Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity

https://doi.org/10.1016/j.brat.2008.12.001Get rights and content

Abstract

A large body of research has examined the development of internalizing and externalizing symptoms in childhood and early adolescence. Notably, there is significant concomitant impairment associated with early adolescent symptomatology, as well as association of these symptoms with future development of psychopathology, poor physical health, self-destructive thoughts and behaviors, criminal behavior, and HIV risk behaviors. Drawing on negative reinforcement theory, the current study sought to examine the potential role of distress tolerance, defined as the ability to persist in goal-directed activity while experiencing emotional distress, as a potential mechanism that may underlie both internalizing and externalizing symptoms among 231 Caucasian and African American youth (M age = 10.9 years; 45.5% female; 54.5% Caucasian ethnicity). A series of regressions resulted in significant moderated relationships, such that low distress tolerance conferred increased risk for alcohol use among Caucasians, delinquent behavior among African Americans, and internalizing symptoms among females. Clinical implications, including the potential role of negative reinforcement models in early intervention with young adolescents, are discussed.

Introduction

A large body of research has examined the development of internalizing and externalizing symptoms in childhood and early adolescence, noting the impairment associated with such symptoms, as well as their association with the future development of psychopathology (Colman et al., 2007, DeWit et al., 2000), poor physical health (Keenan-Miller, Hammen, & Brennan, 2007), self-destructive thoughts and behaviors (Klomek et al., 2008), criminal behavior (Sourander et al., 2007), and HIV risk behaviors (Brook, Adams, & Balka, 2004). Although often treated separately and considered to develop through different pathways (Achenbach & Edelbrock, 1984), internalizing and externalizing symptoms share important commonalities in their association with negative affect (Oland & Shaw, 2005). As such, to better understand and assess common mechanisms underlying the development of both internalizing and externalizing symptoms, a negative reinforcement-based model provides a potentially useful approach (Baker et al., 2004, Khantzian, 1985).

Negative reinforcement models emphasize that the motivational basis of behavior is the escape or avoidance of negative affective states. Although negative reinforcement models have been applied almost exclusively to the dependence stages of substance use (see Eissenberg, 2004 for an exception), with the use of substances functioning to reduce incipient physical and psychological symptoms of withdrawal (Baker et al., 2004), this model may be particularly relevant for understanding early adolescent development of internalizing and externalizing symptoms. Specifically, the ways in which emerging adolescents respond to developmental changes, and the accompanying negative affect that often coincides with such stressors, may impact current and future adjustment and psychopathology (Grant et al., 2004, McMahon et al., 2003, Schneiders et al., 2006). For instance, a large body of literature has demonstrated that the normative stressors that come with adolescence often result in increased levels of negative affect (e.g., Brooks-Gunn and Warren, 1989, Larson and Ham, 1993), and those individuals who rely on dysfunctional styles of coping in the face of negative emotions are less able to effectively regulate their negative mood states. This inability to regulate affective distress thereby increases vulnerability to the immediate relief offered by either: (1) isolating themselves, as is common in depression and anxiety; or (2) engaging in various risky behavioral alternatives (e.g., alcohol use). Engagement in these behaviors often brings relief (perceived and/or actual), thereby enhancing the attractiveness and likelihood of such behavior for future situations. For example, a socially anxious youth who feels uncomfortable around peers may find that when they drink alcohol their anxiety is reduced, completely absent of any dependence or accompanying withdrawal symptoms. Because drinking alcohol in this case aided in successfully reducing their anxiety/negative affect, the youth is more likely to drink alcohol in the future. This scenario fits well with the established empirical literature examining the role of social anxiety and social discomfort in relation to alcohol use which has a strong basis in stress-coping and other negative reinforcement models (e.g., Morris et al., 2005, Myers et al., 2003, Weinberg and Bartholomew, 1996). Further, prominent behavioral theories of anxiety among youth have long implicated the role of avoidance in both the development and maintenance of anxiety symptoms and behavior (e.g., Barlow, 2002).

