Social cognitive mediators of the relationship between impulsivity traits and adolescent alcohol use: Identifying unique targets for prevention
Introduction
Adolescent alcohol use is associated with alcohol related problems, including mortality (Australian Institute of Health and Welfare, 2014; Geels et al., 2012; Keyes, Li, & Hasin, 2012). Due to the trajectory of alcohol use from adolescence to adulthood (Duncan, Duncan, & Strycker, 2006; Stoolmiller et al., 2012), prevention through identification and targeting of key risk factors is a commonly proposed solution to reducing alcohol-related harm. Consequently, there has been a push to identify modifiable psychological risk factors that predict alcohol use in adolescents.
Impulsivity is a strong predictor of adolescent alcohol use and problematic consumption (Moffitt et al., 2011; Stautz & Cooper, 2013; Stautz, Dinc, & Cooper, 2017). The adolescent developmental period is associated with increased impulsivity and sensitivity to reward due to rapid neurological changes which occur while the cognitive and emotional regulatory neurological systems are still developing (Gullo & Dawe, 2008; Steinberg, 2008). While there is debate over the structure of trait impulsivity, including the precise number of factors (Hamilton et al., 2015, Hamilton et al., 2016; Whiteside & Lynam, 2001), recent empirical studies (Sharma, Kohl, Morgan, & Clark, 2013; Stautz et al., 2017) and a theoretical review (Gullo, Loxton, & Dawe, 2014) implicate two factors of impulsivity as uniquely involved in substance use.
According to the 2-Component Approach to Reinforcing Substances model (2-CARS; Gullo & Dawe, 2008; Gullo, Dawe, Kambouropoulos, Staiger, & Jackson, 2010), impulsivity is composed of dual systems: one characterised by reward sensitivity and appetitive motivation, related to lower order mesolimbic dopamine systems (reward sensitivity/drive); and another characterised by difficulty inhibiting approach behaviour in light of negative future consequences, related to higher order prefrontal serotoninergic systems (“rash” impulsiveness; Gullo et al., 2014; Steinberg & Chein, 2015; Steinberg, 2008). Reward drive and rash impulsiveness create separate pathways of alcohol risk (Gullo, Ward, Dawe, Powell, & Jackson, 2011). Reward sensitive adolescents have a higher drive to seek the rewarding aspects of alcohol use, whereas rash impulsive adolescents may have a reduced capacity to inhibit the impulse to engage in drinking, end a drinking session, or to withdraw from drinking patterns once they are established (Dawe, Gullo, & Loxton, 2004).
Evidence from cross-sectional and prospective structural equation modeling analyses show that impulsivity traits have distinct and unique associations with alcohol-related cognition (i.e., adjusted effects); specifically, reward drive predicts increases in positive alcohol expectancies and rash impulsiveness predicts decreases in drinking-refusal self-efficacy (Connor, Gullo, Feeney, & Young, 2011; Gullo et al., 2010; Gullo & Dawe, 2008). Positive alcohol expectancies reflect an individual's positive beliefs about the outcomes of drinking. Adolescents, in particular, are driven by the expectations of social reward relating to alcohol use (Jester et al., 2015; Tomlinson & Brown, 2012). Drinking refusal self-efficacy pertains to an individual's belief in their ability to refrain from drinking alcohol in varying contexts (Oei & Baldwin, 1993). Both of these cognitive factors are robust predictors of hazardous alcohol use as well as earlier alcohol use onset (Connor, George, Gullo, Kelly, & Young, 2011; Ehret, Ghaidarov, & LaBrie, 2014; Morawska & Oei, 2005) and are of particular utility in alcohol naïve and adolescent populations as they can be derived from vicarious as well as direct experience (e.g., observing alcohol effects on parents; Bandura, 1977, Bandura, 1986).
The 2-CARS model has been expanded to include the Social Cognitive Theory (SCT) risk factors, a model known as the bioSocial Cognitive Theory (bSCT) (Gullo et al., 2010). The bSCT theorises that the effects of rash impulsiveness and reward drive on drinking are, in part, mediated through positive alcohol expectancies and drinking refusal self-efficacy. Reward drive is hypothesised to produce a learning bias for the rewarding/positive outcomes of drinking, which then increases alcohol use and undermines drinking refusal self-efficacy. In contrast, rash impulsiveness' impact on alcohol misuse is thought to be mediated by reduced drinking refusal self-efficacy, which then increases alcohol misuse. That is, individuals who know they tend to act without considering the consequences of their actions may be less likely to believe they can refuse alcohol in a tempting situation. It is proposed that this creates a self-fulfilling prophecy that is reinforced when realised. Several studies now empirically support the bSCT model in a range of populations (Gullo, St. John, et al., 2014; Harnett, Lynch, Gullo, Dawe, & Loxton, 2013; Kabbani & Kambouropoulos, 2013; Leamy, Connor, Voisey, Young, & Gullo, 2016; Papinczak, Connor, Harnett, & Gullo, 2018).
