Impulsivity-related personality traits and adolescent alcohol use: A meta-analytic review
Introduction
Adolescent alcohol use is a persistent social issue. Data from the US and UK indicate that the percentage of adolescents reporting alcohol use increases linearly with age, with a sharp rise in abuse and dependence symptoms during the ages of 16 to 18 (Fuller, 2012, Johnston et al., 2012, Young et al., 2002). Quantity and frequency of alcohol use in adolescence are associated with levels of consumption in adulthood and heightened use is predictive of later alcohol problems (McCambridge, McAlaney, & Rowe, 2011). Such risks appear to be more likely in those who initiate alcohol use earlier in adolescence (Grant, Stinson, & Harford, 2001). Whilst for many individuals alcohol use in adolescence is a normative behaviour and part of a general increase in risk-taking during this developmental period (Spear, 2000), a number of teenagers seem prone to drink excessively and experience negative consequences. It is therefore important to establish risk factors that can reliably predict excessive and problematic drinking so that education and intervention strategies can be directed at the individuals they will most benefit.
Personality has been widely studied as a potential risk factor for alcohol-related problems. Personality traits are associated with consistent patterns of cognition, affect, and behaviour, and elevated levels of certain traits may predispose an individual to alcohol problems through mechanisms such as a heightened vulnerability to alcohol's effects, an increased tendency to use alcohol to regulate emotions, and a propensity to engage in deviant or risky behaviour (Sher, Trull, Bartholow, & Vieth, 1999). Expression of certain traits forms part of a multifactorial liability to alcohol and other substance use disorders (Vanyukov et al., 2003), and may increase the likelihood that an individual also comes into contact with environmental risk factors such as substance using peers (Littlefield & Sher, 2010).
The broad personality dimension of impulsivity appears to be the most relevant to alcohol use, and is consistently found to be elevated in alcoholics and heavy drinkers (Bjork et al., 2004, Dom et al., 2006, Rubio et al., 2008). Although the direction of association can be difficult to ascertain due to alcohol's derogatory effects on brain areas associated with behavioural control (e.g. Oscar-Berman & Marinković, 2007), impulsivity has been found to be elevated in at-risk populations such as those with externalising behavioural disorders and the children of parents with substance use disorders, even before initiation of alcohol or other substance use (Verdejo-García, Lawrence, & Clark, 2008). Impulsivity and related traits are most associated with what researchers have termed type 2 alcoholism, characterised by early onset, spontaneous alcohol seeking, and a higher frequency of antisocial and aggressive behaviour (Cloninger, 1987). The link between impulsivity and alcohol use is perhaps best seen as a reciprocal process whereby elevated levels of the trait influence the likelihood of heightened alcohol consumption, and are further exacerbated due to neurobiological changes caused by alcohol.
Impulsivity is represented in most contemporary models of human personality, yet the ways in which the trait has been conceptualised and measured differ to such a degree that combining findings can be problematic. To resolve this issue, researchers have attempted to recast the construct of impulsivity as a number of separate but related traits. Dawe, Gullo, and Loxton (2004) and Dawe and Loxton (2004) have proposed that impulsivity is best conceived as having two components, termed reward sensitivity (or reward drive) and rash impulsiveness. Reward sensitivity reflects the reactivity of a conceptual behavioural approach (or activation) system (BAS; Gray, 1991, Pickering and Smillie, 2008), a set of neural pathways involved in reward processing and incentive motivation, possibly best represented by dopaminergic projections from the ventral tegmental area to the nucleus accumbens (Gullo and Dawe, 2008, Pickering and Gray, 2001). Rash impulsiveness is defined as the inability to alter or inhibit responses even when behaviour may lead to negative consequences. Individual differences in this trait are thought to reflect functioning of frontal brain areas such as the orbitofrontal cortex and anterior cingulate cortex (Dawe et al., 2004).
Reward sensitivity can be measured with self-report questionnaires such as the Sensitivity to Reward scale (Torrubia, Ávila, Moltó, & Caseras, 2001) and the Drive and Reward Responsiveness subscales of the BIS/BAS scales (Carver & White, 1994). Scores on these measures are believed to indicate responsiveness to appetitive cues and the capacity to employ approach behaviour in situations of potential reward. Whilst high reward sensitivity may not necessarily entail frequent impulsive behaviour, individuals high in reward sensitivity would be expected to be more susceptible to the positive reinforcing aspects of stimuli such as alcohol (Gullo & Dawe, 2008), and may in turn act impulsively in response to conditioned cues related to such stimuli.
