (viene todos los días)
o Si, con cama (duerme en la casa)
Acerca de tu casa contesta las siguientes preguntas
12.1 ¿hay auto en tu casa? Escribe la cantidad
12.2 ¿hay TV en tu casa? Escribe la cantidad
12.3 ¿hay heladera en tu casa? Escribe la cantidad
12.4 ¿hay baño en tu casa? Escribe la cantidad
13. ¿En tu casa, cuántas personas reciben sueldo/ pensión/ jubilación?
14. Cantidad de personas que viven en tu casa incluido tu:
15. . Marca con quienes vives en tu casa
Padre Padre Hermano/a
Abuelo/a Tío/a Madrastra
Padrastro Tu pareja Hijos
Otro (escribe quien)
16. ¿Cómo acostumbran a resolver los problemas familiares? Marca una opción
o Con poca dificultad (Ej. conversando, se apoyan entre si, buscan ayuda)
o Con alguna dificultad. (Ej. Dejan de hablarse, se alejan)
o Con mucha dificultad (Ej., gritando, rompiendo cosas, con insultos
17. ¿tienes algún mejor amigo/a? ¿Cuántos?
18. En el último año, ¿cómo te fue en los estudios? Marca una opción
o Muy bien (nota 912)
o Bien (nota 68)
o Regular (nota 15)
54
19. ¿Tienes novio o novia?
20. ¿Realizas actividad física fuera de clases?
21. ¿Participas en actividades religiosas? Marca una opción
o Si (participo voluntariamente en actividades como: misa, catequesis, grupos
asociativos, etc.)
o No
22. ¿Qué sientes más a menudo? Puedes marcar más de una
Alegría Vergüenza
Enojo Sorpresa
Miedo Tristeza
23. De lunes a viernes, ¿Cuántas horas duermes de noche? Marca una opción
o Menos de 6 hs
o Entre 6 y 8 hs
o Entre 8 y 10 hs
o Más de 10 hs
24. Acerca de tus hábitos, consumes… (marca una opción por fila!)
nunca Algunas veces Fines de
semana
Siempre
Tabaco
Alcohol
Pasta base
Marihuana
25. ¿Cuántas horas al día dedicas a….? (marca una opción por fila!)
nada Menos de 4h Entre 4 y 6 hs Más de 6h
Televisión
Redes sociales
Video juegos
55
Web de
adultos
26. ¿Para qué usas las redes sociales? Puedes marcar más de una
o Comunicarme con amigos
o Conocer gente diferente
o Conseguir amigos
o Conseguir novio/a
o Salir con un chico/a
o Hacer de cuenta que soy otra persona
o Otros
27. En el último año, ¿Has pasado por alguna de estas situaciones? Puedes marcar más
de una
o Accidente con daño importante
o Alguna enfermedad grave
o Maltrato físico
o Muerte de alguien cercano
o Robo violento / Copamiento
o Mudanza
o Romper con tu novio/a
o Divorcio de padres
o Ninguna
Tus respuestas contribuirán al bienestar de muchos jóvenes como tú.
¡Muchas gracias!
56
Annex 4: Alcohol and marijuana consumption
CONSUMO DE BEBIDAS ALCOHOLICAS. Marca la que corresponde o redondea.
1. ¿Ha consumido bebidas alcohólicas alguna vez en la vida?
Sí No (si contestaste No pasa a la pregunta 7)
¿Cuándo fue la primera vez que consumiste bebidas alcohólicas?
Últimos 30 días Hace mas de 1 mes pero menos de 1 año Hace
más de 1 año
¿Qué edad tenías cuando consumiste bebidas alcohólicas por primera vez?
(10-18)…… Años No recuerda No contesta
¿Has consumido bebidas alcohólicas en los últimos 12 meses? Sí No
2. ¿Cuáles fueron los principales motivos por los que probaste alcohol?
Curiosidad Entorno/amigos olvidarme de problemas No se Otros
6.
¿En los últimos 15 días, cuántas veces
has consumido en una misma salida más
de 2 litros de cerveza o/ más de 3/4 litros
de vino/o más de 4 medidas de whisky o
tragos combinados?
………………………………………………………….
N° de veces
7. Opinión sobre riesgos
¿Cuál crees que es el riesgo que corre una persona que… ?