While these studies have furthered the understanding of the mechanisms of impulsivity on alcohol use, no study has examined prospective mediation of impulsivity-related risk by cognition. Prospective analyses are pertinent for adolescent populations as recent evidence has shown the importance of considering developmental perspectives on substance use interventions (Onrust, Otten, Lammers, & Smit, 2016). Onrust et al. (2016) found in their systematic review and meta-regression analysis that characteristics of intervention programs had differing effects at different developmental stages. For example, teaching drinking refusal skills – a common prevention technique that presumably increases self-efficacy – actually increased alcohol use in early and mid-adolescents, and only reduced drinking for late adolescents.
This study prospectively examined the relationships between impulsivity, alcohol-related cognition, and growth in alcohol consumption and hazardous alcohol use in adolescents, controlling for family and community risk factors. Data were analyzed from 1911 Australian adolescents who took part in the International Youth Development Study (IYDS; McMorris, Hemphill, Toumbourou, Catalano, & Patton, 2007). The hypothesised model based on the bSCT is depicted in Fig. 1. It is hypothesised that (a) drinking refusal self-efficacy will mediate the relationship between rash impulsiveness and alcohol misuse, (b) positive alcohol expectancies will mediate the relationship between reward drive and alcohol misuse, and (c) drinking refusal self-efficacy will mediate the relationship between positive alcohol expectancies and alcohol misuse. It is also hypothesised that the older and younger cohorts will differ in the size but not direction of proposed effects. We expect that as adolescents progress from elementary to early-adolescence and early to mid-adolescence, the impact of drinking refusal self-efficacy will increase as their exposure to alcohol increases (i.e., stronger positive DRSE-alcohol association). We also expect that the older adolescents' positive expectations of alcohol use will increase as their perceptions of reward and social influence become more salient and appealing, consistent with stage-relevant developmental tasks and cognitive maturation (i.e., significantly larger positive slope on expectancy growth) (Onrust et al., 2016).
Section snippets
Participants
The current study utilised the first three time points for two Australian cohorts (N = 1911), Cohort 1 (younger cohort) and Cohort 2 (older cohort), from the International Youth Development Study (IYDS) (see Table 1 for participant information). The IYDS is an ongoing international longitudinal panel survey of three cohorts of Australian students (Grades 5, 7, and 9) in Victoria, Australia and Washington, the United States of America, obtained through two-stage cluster random sampling aimed at
Results
Sixty (3.14%) students were removed from the dataset based on negative responses to at least one of the honesty measures for each time point (e.g., reporting use of a fake illicit substance). After deletion, 1851 students remained. Missing data were imputed using the Expectation Maximisation method in SPSS (version 22).
Discussion
This large scale study (N = 1911) tested prospective mediation relationships between impulsivity and social cognitive risk factors for adolescent alcohol use. The hypothesised model was based on the bioSocial Cognitive Theory (bSCT) of substance use (Gullo et al., 2010). Results demonstrated the selective influence for reward drive and rash impulsiveness on the development of alcohol-related beliefs and adolescent drinking over two subsequent years.
Our findings show that pathways to alcohol use
Role of funding sources
Data collection for the International Youth Development Study has been supported by the National Institute on Drug Abuse (R01-DA012140-05), the Australian Research Council (ARC) Discovery Projects (DPO663371, DPO877359, DP1095744), and the Australian National Health and Medical Research Council (NHMRC) (Project 594793). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies. The funders had no input
Contributors
JW Toumbourou and RF Catalano designed and ran the IYDS. MJ Gullo, JP Connor, and KA Patton designed the present study and analyses. KA Patton wrote the manuscript. GCK Chan provided technical support. All authors revised and reviewed the manuscript. All authors approved of the final manuscript before submission.
Conflicts of interest
None to declare.
Acknowledgements
MJ Gullo was supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (1036365). JP Connor is supported by a NHMRC Career Development Fellowship (1031909). KA Patton was funded by a Research Training Program stipend.
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