The measurement of rash impulsiveness is less straightforward. The construct has been gauged with a diverse set of scales including Eysenck's I7 (Eysenck, Pearson, Easting, & Allsopp, 1985), Barratt's impulsivity scale (Patton, Stanford, & Barratt, 1995), Zuckerman's (1994) sensation seeking scale, Cloninger's (1989) measure of novelty seeking, and Dickman's (1990) measure of dysfunctional impulsivity (Gullo, Ward, Dawe, Powell, & Jackson, 2011). Consequently, although some studies have supported the two dimensional conceptualisation (Franken and Muris, 2006a, Quilty and Oakman, 2004), converging psychometric evidence suggests that two dimensions are insufficient to cover the wide variation in impulsive behaviour. Whiteside and Lynam (2001) used factor analysis on a number of frequently used self-report measures of impulsivity, deriving four dimensions termed urgency, lack of premeditation, lack of perseverance, and sensation seeking. These dimensions show different patterns of association with higher order traits from the five factor model (FFM; Costa & McCrae, 1992), and can be assessed using the UPPS Impulsive Behaviour Scale. Urgency reflects a disposition to engage in mood-based rash action, and has since been separated into two facets (Cyders and Smith, 2007, Cyders and Smith, 2008). The tendency to act impulsively when distressed is termed negative urgency, whereas the tendency to act impulsively when in an exceptionally good mood is termed positive urgency. Lack of premeditation is the form of impulsivity most commonly referred to in the literature, the tendency to act without forethought. Lack of perseverance reflects a reduced capacity to persist with a task, or a heightened susceptibility to boredom. Sensation seeking is the desire for novel, intense, and varied experiences (Arnett, 1994, Zuckerman, 1994), and has parallels with traits such as novelty seeking (Cloninger, 1986), fun seeking (Carver & White, 1994), and an excitement seeking facet of FFM extraversion.
The UPPS model helps to clarify the variation observed in behaviour characteristic of rash impulsiveness. However, the reward sensitivity aspect of the two-factor model of impulsivity is not represented in the four UPPS dimensions, likely because measures of this construct were not included in Whiteside and Lynam's (2001) original factor analysis. This review will include reward sensitivity alongside the UPPS traits in order to provide a detailed as possible investigation into the relationship between impulsivity-related personality traits and adolescent alcohol use.
Although impulsivity-related traits may influence alcohol use throughout the lifespan, it seems particularly important to understand such effects in adolescence. This is a developmental period that is in many ways characterised by impulsive decision making and behaviour. Adolescents tend to frequently seek new experiences, act without forethought, take risks, and disregard potential negative consequences of their actions (Ernst, Romeo, & Andersen, 2009). Whilst this heightened propensity towards novelty and risk is thought to reflect an evolutionarily preserved pattern of behaviour encouraging a move away from parents and towards autonomy (Spear, 2000), an exaggerated inclination to engage in risky decision making may lead individuals into negative and potentially life-threatening outcomes.
Adolescent risk-taking is thought to be mediated by interactions between two brain systems which appear to be in competition during this stage of development (Steinberg, 2007). The first is a subcortical socio-emotional system, comprising areas including the nucleus accumbens, amygdala, and medial prefrontal cortex; essentially the mesolimbic dopamine circuit (Alcaro, Huber, & Panksepp, 2007). The second is a cognitive control system located in outer regions including the lateral prefrontal cortex and parts of the anterior cingulate cortex. Note that these appear to be the same systems that the reward sensitivity and rash impulsiveness traits are proposed to reflect. The socio-emotional system goes through a process of post-pubertal remodelling which enhances its sensitivity and efficiency, with overactive dopaminergic activity leading to hyper-responsiveness to incentives (Galvan, 2010, Steinberg, 2008). Conversely, frontal areas making up the cognitive control system undergo a slower process of maturation not complete until young adulthood. This combination of disproportionately activated reward circuitry and an underdeveloped and overtaxed control system may explain why adolescents appear to place emphasis on the potential rewarding aspects of risk-taking whilst showing a strained capacity for regulatory control (Galvan et al., 2006, Wahlstrom et al., 2010).
These patterns of neural development show a degree of overlap with the expression of certain impulsivity-related traits across adolescence. In a study of over 900 individuals aged between 10 and 30, Steinberg et al. (2008) found a distinction between the developmental trajectories of self-reported sensation seeking and impulsivity (measured as an amalgam of lack of premeditation and perseverance). Sensation seeking showed a curvilinear relationship, rising throughout early adolescence before declining from around age 15, whereas impulsivity showed a linear decline from age 10 onwards. These trajectories appear to map onto the differential development of subcortical reward-processing areas and of the prefrontal cortex, respectively, with sensation seeking appearing to peak during the period where reward pathways are highly developed in comparison with the late-developing frontal areas.
Although expression of impulsivity-related traits declines into later adolescence, neural maturation continues into the early 20s (Steinberg, 2007). Thus, individuals viewed as adults according to certain sociocultural norms, and in turn provided with a greater degree of independence, might still be considered adolescent in terms of their neurodevelopment. This presents an interesting issue for the current review. Many studies investigating alcohol use among older adolescents draw participants from college student populations. College is an environmental context where adolescents experience a significantly lower degree of monitoring from their parents and an increase in freedom over their own behaviour. It is possible that any personality-related disposition towards alcohol use may become more prominent in this context. This issue will be addressed here by comparing data from college and non-college samples.
