The Prospective Association Between Internalizing Symptoms and Adolescent Alcohol Involvement and the Moderating Role of Age and Externalizing Symptoms

Abstract

Background As predicted by self-medication theories that drinking is motivated by a desire to ameliorate emotional distress, some studies find internalizing symptoms (e.g., anxiety, depression) increase risk for adolescent drinking; however, such a risk effect has not been supported consistently. Our prior work examined externalizing symptoms as a potential moderator of the association between internalizing symptoms and adolescent alcohol use (AU) to explain some of the inconsistencies in the literature. We found that internalizing symptoms were protective against early adolescent AU particularly for youth elevated on externalizing symptoms (a two-way interaction). Our sample has now been followed for several additional assessments that extend into young adulthood, and the current study tests whether the protective effect of internalizing symptoms may change as youth age into young adulthood, and whether this age moderating effect varied across different clusters of internalizing symptoms (social anxiety, generalized anxiety, and depression). Internalizing symptoms were hypothesized to shift from a protective factor to a risk factor with age, particularly for youth elevated on externalizing symptoms. Method A community sample of 387 adolescents was followed for nine annual assessments (mean age =12.1 years at the first assessment and 55% female). Multilevel cross-lagged two-part zero-inflated poisson models were used to test hypotheses. Results The most robust moderating effects were for levels of alcohol use, such that the protective effect of all internalizing symptom clusters was most evident in the context of moderate to high levels of externalizing problems. A risk effect of internalizing symptoms was evident at low levels of externalizing symptoms. With age, the risk and protective effects of internalizing symptoms were evident at less extreme levels of externalizing behavior. With respect to alcohol-related problems, findings did not support age moderation for generalized anxiety or depression, but it was supported for social anxiety. Conclusions Findings highlight the importance of considering the role of emotional distress from a developmental perspective and in the context of externalizing behavior problems.

Risk Factors Associated with Alcohol Use in Early Adolescence among American Inner-City Youth: A Longitudinal Study

“…Moreover, internalizing behaviors during childhood were negatively associated with early adolescent alcohol experimentation in a population-based sample of UK children (Edwards et al, 2014). There is no evidence that anxiety disorders predict alcohol use in adolescence (Colder et al, 2017;Hussong et al, 2017;Marshall, 2014). On the contrary, anxiety symptoms may even reduce engagement in deviant behaviors in young age groups as some types of anxiety, e.g., social anxiety, may result in avoidance of social situations where alcohol is likely to be available, and/or lower consumption of alcohol due to the fear of negative evaluation (Colder et al, 2017).…”

“…In contrast, internalizing risk factors were not associated with higher levels of alcohol consumption. Even though anxiety disorders do not seem to increase the risk for alcohol use in adolescence (Colder et al, 2017;Hussong et al, 2017;Marshall, 2014), depression has been linked to excessive drinking (King et al, 2004;Parrish et al, 2016), while in a recent review investigating the effect of internalizing behaviors on adolescent substance use, depression was described as a unique predictor of alcohol use in adolescence (Hussong et al, 2017). Although this conflicts with the results from our study it should be noted that many studies have reported a null association between depression and alcohol use (Hussong et al, 2017), while the age range in previous studies has also been very broad.…”

“…Moreover, even though externalizing behaviors seem to be of relevance for alcohol use at a younger age (Colder et al, 2013;King, Iacono, & McGue, 2004), until now, longitudinal studies on the association between internalizing behaviors and early alcohol use have been inconclusive, with reports of both an increased (King et al, 2004;Parrish, Atherton, Quintana, Conger, & Robins, 2016) and reduced risk for drinking alcohol during early adolescence (Edwards et al, 2014). It has been suggested that as alcohol use becomes more normative with age, externalizing behaviors may be of greater importance for early drinking in younger age groups, whereas internalizing behaviors, and especially symptoms of anxiety, might reduce engagement in deviant behaviors in this age group (Colder et al, 2017).…”

Risk and Protective Factors for Problematic Drinking in Early Adolescence: A Systematic Approach

“…to escape or avoid negative emotions [27]. The results of previous prospective studies on depression as a predictor of alcohol use/problems in early adolescence are however mixed [17], with reports of both an association [14] and no association [15], with one study even suggesting a protective effect against early alcohol use [13] which is why it has been argued that internalizing symptoms may be regarded as a protective factor at early ages before drinking becomes normative [16]. However, our finding rather supports previous reports of depression as a unique predictor for substance use and misuse, even at this young age.…”

“…Studies on internalizing symptoms have produced somewhat mixed results, with the report of an association between depression at age 11 and alcohol problems at age 14 [14], whereas other research has found no association between internalizing psychopathology and alcohol use disorder onset [15], or even suggested a protective effect against early substance use [13]. Since the use and misuse of alcohol becomes more normative with increasing age, it has been suggested that externalizing symptoms such as impulsivity and antisocial behavior may have a larger impact at early ages, whereas internalizing symptoms such as anxiety problems may be protective during these early years [16]. Thus, the reported findings on depression as a unique predictor for substance use among late adolescents and young adults [17], may not necessarily be valid in early adolescence.…”