Full length articleInternalizing and externalizing disorders as predictors of alcohol use disorder onset during three developmental periods
Introduction
Contemporary epidemiological perspectives suggest that developmental pathways for alcohol use disorders (AUDs) are established well before problematic alcohol use begins (Clark, 2004), and likely causally related to processes that increase vulnerabilities to externalizing and internalizing psychiatric disorders (Hussong et al., 2011, Sher et al., 2005, Vanyukov et al., 2012). The internalizing-externalizing organizational model of psychopathology (Achenbach, 1966, Krueger, 1999) is a statistically-derived framework that accounts well for the covariation among psychiatric symptoms and disorders among children and adults in cross-sectional and longitudinal studies (e.g., Achenbach, 1966, Caspi et al., 2014, Farmer et al., 2013b, Kessler et al., 2011, Krueger and Markon, 2006), and has been suggested as a guiding framework for research on common causal pathways that account for lifetime disorder comorbidity (Kessler et al., 2011, Krueger, 1999), including AUDs (Hussong et al., 2011).
Externalizing disorders and their precursors are associated with oppositional, aggressive, impulsive, disruptive, and rule-breaking behavior. Prospective studies have documented that externalizing tendencies or disorders robustly predict the future onset of alcohol use problems or AUDs (Chassin et al., 2004, Elkins et al., 2006, Englund et al., 2008, Feingold et al., 2015, Fergusson et al., 2007, Grekin et al., 2006). Internalizing disorders and their precursors, in contrast, are associated with depression, anxiety, fear, rumination, and distress. Compared to externalizing developmental pathways, the role of internalizing pathways in the development of AUDs has been little researched (Hussong et al., 2011). Although internalizing symptoms or disorders are often concomitants with alcohol use problems or disorders in cross-sectional research (e.g., Burns and Teesson, 2002, Hasin et al., 2007, Kessler et al., 2005), prospective studies on the risk posed by internalizing tendencies or disorders on future alcohol use problems or AUDs have produced mixed findings (Boschloo et al., 2013, Buckner et al., 2008, Buckner and Turner, 2009, Crum and Pratt, 2001, Elkins et al., 2006, Gilman and Abraham, 2001, Grekin et al., 2006, Kushner et al., 1999, Trautmann et al., 2015, Zimmermann et al., 2003).
There are three primary aims associated with this study. First, this research evaluated whether risk for index AUD episodes within each of the developmental periods examined was associated with prior externalizing or internalizing disorders. Three developmental periods corresponding to AUD onset were defined: early-to-middle adolescence (age 13.0–17.9), late adolescence (18.0–20.9), and early adulthood (21.0–30.0). Outcomes from the analyses associated with this aim are expected to elucidate the relative contributions of externalizing and internalizing disorders in the prediction of AUD risk as well as the developmental specificity versus generality of these predictors. Second, for the two latter developmental periods studied, we evaluated whether distal externalizing and internalizing disorders from earlier developmental periods also predicted risk for AUDs. Findings from these analyses are expected to highlight whether risk factors that occurred later versus earlier in development are most relevant in the prediction of subsequent AUD risk. Third, important differences in the development and course of AUDs among men and women have been reported (Ammon et al., 2008, Kessler et al., 1994, Nolen-Hoeksema, 2004). Consequently, in the present research, we explored whether gender moderates observed effects.