To capture an individual's propensity towards behavior motivated by negative reinforcement, studies on adult samples have utilized behavioral assessments of distress tolerance, defined as the ability to persist in goal-directed activity while experiencing emotional distress. Briefly, the behavioral assessment of distress tolerance involves participant engagement in and persistence on a computerized task that gradually increases in difficulty thereby increasing affective distress. The participant has the option to persist (with some small positive reinforcement available for persisting) or, in contrast, to terminate the task, thereby reducing emotional distress in the short term (negative reinforcement) but losing out on the rewards in the long term. In regard to externalizing behavior such as substance use and delinquent behavior, low distress tolerance as measured by these behavioral tasks is associated with increased substance use (Quinn, Brandon, & Copeland, 1996), shorter durations of smoking cessation and illicit drug use abstinence attempts (Brandon et al., 2003, Brown et al., 2002, Daughters et al., 2005b), increased dropout rates from residential drug treatment (Daughters, Lejuez, Bornovalova, et al., 2005a), and higher rates of antisocial personality disorder among a sample of male participants (Daughters, Sargeant, Bornovalova, Gratz, & Lejuez, 2008). Speaking to internalizing symptoms, low distress tolerance is associated with higher rates of borderline personality disorder in a sample consisting largely of female participants (Bornovalova et al., 2008), anxiety sensitivity (Anestis, Selby, Fink, & Joiner, 2007) and depression (Buckner, Keough, & Schmidt, 2007).

In order to begin to translate our understanding of distress tolerance and adult outcomes to an early adolescent sample, it is important to consider potential moderators of the relationship between negative affect and behavior, especially given evidence of clear gender and ethnicity differences in internalizing and externalizing symptoms. As such, the following sections highlight the potential role of gender and ethnicity in the development of these symptoms and behaviors.

Evidence indicates that female adolescents in comparison to males report higher levels of internalizing symptoms such as depression, anxiety, and psychosomatic complaints (Angold et al., 2002, Kolip, 1997, Lewinsohn et al., 1998, Wade et al., 2002). This may be the result of females and males responding to normative adolescent stressors differently. For instance, the relationship between the frequency of stressful life events and depressive symptoms intensifies as females mature, but diminishes for males. Female adolescents also report a higher number of stressful life events, have more acute reactions to these events, and view these events as more taxing than adolescent males (e.g., Jose & Ratcliffe, 2004). Risk factors, such as body image, self-esteem, pubertal changes, and transitions to high school also increase adolescents’ chance of developing depression and the effect of these risk factors have been show to be more intense for female versus male adolescents (Marcotte, Fortin, Potvin, & Papillon, 2002). Furthermore, the most pronounced gender differences in depression are among symptoms of affective distress, such as a depressed and anxious mood, while less significant gender differences were found in other symptoms of depression, such as sleep and concentration problems (Compas et al., 1997). In line with a negative reinforcement approach, the link between symptoms of affective distress and internalizing symptoms such as depression and anxiety among females may be a gender specific consequence of an inability to effectively cope with affective distress.

