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. Author manuscript; available in PMC: 2015 Dec 1.
Published in final edited form as: Psychol Addict Behav. 2014 Dec;28(4):1246–1252. doi: 10.1037/a0038372

Dynamic associations among alcohol use and anxiety symptoms in early adolescence

Carolyn Speidel Pardee 1,1, Craig R Colder 1, Julie C Bowker 1
PMCID: PMC4273670  NIHMSID: NIHMS636472  PMID: 25528052

Abstract

The relationship between anxiety and alcohol use in adolescence remains unclear, with evidence for no association, as well as risk and protective effects of anxiety. Considering developmental trajectories may be important for understanding the association between anxiety and alcohol use, and may help clarify prior mixed findings. The present study examined trajectories of alcohol use, social anxiety and general anxiety symptoms in early to middle adolescence using univariate and parallel process growth models. Social anxiety and general anxiety symptoms declined, while alcohol use increased with age. Parallel process growth models suggested that less rapid declines in social anxiety and general anxiety symptoms were associated with more rapid escalation in alcohol use. These results suggest that young adolescents who do not show normative declines in social anxiety or general anxiety symptoms may be at risk for more rapid increases in alcohol use.

Keywords: adolescence, alcohol use, generalized anxiety, social anxiety

Anxiety, most commonly generalized and social anxiety symptoms, is often discussed as a risk factor for adolescent drinking, typically via a self-medication pathway whereby alcohol use is posited to be motivated to relieve emotional distress. However, the literature documents mixed findings regarding the link between anxiety and adolescent alcohol use (Blumenthal, Leen-Feldner, Badour & Babson, 2012). General and social anxiety symptoms and alcohol use show age-related changes during adolescence (Van Oort et al., 2009; LaGreca, 1999). Understanding the dynamics of normative developmental trajectories of anxiety and alcohol use may help clarify the mixed literature, yet limited research has examined this issue. The present study addresses this gap by examining age-related changes in anxiety and adolescent alcohol use, and dynamic associations between these constructs.

The role of anxiety in the etiology of adolescent alcohol use may vary with age and stage of drinking, such that anxiety protects youth from alcohol use in early adolescence when drinking is typically initiated, but after initiation, anxiety predicts escalation of alcohol use (Colder, Chassin, Lee & Villalta, 2010). There is evidence that generalized anxiety symptoms are associated with escalation, but not initiation of alcohol use (Sung, Erkanli, Angold & Costello, 2004; Sartor, Lynsky, Heath, Jacob & True, 2007; Frojd et al., 2011). The pattern of findings is less clear for social anxiety, such that social anxiety may be unrelated to early adolescent alcohol use (Blumenthal et al., 2012), or may operate as a protective factor (Wu et al., 2010; Frojd et al., 2011) or as a risk factor (Marmorstein, White, Loeber & Stouthamer-Loeber, 2010). Yet by late adolescence there is consistent support for social anxiety as a risk factor for alcohol use (Burke & Stevens, 1999). In sum, the literature suggests some support for anxiety showing different associations with alcohol in early versus late adolescence, but the evidence is stronger for generalized anxiety than social anxiety.

When considering the impact of anxiety on the development of adolescent alcohol use, it is important to consider that both alcohol use and anxiety symptoms show normative changes during adolescence. Most youth begin using alcohol in early adolescence, with use escalating into late adolescence (Chen & Kandel, 1995; Colder et al., 2002; Johnson et al., 2010). Social and general anxiety symptoms decline modestly during early adolescence, and then increase from middle adolescence through late adolescence (Van Oort et al., 2009; LaGreca, 1999). Considering developmental changes in anxiety may help elucidate the link between anxiety and adolescent alcohol use, yet no studies to our knowledge have examined potential associations between trajectories of anxiety and alcohol use during adolescence.

Adolescents who are elevated on social anxiety in early adolescence may be delayed in onset of alcohol use because the associated social withdrawal and avoidance may protect them from peer contexts where drinking is most likely to occur (Hussong, 2000). Early generalized anxiety symptoms may protect youth from drinking because of worry about harm or getting into trouble for engaging in an illegal activity. As alcohol use becomes more normative in middle and late adolescence, increased modeling of alcohol use by peers coupled with greater access to alcohol may result in increased risk for alcohol use by adolescents with anxiety symptomology (Hussong, Jones, Stein, Baucom & Boeding, 2011). Through learning, drinking may come to be viewed as a means of facilitating social relationships, conforming to perceived social norms, and self-medicating distress, particularly among anxious youth, resulting in escalation of alcohol use (Blumenthal, Leen-Feldner, Frala, Badour & Ham, 2010; Burke & Stephens, 1999; Ham, Hope, White & Rivers, 2002; Buckner, Eggleston & Schmidt, 2006). Indeed, coping and conformity drinking motives have been shown to mediate the relationship between social anxiety (particularly fear of negative evaluation) and alcohol use in late adolescence, as well as general distress and alcohol use in adolescence (Stewart, Morris, Mellings & Komar, 2006; Stewart, Zvolensky, & Eifert, 2001; Cooper, Frone, Russell & Mudar, 1995). Thus, anxiety may protect against alcohol use in early adolescence, but may be associated with escalation of drinking.