Ningún
riesgo
Riesgo
leve
Riesgo
moderado
Gran
riesgo
No sé
que
riesgo
corre
A.- Toma bebidas alcohólicas
algunas veces 1 2 3 4 5
B.- Toma bebidas alcohólicas
frecuentemente 1 2 3 4 5
57
C.- Se emborracha con bebidas
alcohólicas 1 2 3 4 5
D.- Prueba marihuana una o dos
veces en la vida 1 2 3 4 5
E.- Fuma marihuana algunas veces 1 2 3 4 5
F.- Fuma marihuana
frecuentemente 1 2 3 4 5
CONSUMO DE Marihuana. Marca la que corresponde o redondea.
¿Tienes amigos/as que consumen marihuana? Si No
¿Ha consumido marihuana (porro) alguna vez en la vida?
Sí No (solo si marcaste SI, continúa con las preguntas)
¿Cuándo fue la primera vez que consumiste marihuana?
Últimos 30 días Hace mas de 1 mes pero menos de 1 año Hace más de 1
año
¿Qué edad tenías cuando consumiste marihuana por primera vez?
____ Años No recuerda No contesta
¿Has consumido marihuana en los últimos 12 meses? Sí No
6. ¿Con qué frecuencia has usado
marihuana en los últimos 12 meses?
Una sola vez 1
Algunas veces durante los últimos 12
meses 2
Algunas veces mensualmente 3
Algunas veces semanalmente 4
Diariamente 5
7.¿Cuáles fueron los principales motivos por los que probaste marihuana?
Curiosidad Entorno/amigos olvidarme de problemas No se Otros
58
8.
Si en tu grupo de amigos más cercanos
supieran que fumas marihuana, ¿tú
crees que :
(Marcá 1 sola opción)
Te criticarían o dirían algo para que
no lo hicieras 1
Algunos te criticarían y otros no 2
No harían ningún crítica o no te
dirían nada 3
Te alentarían para que lo hicieras 4
No sabes bien lo que harían o te
dirían 5
59
Annex 5: The Cannabis Abuse Screening Test
Con que frecuencia te ha ocurrido algo de lo que se describe a continuación en los
últimos 12 meses
N
ú
m
e
r
o
PREGUNTA
Nu
nca
Rar
amen
te
De
vez
en
cu
and
o
Bas
tan
te a
men
ud
o
Mu
y a
men
ud
o
1 2 3 4 5
1 ¿Has fumado marihuana antes del mediodía?
2 ¿Has fumado marihuana estando solo/a?
3 ¿Has tenido problemas de memoria al fumar marihuana?
4 ¿Te han dicho los amigos o miembros de tu familia que deberías
reducir el consumo de marihuana?
5 ¿Has intentado reducir o dejar de consumir marihuana sin
conseguirlo?
6 ¿Has tenido problemas debido a tu consumo de marihuana?
¿Cuáles? (disputa, pelea, accidente, mal resultado escolar, etc.)
Hasta donde tú sabes o has visto, en
los últimos 30 días, en tu casa
consumieron….
Marca una respuesta en cada fila
SI NO No se
A.- Tabaco 1 2 3
B.- Alcohol 1 2 3
C.-
Tranquilizantes 1 2 3
D.- Marihuana 1 2 3
E.- Otras drogas 1 2 3
¿Han tenido tratamiento psiquiátrico alguna vez? Padre SI NO Madre SI NO
60
Annex 6: The Personal Wellbeing Index
A continuación encontrarás una serie de preguntas acerca de si estas contento o no.
0 significa que no te encuentras para nada satisfecho, y 10 significa que estas
completamente satisfecho.
1. ¿Qué tan satisfecho te encuentras con tu salud?
0 1 2 3 4 5 6 7 8 9 1
0
2. ¿Qué tan satisfecho te encuentras con tu nivel de vida?
0 1 2 3 4 5 6 7 8 9 1
0
3. ¿Qué tan satisfecho te encuentras con las cosas que has logrado en la vida?
0 1 2 3 4 5 6 7 8 9 1
0
4. ¿Cuán seguro/a te sientes?
0 1 2 3 4 5 6 7 8 9 1
0
5. ¿Qué tan satisfecho te encuentras con los grupos de gente del cual formas parte?
0 1 2 3 4 5 6 7 8 9 1
0
6. ¿Qué tan satisfecho te encuentras con tu seguridad de tu futuro?
0 1 2 3 4 5 6 7 8 9 1
0
7. ¿Qué tan satisfecho te encuentras con tus relaciones con las otras personas?
0 1 2 3 4 5 6 7 8 9 1
0