Emerging evidence suggests clear ethnicity differences in the engagement of externalizing behaviors, with a specific focus on alcohol use and delinquent behavior. In regard to alcohol use, Caucasian adolescents are significantly more likely to consume alcohol than their African American peers (Blum et al., 2000, Broman, 2007, Horton, 2007). Furthermore, Caucasians report drinking on more days and having more alcohol related problems than African Americans (Horton, 2007). Potential environmental mediators for ethnicity differences include less alcohol use, and stronger negative views about the harmful effects of alcohol, among African American than Caucasian parents (Peterson, Hawkins, Abbott, & Catalano, 1994). Differences in parental views and behavior may translate into children's attitudes toward alcohol use. In support of this view, African American elementary school students express stronger expectations that alcohol use will result in a loss of control and more long term negative effects, while Caucasian students believe that alcohol use will lead to positive affective reactions (Rinehart, Bridges, & Sigelman,, 2006). Further, African American children convey more negative attitudes toward adult alcohol use and fewer intentions to use alcohol as adults than their Caucasian peers. In regard to violent and delinquent behavior, evidence suggests that this behavior is more common among African American youth than their Caucasian peers (Eaton et al., 2006, Sampson et al., 2005). For instance, compared to Caucasians, studies indicate that African American youth are more likely to be diagnosed with conduct disorder (Cameron & Guterman, 2007), self -report engaging in a higher rate of index offenses (Elliot, Huizinga, & Ageten, 1985), and to be involved in more serious delinquent behavior such as weapons offenses, auto theft, burglary, and felony drug offenses (Farrington, Loeber, Stouthamer-Loeber, Van Kammen, & Schmidt, 1996; Kurtz, Giddings, Sutphen, Gill, & Martin, 1991).

Given evidence indicating that externalizing problems in youth are linked with global measures of negative emotionality, as well as specific indices of anger, hostility, and emotionality (e.g., Clark et al., 1994, Eisenberg et al., 2000, Lengua et al., 1998, Rothbart and Bates, 1998), negative reinforcement processes may be underlying the engagement in risk behavior, such that individuals’ unable to tolerate negative emotions are engaging in an increase in externalizing behavior. In support of this, previous studies have implicated avoidant-coping in the engagement of delinquent behaviors (Vassallo et al., 2002, Eftekhari et al., 2004, Hasking, 2007).

The construct of distress tolerance has been largely unstudied within early adolescent samples. Thus, it remains unclear whether a tendency to engage in negative reinforcement behavior (i.e., low distress tolerance) is present prior to regular engagement in substance use, delinquent behavior, and expression of internalizing symptoms. Further, the research that has been conducted has paid little attention to gender and race. This is of particular relevance because low distress tolerance may be a pathway to different aspects of internalizing and externalizing problems, to the extent that these problems differ as a function of race and gender as outlined above. Thus, the aim of the present investigation was to examine the main and interactive effects of distress tolerance in regard to internalizing and externalizing symptoms among a diverse sample of emerging adolescents. Specifically, it was hypothesized that emerging adolescents with low distress tolerance will report significantly greater rates of alcohol use, delinquent behavior, and internalizing symptoms, and that the nature of these relationships would depend upon gender and ethnicity. Specifically, it was hypothesized that low distress tolerance would be significantly related to an increase in alcohol use among Caucasians, delinquent behavior among African Americans, and internalizing symptoms among females.

Section snippets

Participants

Cross-sectional data were collected from a socioeconomically and ethnically diverse sample of 231 Caucasian and African American youth participating in a larger prospective study of behavioral, environmental, and genetic mechanisms of risk for HIV-related risk behaviors in youth. Participants were recruited through media outreach in the greater Washington, DC metropolitan area, as well as mailings sent to area schools, libraries, and boys and girls clubs. The average age of participants in the

Data analysis plan

Analyses were conducted with past year alcohol use, delinquent behavior, and internalizing symptoms as the primary dependent variables. Alcohol use was coded categorically (no use, one time, a few times or more), and both delinquent behavior and internalizing symptoms were coded continuously (number of delinquent behaviors, total RCADS score). Baseline demographic data were first examined for associations with each of the dependent variables (past year alcohol use, delinquent behavior,

Discussion

Although negative reinforcement processes may represent a common pathway for internalizing and externalizing symptoms, little work has been focused on this factor among early adolescents. Further, work that has been conducted on negative reinforcement mechanisms has yet to consider meaningfully the role of gender and ethnicity in the development of internalizing and externalizing symptoms. Towards this end, the current study examined a behavioral task of distress tolerance as a proxy for

References (68)

  • T.J. Wade et al.