The present study examined associations between alcohol use and two facets of anxiety in a longitudinal community sample of early to middle adolescents. We modeled growth in generalized anxiety and social anxiety symptoms and alcohol use, and examined associations between initial levels of anxiety symptoms and initial levels of alcohol use as well as growth in alcohol use. Hypotheses are presented in Table 1. Although we expected social anxiety and general anxiety to have similar associations with alcohol use, we separated the constructs given stronger evidence in the literature for developmental shifts in association with alcohol for general anxiety. Given the considerable overlap between generalized anxiety and social anxiety (Costello & Angold, 1995), we considered the prediction of general anxiety on alcohol use controlling for social anxiety and vice versa.

Table 1.

Hypotheses

Initial level of anxiety Association with alcohol
1.High initial social or general anxiety Low initial alcohol use a
2.High initial social or general anxiety Increasing alcohol use b
Initial level of alcohol use Association with anxiety
3. High initial alcohol use No association with changes in social or general anxiety
Changing levels of anxiety Associations with growth in alcohol
No hypotheses offered c
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a

Due to social avoidance or worry about the potential negative consequences of drinking.

b

Perhaps reflecting attempts to cope with distress associated with excessive worry or social concerns by drinking.

c

Given the dearth of studies on growth in anxiety and alcohol use in early adolescence

Method

Participants and procedures

The community sample included 387 adolescent-caregiver pairs interviewed annually for three years as part of a longitudinal project examining behavior problems and the development of substance use. The sample was recruited by means of random digit dialing within Erie County, NY (see Sample 1, Colder et al., 2012 for further details on recruitment and sample description). At wave 1, 55% of the adolescents were female and 83% were White/non-Hispanic. At the first assessment, the mean age was 12.09 (range 11 – 13) and median family income was $70,000 (range $1,500-$500,000). Retention was strong, with a combined attrition rate across waves 2 and 3 of 4.4%. Most follow-up interviews (90%) occurred within two months of the year anniversary of the previous assessment. Measures were computer administered by trained research assistants on a university campus over approximately 2.5 hours. Families received $75 (Wave 1), $85 (Wave 2), and $125 (Wave 3).

Measures

Social Anxiety

Social anxiety was assessed using the Social Anxiety Scale for Children, Revised (adolescent report; SASC-R; La Greca, 1999). Cronbach's alpha was .90, .92, and .93 at waves 1-3, respectively.

Generalized Anxiety

Generalized anxiety was assessed using the Youth Self Report (YSR; Achenbach & Rescorla, 2001), and scored using Lengua's system that distinguishes DSM categories of anxiety (Lengua, Sadowski, Friedrich & Fisher, 2001). Cronbach's alpha was .67, .70 and .76 at Waves 1-3, respectively.

Alcohol Use

Quantity and frequency of past year alcohol use was assessed using two items taken from the National Youth Survey (NYS; Huizinga & Elliott, 1983). Rates of use in the past year were 14%, 19%, and 29%, respectively at Waves 1-3. A quantity x frequency index (total drinks in the past year) was computed and converted into a three-level ordinal variable (no use in the past year, one to five drinks in the past year, and five or more drinks in the past year) to accommodate the expected low frequency of use.

Data analytic plan

Latent growth curve modeling with individually-varying ages of observation (modeling growth as a function of age) was used to account for variability in age at the first assessment and variability in follow-up intervals. This approach yielded an age range of 11.0 to 15.5 years over three waves. Analyses were performed using Mplus 6.1 (Muthen & Muthen, 2010), using full information maximum likelihood estimation when modeling anxiety symptoms (as they showed acceptable levels of skew) and weighted least squares when modeling the ordinal alcohol use variable. Because these models do not generate traditional model fit indices, nested likelihood ratio tests were used to evaluate if adding random linear trends improved model fit. The models included linear trends with the intercept specified to represent levels of the outcome (anxiety or alcohol use) at age 11. We began with unconditional growth models for each variable (social anxiety, general anxiety, and alcohol use). Next we ran a growth model for social anxiety and included generalized anxiety symptoms as a time-varying covariate so that we could examine change in social anxiety above and beyond generalized anxiety. We ran a similar model for generalized anxiety symptoms controlling for social anxiety symptoms. Finally, we ran parallel process models that included alcohol use and one symptom variable (social anxiety or general anxiety).

