Family, Peer Influence Key in Child Substance Use Predictors

New study finds co-occurring physical and mental health symptoms increase risk, but family rules and peer behaviors are stronger predictors of early substance use

Published on Feb. 24, 2026

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A new University of Michigan study found that while children with co-occurring persistent pain and mental health symptoms face higher risk for early substance use, the strongest predictors of whether a child starts using alcohol, tobacco or cannabis by age 14 are family environment and peer influence. The study analyzed five years of data from the Adolescent Brain and Cognitive Development Study and identified key factors that can help prevent early substance use initiation.

Why it matters

This research highlights the critical role that parents and peers play in shaping adolescent substance use behaviors, even more so than the presence of physical and mental health symptoms. Understanding these key predictors can inform early intervention strategies to delay substance use onset and prevent problematic use later in life.

The details

The study found that children experiencing co-occurring symptoms, such as persistent or worsening pain, anxiety and depression, were 40% more likely to initiate use of alcohol, tobacco or marijuana during early adolescence. However, this association was dampened when the effect of parent rules, monitoring and peer behaviors were considered. Children in households with no clear rules regarding substance use were 70% more likely to start using early, and a child was three times more likely to initiate use if they perceived that their peers were also using substances.

  • The study analyzed five years of data from the federally funded Adolescent Brain and Cognitive Development Study.

The players

Terri Voepel-Lewis

Professor at the U-M School of Nursing and has an appointment in the Department of Anesthesiology at Michigan Medicine.

University of Michigan

The institution where the study was conducted.

National Institutes of Health

The agency that provided funding for the study.

National Institute on Drug Abuse

The agency that provided funding for the study.

Adolescent Brain and Cognitive Development Study

The federally funded national study that provided the data analyzed in this research.

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What they’re saying

“The takeaway for parents and clinicians is that early intervention is key. Recognizing and addressing the child's physical and mental health symptoms and strengthening positive parenting skills may be particularly important to prevent early substance use initiation that can lead to problematic use later on.”

— Terri Voepel-Lewis, Professor at the U-M School of Nursing (Mirage News)

“A major takeaway is that the influence of parents remains strong throughout early adolescence. The other thing that parents should know is that being available to their kids can really make a big difference in preventing their substance use onset. The longer substance use can be delayed during adolescence, the better for kids for many reasons.”

— Terri Voepel-Lewis, Professor at the U-M School of Nursing (Mirage News)

“When children present to clinics with higher anxiety, depression, pain, it is essential to assess family dynamics and substance use issues. Early recognition by middle school may facilitate intervention prior to escalating symptoms and behaviors.”

— Terri Voepel-Lewis, Professor at the U-M School of Nursing (Mirage News)

What’s next

Researchers recommend that pediatricians screen young teens not only for drug use but also for the underlying physical and emotional symptoms that may precede it, in order to facilitate early intervention before substance use escalates.

The takeaway

This study underscores the critical importance of addressing family dynamics and peer influences, in addition to a child's physical and mental health symptoms, in order to prevent early substance use initiation and the potential for problematic use later in life.