    Emergence of gender differences in depression during adolescence: national panel results from three countries

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2002)
  • T.M. Achenbach et al.

    Psychopathology of childhood

    Annual Review of Psychology

    (1984)
  • M.D. Anestis et al.

    The multifaceted role of distress tolerance in dysregulated eating behaviors

    International Journal of Eating Disorders

    (2007)
  • A. Angold et al.

    Depression scale scores in 8–17-year-olds: effects of age and gender

    Journal of Child Psychology and Psychiatry and Allied Disciplines

    (2002)
  • T.B. Baker et al.

    Addiction motivation reformulated: an affective processing model of negative reinforcement

    Psychological Review

    (2004)
  • D.H. Barlow

    Anxiety and its disorders: the nature and treatment of anxiety and panic

    (2002)
  • R.W. Blum et al.

    The effects of race/ethnicity, income, and family structure on adolescent risk behaviors

    American Journal of Public Health

    (2000)
  • T.H. Brandon et al.

    Pretreatment task-persistence predicts smoking cessation outcome

    Journal of Abnormal Psychology

    (2003)
  • C.L. Broman

    Perceived discrimination and alcohol use among Black and White college students

    Journal of Alcohol and Drug Education

    (2007)
  • J.S. Brook et al.

    Illicit drug use and risky sexual behavior among African American and Puerto Rican urban adolescents: the longitudinal links

    Journal of Genetic Psychology

    (2004)
  • J. Brooks-Gunn et al.

    Biological and social contributions to negative affect in young adolescent girls

    Child Development

    (1989)
  • R.A. Brown et al.

    Distress tolerance and duration of past smoking cessation attempts

    Journal of Abnormal Psychology

    (2002)
  • M. Cameron et al.

    Diagnosing conduct problems of children and adolescents in residential treatment

    Child & Youth Care Forum

    (2007)
  • Centers for Disease Control and Prevention. (2001). National school-based Youth Risk Behavior Survey. Public-use data...
  • K.W. Chen et al.

    Understanding differences in marijuana use among urban black and suburban white high school students from two U.S. community samples

    Journal of Ethnicity in Substance Abuse

    (2006)
  • L.A. Clark et al.

    Temperament, personality, and the mood and anxiety disorders

    Journal of Abnormal Psychology

    (1994)
  • I. Colman et al.

    Forty-year psychiatric outcomes following assessment for internalizing disorder in adolescence

    American Journal of Psychiatry

    (2007)
  • B.E. Compas et al.

    Gender differences in depressive symptoms in adolescence: Comparison of national samples of clinically referred and nonreferred youths

    Journal of Consulting and Clinical Psychology

    (1997)
  • E.P. Copeland et al.

    Differences in young adolescents’ coping strategies based on gender and ethnicity

    Journal of Early Adolescence

    (1995)
  • S.B. Daughters et al.

    Distress tolerance as a predictor of early treatment dropout in a residential substance abuse treatment facility

    Journal of Abnormal Psychology

    (2005)
  • S.B. Daughters et al.

    Psychological distress tolerance and duration of most recent abstinence attempt among residential treatment seeking substance abusers

    Psychology of Addictive Behaviors

    (2005)
  • S.B. Daughters et al.

    The Relationship between distress tolerance and antisocial personality disorder among male residential treatment seeking inner-city substance users

    Journal of Personality Disorders

    (2008)
  • M.P. DelBello et al.

    Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review

    Journal of Child and Adolescent Psychopharmacology

    (2001)
  • D.J. DeWit et al.

    Age of first alcohol use: a risk factor for the development of alcohol disorders

    American Journal of Psychiatry

    (2000)
  • Cited by (136)

    View all citing articles on Scopus

    This research was funded by R21 DA022741 (Dr. Daughters) and R01 DA18647 (Dr. Lejuez) from the National Institute on Drug Abuse.

    View full text