This study builds on existing studies in the following ways. First, this research was conducted with a large representative community sample. Many earlier studies that have sought to identify externalizing or internalizing predictors of AUDs utilized high-risk, treatment, or convenience samples (e.g., university students). Second, it is often unclear from existing prospective studies if risk-based evaluations of internalizing and externalizing disorders are referenced to the first or subsequent episode of problematic drinking or an AUD. This is an especially important consideration when evaluating risk factors for versus consequences of AUDs, as AUDs are known to increase risk for future internalizing disorders (Fergusson et al., 2011) as well as externalizing disorders, especially other substance use disorders (Kandel et al., 1992). Third, rather than limiting prediction models to single diagnostic categories, externalizing and internalizing disorder domains in the present research are represented by several individual disorders, thus resulting in broader coverage of content domains associated with risk-related pathways. Fourth, studies that have examined internalizing tendencies or disorders as risk factors for future AUDs often do not statistically control for externalizing features or disorders, and vice versa (Hussong et al., 2011). In the present research, we evaluated adjusted prediction models that controlled for demographic and psychosocial variables as well as the disorder domain that was not the primary predictor variable modeled in the analysis.
Section snippets
Participant sampling, composition, and retention
At the first wave of data collection (T1; ∼age 16), the sample consisted of 1709 adolescents randomly selected from 9 high schools that were representative of urban and rural districts in western Oregon. About one year later (T2), 1507 (88%) of these persons were reassessed. At T3 (∼age 24), a sampling stratification procedure was introduced whereby eligible participants included all non-white participants to enhance ethnic diversity and all persons with a positive history of a psychiatric
Demographic predictors of AUD onset
By age 30.0, 34.3% of the weighted T4 panel had a lifetime AUD diagnosis. Demographic variables were individually evaluated as predictors of AUD onset with Cox PH regression methods. Findings from these analyses, which were conducted with the entire sample, are presented in Table 1. Male gender, ethnic/racial minority status, and late versus on-time puberty by T1 were each significantly associated with AUD onset. All demographic variables, regardless of their individual significance, were
Discussion
This study evaluated psychiatric disorder risk factors as predictors of future AUD episode onsets, and explored whether significant predictors differed in relation to the developmental period during which AUDs first emerged. To evaluate whether predictors differed as a function of AUD onset age and to comparatively evaluate the influence of proximal and distal predictors, statistical models were generated separately for each of three developmental periods (early-to-middle adolescence, late
Role of funding source
National Institutes of Health grants MH40501, MH50522, and DA12951 to Peter M. Lewinsohn and R01AA020968 to Richard F. Farmer and John R. Seeley supported this research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Conflict of interest
No conflict declared.
Contributors
R.F. and J.G. had the initial idea and conducted background literature searches. P.L. and J.S. were involved in the original study protocol and data collection. J.G. and D.K. programmed and conducted statistical analyses. R.F. and J.G. wrote the first draft of the manuscript. R.F., J.G., J.S., D.K., K.S., and P.L. contributed to interpreting the findings and writing further drafts of the manuscript. All authors reviewed and have approved the final manuscript.
References (52)
- et al.
Social anxiety disorder as a risk factor for alcohol use disorders: a prospective examination of parental and peer influences
Drug Alcohol Depend.
(2009) - et al.
Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence
J. Psychiatr. Res.
(2008) - et al.
Alcohol use disorders comorbid with anxiety, depression and drug use disorders: findings from the Australian National Survey of Mental Health and Well Being
Drug Alcohol Depend.
(2002) - et al.
Hierarchical organization of axis I psychiatric disorder comorbidity through age 30
Compr. Psychiatry
(2013) - et al.
Proximal vs. distal predictors of alcohol use disorders and treatment utilization in at-risk men in early middle age
Compr. Psychiatry
(2015) - et al.
Conduct and attentional problems in childhood and adolescence and later substance use, abuse and dependence: results of a 25-year longitudinal study
Drug Alcohol Depend.
(2007) - et al.
A longitudinal study of the order of onset of alcohol dependence and major depression
Drug Alcohol Depend.
(2001) - et al.
Is psychopathology associated with the timing of pubertal development?
J. Am. Acad. Child Adolesc. Psychiatry
(1997) - et al.
Separate dimensions of anxiety differentially predict alcohol use among male juvenile offenders
Addict. Behav.
(2015) Gender differences in risk factors and consequences for alcohol use and problems
Clin. Psychol. Rev.
(2004)