Executive Functioning and Decision-Making Skills as Mediators Underlying the Relationship Between Family Functioning and Opioid Risk Perception Among Adolescents
Year: 2026
Type: preprint
Study design: Observational Study
Abstract: Opioid misuse remains a significant public health concern in the United States, with adolescents representing a particularly vulnerable population for opioid misuse initiation (Yule et al., 2018). Well-established protective factors against adolescent substance use initiation include high family functioning and high risk perception of substances (Lipari et al., 2013; Rusby et al., 2008; Van Ryzin et al., 2016). Recent research has shown that these protective factors are significantly related in the context of opioids, such that better family functioning is associated with greater perceived risk of harm from opioid misuse among adolescents (Meyer et al., 2026). Although this association has been established, the psychological mechanisms underlying this relationship remain unclear. The purpose of this observational study is to examine potential mediators that may explain the relationship between family functioning and opioid risk perception among adolescents. The variables of interest for mediation analysis are cognitive-executive functioning (attention, working memory, processing speed, and novel-problem solving) and decision-making skills. Previous research has shown that children and adolescents raised in supportive family environments, often characterized by effective parent-child communication, cohesion, and responsible parenting practices, tend to demonstrate stronger executive functioning and decision-making abilities (Berthelsen et al., 2017; Brown et al., 1990; Sosic-Vasic et al., 2017). These cognitive processes are also important in the formation of risk perception, as executive functioning and decision-making abilities allow individuals to integrate information, consider potential consequences, and evaluate the risks and benefits associated with risky behaviors. Research by Magar et al. (2008) found that stronger executive functioning was a key predictor of participant ratings that placed greater emphasis on the risks rather than the benefits of risky behaviors, on a composite measure spanning six risk domains (including trying an unfamiliar drug, smoking cigarettes, and drinking alcohol). Additionally, research by Weller et al. (2015) found a related pattern for decision-making competence, where participants with greater decision-making competence perceived health/safety-related risky behaviors (e.g., not wearing a helmet while riding a motorcycle) as riskier and less beneficial. Thus, we hypothesize that stronger executive functioning and decision-making skills, both of which support careful evaluation of potential consequences, may contribute to greater perceived risk of harm from opioid misuse among adolescents from higher-functioning family environments. This secondary analysis will use self-reported baseline and 3-month follow-up data from a previous supplemental study of a randomized controlled trial of adolescents ages 16-19 (N = 262) recruited from high schools in Connecticut between 2022 and 2024. The previous randomized controlled trial aimed to evaluate PlaySmart, a videogame targeting perceived risk of harm from opioids among adolescents. Eligibility criteria required participants to report no prior opioid misuse and at least one of the following: 1) score ≥ 1 on the Patient Health Questionnaire-2 scale, 2) ≥ 1 on the Generalized Anxiety Disorder-2 scale, 3) past 30-day use of any substance other than opioids. Mediation analyses will be conducted with family functioning as the independent variable and perceived risk of harm from opioid misuse as the dependent variable. “Family functioning” was measured across eight domains: cohesion, conflict, open and problematic communication, connectedness, parental monitoring, parenting practices, and family support. A composite family functioning score will be used, with higher scores indicating better overall family functioning. “Perceived risk of harm from opioid misuse” was measured using eight items and included questions such as “How much do you think people risk harming themselves (physically or in other ways) if they 1) Try heroin once or twice 2) Try any narcotic other than heroin (Codeine, Vicodin, OxyContin, Percocet, etc.) once or twice.” Participants