Results

Correlations, stabilities and descriptive statistics are presented in Table 2. Means suggest that social anxiety and general anxiety decline modestly over time. Cross-sectional correlations between social anxiety and general anxiety are moderate (.44 to .51).

Table 2.

Correlations, stabilities and descriptive statistics

1. 2. 3. 4. 5. 6.
1. Social Anxiety (Tl) 1.000
2. Social Anxiety (T2) 0.663** 1.000
3. Social Anxiety (T3) 0.536** 0.708** 1.000
4. General Anxiety (Tl) 0.443** 0.376** 0.320** 1.000
5. General Anxiety (T2) 0.331** 0.491** 0.449** 0.548** 1.000
6. General Anxiety (T3) 0.305** 0.417** 0.510** 0.504** 0.710** 1.000
M 2.163 2.077 2.033 0.365 0.315 0.302
SD 0.613 0.599 0.629 0.302 0.302 0.318
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Note. Possible range of the social anxiety measure is one to five, and for general anxiety range is zero to two.

**

p < .01

* p < .05

† p < .10

Multiple group models suggested no gender differences, and therefore we report results for the males and females combined. Nested chi square tests supported a random linear trend for social anxiety (X2 (3, N=387) = 23.53, p<.05), general anxiety (X2 (3, N=387) = 19.61, p<.05), and alcohol use (X2 (3, N=387) = 69.58, p<.05). Univariate models suggested that, on average, both social anxiety and generalized anxiety declined with age with statistically reliable individual variability in both initial levels and rates of change (Tables 3 and 4). Alcohol increased with age with statistically reliable individual variability in both the intercept and slope (Table 5).1

Table 3.

Parameter estimates from growth curve model of social anxiety

Model 1 a Model 2 b
Intercept Mean 2.208** 2.209**
Slope Mean −.058** −0.059**
Intercept Variance .319** 0.242**
Slope Variance 0.029** 0.022**
Intercept Slope Covariance −0.047* −0.040*
Beta for time-varying covariate (generalized anxiety)
    Time 1 0.699**
    Time 2 0.743**
    Time 3 0.806**
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Note. Residual variances were specified as uncorrelated and freely estimated.

a

Linear growth model – no covariates.

b

Linear growth model – general anxiety as a time-varying covariate.

**

p < .01

*

p < .05

† p < .10

Table 4.

Parameter estimates from growth curve model of general anxiety

Model 1 a Model 2 b
Intercept Mean 0.377** 0.379**
Slope Mean −0.025** −0.025**
Intercept Variance .066** 0.049**
Slope Variance 0.006** 0.005*
Intercept Slope Covariance −.008† −0.008
Beta for time-varying covariate (social anxiety)
    Time 1 0.011**
    Time 2 0.011**
    Time 3 0.010**
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Note. Residual variances were specified as uncorrelated and freely estimated.

a

Linear growth model – no covariates.

b

Linear growth model – social anxiety as a time-varying covariate.

**

p < .01

*

p < .05

†

p < .10

Table 5.

Parameter probabilities from growth curve model of alcohol use

Age Category 1 a Category 2 b
11 0.009 0.0002
12 0.025 0.0006
13 0.065 0.0016
14 0.155 0.0043
15 0.32 0.011
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Note. Mean of intercept and slope factors = −4.619 and 0.975, respectively. Variance of intercept and slope factors = 11.996 and 1.382, respectively. All means and variances statistically significant (p<.05). Residual variances were specified as uncorrelated and freely estimated.

a

Probability of being in category 1 (reporting 1-5 drinks consumed over the past 12 months).

b

Probability of being in category 2 (reporting >5 drinks consumed over the past 12 months).

