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 of 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 to explain some of the inconsistencies in the literature. We found that internalizing symptoms were protective against early adolescent alcohol use particularly for youth elevated on externalizing symptoms (a 2-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.

Methods: A community sample of 387 adolescents was followed for 9 annual assessments (mean age = 12.1 years at the first assessment and 55% female). Multilevel cross-lagged 2-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.

Keywords: Adolescents; Alcohol; Externalizing; Internalizing.

Figure 1

Panels a-d present simple slopes of generalized anxiety prospectively predicting number of drinks in the past year across levels of externalizing behavior (ext) and age. Numbers in parentheses in the legend correspond to standard deviations units from the sample mean of the observed externalizing symptom distribution. Panels e-h present 95% confidence bands for simple slopes of generalized anxiety predicting number of drinks in the past year across levels of externalizing problems and age. Vertical dashed lines indicate the point on the externalizing continuum that the confidence band does not include zero, and the simple slope becomes statistically significant (p < .05).

Figure 2

Panels a-d present simple slopes of depression prospectively predicting number of drinks in the past year across levels of externalizing behavior (ext) and age. Numbers in parentheses in the legend correspond to standard deviations units from the sample mean of the observed externalizing symptom distribution. Panels e-h present 95% confidence bands for simple slopes of depression predicting number of drinks in the past year across externalizing problems and age. Vertical dashed lines indicate the point on the externalizing continuum that the confidence band does not include zero, and the simple slope becomes statistically significant (p < .05).

Figure 3

Panels a-d present simple slopes of social anxiety prospectively predicting number of drinks in the past year across levels of externalizing behavior (ext) and age. Numbers in parentheses in the legend correspond to standard deviations units from the sample mean of the observed externalizing symptom distribution. Panels e-h present 95% confidence bands for simple slopes of social anxiety predicting number of drinks in the past year across externalizing problems and age. Vertical dashed lines indicate the point on the externalizing continuum that the confidence band does not include zero, and the simple slope becomes statistically significant (p < .05).

Figure 4

Panels a & b present simple slopes of social anxiety prospectively predicting number of alcohol problems in the past year across levels of externalizing behavior (ext) and age. Numbers in parentheses in the legend correspond to standard deviations units from the sample mean of the observed externalizing symptom distribution. Panels c & d present 95% confidence bands for simple slopes of social anxiety predicting number of alcohol problems in the past year across externalizing problems and age. Vertical dashed lines indicate the point on the externalizing continuum that the confidence band does not include zero, and the simple slope becomes statistically significant (p < .05).