responded with either 1= “no risk”, 2= “slight risk”, 3= “moderate risk”, or 4= “great risk.” Proposed mediators include executive functioning and decision-making skills. “Cognitive-executive functioning” was measured using sub-scales from the Learning, Executive, and Attention Functioning (LEAF) scale, including attention, working memory, processing speed, and novel problem-solving. Multicollinearity among sub-scales will be assessed; if subs-cales show high intercorrelation, a composite executive functioning score will be used. If sub-scales show sufficient distinctiveness, they will be analyzed individually, which is consistent with the intended structure of the LEAF scale (Kronenberger, n.d.). “Decision-making skills” was measured using nine items and included questions such as “Before I make a decision, I think about all the things that may happen as a result of that decision.” Participants responded with either 1= “never”, 2= “seldom”, 3= “about half the time”, 4= “often”, or 5= “always.” Covariates will include baseline opioid risk perception, intervention assignment, age, gender, race/ethnicity, depressive symptoms, anxiety symptoms, lifetime use of alcohol and cannabis, perceived peer norms toward substance use, and neighborhood-level socioeconomic status as measured by the Area Deprivation Index (ADI). This study aims to understand how family environments may contribute to the development of substance use risk perceptions during adolescence. By examining whether executive functioning and decision-making skills mediate the relationship between family functioning and opioid risk perception, this research will help inform future family-based and cognitive interventions aimed at strengthening protective factors against adolescent substance use. Berthelsen, D., Hayes, N., White, S. L. J., & Williams, K. E. (2017). Executive Function in Adolescence: Associations with Child and Family Risk Factors and Self-Regulation in Early Childhood. Frontiers in Psychology, 8, 903. https://doi.org/10.3389/fpsyg.2017.00903 Brown, J. E., & Mann, L. (1990). The relationship between family structure and process variables and adolescent decision making. Journal of Adolescence, 13(1), 25–37. https://doi.org/10.1016/0140-1971(90)90039-a Kronenberger, W. G. (n.d.). LEAF interpretation (Version 1): LEAF scale scoring and interpretation [Scoring manual]. ABCD Study Directions. https://abcdirections.com/wp-content/uploads/2023/12/leafscoring.pdf Lipari RN. Trends in Adolescent Substance Use and Perception of Risk from Substance Use. 2013 Jan 3. In: The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK385059/ Magar, E. C. E., Phillips, L. H., & Hosie, J. A. (2008). Self-Regulation and Risk-Taking. Personality and Individual Differences, 45, 153-159. https://doi.org/10.1016/j.paid.2008.03.014 Meyer, J., Szapocznik, J., Imo, U., Dziura, J., Fiellin, L., & Aneni, K. (2026). Family functioning and adolescent risk perception of opioid misuse: A cross-sectional study. Journal of Family Psychology, 10.1037/fam0001473. Advance online publication. https://doi.org/10.1037/fam0001473 Rusby, J. C., Light, J. M., Crowley, R., & Westling, E. (2018). Influence of parent-youth relationship, parental monitoring, and parent substance use on adolescent substance use onset. Journal of Family Psychology, 32(3), 310–320. https://doi.org/10.1037/fam0000350 Sosic-Vasic Z, Kröner J, Schneider S, Vasic N, Spitzer M and Streb J (2017) The Association between Parenting Behavior and Executive Functioning in Children and Young Adolescents. Front. Psychol. 8:472. doi: 10.3389/fpsyg.2017.00472 Van Ryzin, M. J., Roseth, C. J., Fosco, G. M., Lee, Y. K., & Chen, I. C. (2016). A component-centered meta-analysis of family-based prevention programs for adolescent substance use. Clinical Psychology Review, 45, 72–80. https://doi.org/10.1016/j.cpr.2016.03.007 Weller JA, Ceschi A and Randolph C (2015) Decision-making competence predicts domain-specific risk attitudes. Front. Psychol. 6:540. doi: 10.3389/fpsyg.2015.00540 Yule, A. M., Lyons, R. M., & Wilens, T. E. (2018). Opioid Use Disorders in Adolescents-Updates in Assessment and Management. Current pediatrics reports, 6(2), 99–106. https://doi.org/10.1007/s40124-018-0161-z
Authors: Genesis Jimenez Chavez, Kammarauche Aneni
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
OpenAlex ID: W7170243749
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