Next, we examined growth models for the symptom variables with time-varying covariates. Results were similar when general anxiety was included as a time-varying covariate in the social anxiety growth model and when social anxiety was included as a covariate in the general anxiety growth model (Tables 3 & 4). 2

In the parallel process models, slopes were regressed on intercepts, and covariances were estimated between slope factors and between intercept factors. Results for social anxiety are shown in Figure 1. First, slower than average declines in social anxiety symptoms were associated with more rapid increases in alcohol use (slope covariance). Second, in contrast to hypotheses, higher levels of social anxiety symptoms at age 11 were associated with higherinitial levels of alcohol use, but this association fell short of conventional criteria for statistical significance (intercept to intercept covariance). Third, in contrast to hypotheses, higher levels of social anxiety symptoms at age 11 were associated with less rapid increases in alcohol use (intercept to slope path), but this association fell short of conventional criteria for statistical significance. Cross-construct associations were weakened and none were statistically or marginally reliable when general anxiety was included as a covariate.

Figure 1.

Figure 1

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Parallel process growth curve model of social anxiety symptoms and alcohol use with regression. Partial coefficients in parentheses. Parameter estimates are unstandardized. Residual variances were specified as uncorrelated and freely estimated. **p < .01, * p < .05, † p < .10

Results for general anxiety symptoms are shown in Figure 2. Slower than average declines in general anxiety symptoms were associated with more rapid increases in alcohol use (slope covariance). In contrast to hypotheses, higher levels of generalized anxiety symptoms at age 11 were associated with higher initial levels of alcohol use (intercept covariance), but this association fell short of conventional criteria for statistical significance. When social anxiety symptoms were included as a covariate, all cross-construct associations were weakened and no longer statistically reliable. Effect sizes were generally small (see Table 6).

Figure 2.

Figure 2

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Parallel process growth curve model of generalized anxiety symptoms and alcohol use with regression. Partial coefficients in parentheses. Parameter estimates are unstandardized. Residual variances were specified as uncorrelated and freely estimated. **p < .01, * p < .05, † p < .10

Table 6.

Effect sizes for parallel process growth models

Regression paths ΔR2
Social anxiety slope on alcohol intercept 3.45%
Alcohol slope on social anxiety intercept 1.25%
General anxiety slope on alcohol intercept 1.66%
Alcohol slope on general anxiety intercept 1.52%
Covariances r(x,y)
Social anxiety slope to alcohol slope .37
Social anxiety intercept to alcohol intercept .22
General anxiety slope to alcohol slope .14
General anxiety intercept to alcohol intercept .28
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Discussion

This study examined the association between trajectories of alcohol use and those of social and generalized anxiety in early to middle adolescence. Alcohol use increased, whereas both social anxiety and general anxiety symptoms declined modestly with age. The nature of the relationship between anxiety and alcohol use differed for cross-sectional (intercept to intercept), prospective (intercept to slope), and dynamic (slope to slope) associations, and differed slightly for type of anxiety. Associations were small, suggesting that anxiety does not play a major role in early adolescent alcohol use. These findings will be discussed in turn.

Other studies (LaGreca, 1999; Van Oort et al., 2009), have similarly found that social and general anxiety symptoms decline in early adolescence. This decline may be related to increases in novelty seeking and shifting social goals that are characteristic of early to middle adolescents, which in turn, promote independence from adults and affiliation with peers (Crawford, Pentz, Chou, Li & Dwyer, 2003; Steinberg, 2008). Our finding that alcohol use increased is consistent with prior epidemiological studies (Chen & Kandel, 1995; Johnson et al., 2010). Overall, these findings suggest that both anxiety and alcohol use change during early to middle adolescence.

We also found support for anxiety symptomatology (both social and general anxiety symptoms) and alcohol use changing together, such that slower than normative declines in both general and social anxiety symptoms were associated with more rapid escalation in alcohol use. These dynamic associations may reflect changes in social context and also self-medication motives for drinking. Desire for peer affiliation increases and youth become more responsive to social stimuli during adolescence (Collins & Steinberg, 2006), yet high levels of anxiety are associated with peer difficulties. Thus, anxious adolescents may experience both a push away and pull toward peer relationships. Escalation of alcohol use may be motivated by a desire to gain entrée into social relationships for adolescents who do not show normative declines in anxiety. Another possibility is that adolescents who do not experience normative declines in anxiety symptomatology may be motivated to use alcohol to relieve emotional distress (a self-medication mechanism) as alcohol comes to be more normative with age. The opposing drives to affiliate with peers but also to withdraw due to anxiety may make alcohol an appealing coping strategy as youth learn about the effects of alcohol. Thus, self-medication may be intertwined with strong motives for affiliation for some youth, as is evident from the prominent role that social facilitation and tension reduction beliefs play in the etiology of adolescent drinking (Burke & Stephens, 1999; Smith, Goldman, Greenbaum & Christiansen, 1995). Finally, biologic mechanisms are likely at play as well, given emerging evidence of common neuroanatomical pathways and neurochemical systems involved in alcohol and anxiety-related behavior (Sharko, Fadel & Wilson, 2013).