In studying the relationships between impulsivity-related traits and alcohol use, it is helpful to make a distinction between typical consumption and problematic use, a term that will be used here to encapsulate negative consequences from alcohol use and symptoms of abuse and dependence. Alcohol use does not necessarily lead to problems. It can often help to stimulate desirable positive experiences such as making new friends and having fun (Lee, Maggs, Neighbors and Patrick, 2011, Park, 2004). Over a third of adolescent alcohol users report little or no negative consequences from use (Johnston et al., 1998, Substance Abuse and Mental Health Services Administration, 1998). Conversely, some may be prone to experience negative consequences despite not being heavy alcohol users (Lee, Rose, Engel-Rebitzer, Selya, & Dierker, 2011). Whilst continuously elevated use is likely to lead to problems, the association between typical consumption and problematic use has often been shown to be somewhat modest (Sadava, 1990). For instance, a study of over 10,000 participants found that responses to questionnaire items assessing alcohol consumption showed little correlation with responses to items assessing alcohol-related problems (Gmel, Heeb, & Rehm, 2001).
Typical alcohol consumption and problematic use appear to show different patterns of association with impulsivity-related traits in older samples, with sensation seeking most related to alcohol consumption, and urgency traits most related to alcohol-related problems (Curcio and George, 2011, Smith et al., 2007). Similar findings have been found with regard to wider substance use and risk-taking behaviour, with sensation seeking found to relate most strongly to frequency of engagement in such behaviour, and urgency found to relate more strongly to problematic involvement (Fischer and Smith, 2008, Smith et al., 2007, Verdejo-García et al., 2007). Additionally, urgency, but not sensation seeking, correlates with levels of problematic behaviours such as compulsive buying and excessive internet use, and distinguishes pathological gamblers from non-pathological gamblers (Billieux et al., 2010, MacLaren et al., 2011). Curcio and George (2011) have shown that these differences may lie in the separable mediating pathways associated with each trait. Sensation seeking may be uniquely associated to alcohol consumption through its influence on a tendency to drink for enhancement, i.e. drinking for fun or for a pleasant feeling, whereas negative urgency is related to problematic use through the tendency to use alcohol as a coping strategy. For findings of the present enquiry to be utilised in the consideration of prevention and intervention programmes, it will be helpful to establish whether adolescent data follow a similar pattern to that of older samples.
The body of research described here implies that impulsivity is best considered as a number of discrete traits, and that individual differences in these traits may provide some indication of dispositional risk towards problematic alcohol use. This may be especially so in adolescence when these traits are elevated, perhaps as a consequence of maturational brain development patterns. The traits outlined appear to show different patterns of association with typical and problematic alcohol use in older samples. It therefore seems necessary to cast new light on research that has examined associations between impulsivity and adolescent alcohol use with reference to current theory and evidence. The aim of this quantitative review is to assess relationships between impulsivity-related personality traits and adolescent alcohol use in order to establish the relative importance of each trait. Traits will be categorised in accordance with the UPPS framework, with an additional category for reward sensitivity. Two main alcohol-related outcomes will be examined: typical consumption and problematic use. We also consider two related but lesser-studied alcohol use variables that are particularly relevant to adolescents: binge drinking and alcohol use initiation. Establishing whether certain traits show different patterns of association with these outcomes may provide insight into why certain adolescents are more prone to experience negative alcohol-related consequences and to more rapidly develop alcohol use disorders. In addition to the primary analyses, potential moderator effects of age, sex, ethnicity, sample type, and problematic alcohol use measure employed will be tested.
Section snippets
Literature search
An exhaustive search of published studies was carried out using the following online databases: PubMed, PsychINFO, Elsevier Science Direct, Wiley Online Library, Thomson Reuters Web of Knowledge, EBSCO Academic Search Complete, and Google Scholar. Three categories of search terms were used in combination. The first category contained keywords related to personality traits: impulsivity, impulsive, disinhibition, premeditation, sensation seeking, novelty seeking, behavioural approach, behavioural
Results
Due to the large number of analyses conducted, a conservative alpha level of p = .01 was used for significance testing to reduce the likelihood of Type I errors. Any p values less than .05 are noted in tabulated data. A total of 240 effect sizes from 93 samples reported in 87 published articles were included (Table 3). The majority of these effect sizes pertained to sensation seeking (39%) and lack of premeditation (32%). No univariate outliers were found.
Discussion
This meta-analytic review sought to examine relationships between impulsivity-related personality traits and aspects of adolescent alcohol use. All traits analysed were significantly positively associated with alcohol consumption and with problematic alcohol use. Sensation seeking and positive urgency showed the largest mean associations with alcohol consumption, whilst positive and negative urgency showed the largest associations with problematic use. The data reviewed show a similar pattern
Conclusion
This review has shown that separable impulsivity-related traits show different patterns of association with alcohol use outcomes in adolescence. General alcohol consumption is associated with a tendency to seek out exciting experiences and with an inclination to behave impulsively when in a positive mood. Problematic use appears to be linked to both positive and negative forms of mood-based rash action, although this finding is yet to be confirmed in younger adolescent samples. Findings are in
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Studies preceded by an asterisk were included in meta-analysis.