It should be noted that direction of effects cannot be determined based on the observation that change in anxiety symptoms is associated with change in alcohol use during the same period (slope to slope covariances). It is also possible that increases in alcohol use disrupt normative declines of social and general anxiety symptoms. This alternative cannot be ruled out, but this direction is less plausible given the young ages and low levels of alcohol use in our sample.

Higher initial levels of social anxiety symptoms marginally predicted slower increases in alcohol use, suggesting a trend towards a protective effect of high initial levels of social anxiety. The contrast between the social anxiety-alcohol slope to slope covariance (suggestive of social anxiety being a risk factor) versus the intercept to slope path coefficient (suggestive of anxiety being a protective factor) implies that considering developmental trajectories can help clarify the mixed findings in the literature. Alcohol use during adolescence most often occurs in the context of peers, who provide access to and social reinforcement for drinking (Harford & Spiegler, 1983; Beck, Thombs, & Summons, 1993). A hallmark feature of social anxiety is social avoidance (Watson & Friend, 1969; Beidel, Turner & Morris, 1995), and thus, high levels of social anxiety in early adolescence may protect youth from peer contexts that promote drinking (Fite, Colder & O'Connor, 2006). However, as social relationships become increasingly important with age, adolescents who do not show normative declines in social anxiety symptoms may come to use alcohol as a way of medicating distress and fostering peer relationships as discussed above. Ignoring developmental changes in anxiety would likely obscure these important differences.

This study also examined the unique associations with alcohol use for each facet of anxiety. There was no evidence for unique associations with alcohol use after controlling for the other symptom facet. This suggests that what is common to generalized and social anxiety (e.g., general distress, anxious apprehension, and physiological arousal) (Clark & Watson, 1991; Bogels & Zigterman, 2000) plays a role in the etiology of adolescent alcohol use and that when these overlapping elements are removed, what remains unique to social or generalized anxiety symptoms does not appear to be germane to adolescent alcohol use.

However, specific effects may play a modest role as indicated by a trend towards different patterns of association for social and generalized anxiety. Slope to slope covariation with alcohol was similar for social and general anxiety, suggesting that what is common to these domains of anxiety underlies the dynamic associations. However, there also seems to be a relevant component of social anxiety (i.e., distress and impairment in social relationships) that operates along with what is shared with generalized anxiety (general worry and distress) that serves as a protective factor (the marginal intercept to slope effect seen in social anxiety but not general anxiety parallel process models). This suggests that facets of anxiety may be important in investigating developmental trajectories of adolescent alcohol use, but that unique effects are not informative.

Limitations and Conclusions

This study has several limitations. First, other domains of anxiety not considered in this study may also be germane to adolescent alcohol use such as post-traumatic stress (Kilpatrick, Acierno & Saunders, 2000; Read et al., 2013). Second, our findings may not generalize beyond early to middle adolescence, clinical samples or at risk youth. By adulthood, both general anxiety and social anxiety are more clearly linked to alcohol use (Kushner, Abrams & Borchardt, 2000), and thus, extending trajectories into late adolescence may yield different patterns of association. Additionally, we relied on self-report of youth internalizing and alcohol use (as is typical), and this introduces possibility of common method variance. Finally, our study was predominantly white, and we did not have adequate group sizes to test for race or ethnicity differences. Despite these limitations, the present study fills an important gap in the literature by considering adolescent anxiety and alcohol use in a developmental context. Current developmental models of adolescent alcohol use focus on externalizing symptoms (Hussong et al., 2011; Zucker, 2003). Our findings suggest the importance of considering the normative development of anxiety as well as separating anxiety symptomology into specific domains in clarifying the etiological role of anxiety in adolescent alcohol use.

Acknowledgments

This research was supported by a grant from the National Institute on Drug Abuse (R01 DA019631) awarded to Craig R. Colder.

Footnotes

1

The alcohol growth model and the parallel process models below were also analyzed with an alternate categorization of alcohol use: no use (abstainers), a few sips to two drinks (triers), and more than two drinks (experimenters) in order to evaluate whether small cell sizes in the highest category of alcohol use were unduly influencing the results. The pattern of findings remained consistent with original results, suggesting the observed effects are robust to different thresholds of the drinking categories.

2

Given that depression is correlated with anxiety (Brady & Kendall, 1992), we also included depressive symptoms (as assessed using Lengua et al., 2001 depression scoring of the YSR) as an additional time-varying covariate, and results did not change.

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