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. Author manuscript; available in PMC: 2019 Sep 1.
Published in final edited form as: Anxiety Stress Coping. 2018 Jul 11;31(5):500–513. doi: 10.1080/10615806.2018.1498278

Posttraumatic stress severity is associated with coping motives for alcohol use among in-patient and community recruited adolescents

Renee M Cloutier 1, Keke L Schuler 1, Nathan Kearns 1, Camilo J Ruggero 1, Sarah F Lewis 2, Heidemarie Blumenthal 1
PMCID: PMC6289047  NIHMSID: NIHMS1512443  PMID: 29996679

Abstract

Background and Objectives:

A growing body of work suggests individuals with more severe post-traumatic stress symptoms (PTSS) are at higher risk for developing problematic alcohol use outcomes. Extending work from the adult literature, the present study was the first to examine the extent to which PTSS is related to drinking motives for alcohol use in both clinical and non-clinical samples of adolescents.

Design:

Hierarchical regression analyses were used to predict coping motives for alcohol use from PTSS, above and beyond demographic variables, alcohol use frequency, and other alcohol use motives.

Methods:

Trauma-exposed adolescents before entering treatment (Sample 1 n = 41) and recruited from the local community (Sample 2 n = 55) self-reported on PTSS and alcohol use motives.

Results:

PTSS positively predicted coping motives for alcohol use after controlling for age, gender, and alcohol use frequency.

Conclusions:

The current study highlights the need to consider both PTSS severity, as well as underlying cognitive mechanisms (e.g., motives), to better understand the etiology of problematic alcohol use among trauma-exposed youth. Future work focused on clarifying the trajectory of alcohol use motives and problems as a function of PTSS is needed.

Keywords: post-traumatic stress, alcohol use, adolescence, coping, motives

Introduction

Trauma exposure is remarkably common, with estimates indicating 62–68% of adolescents from the community and 75% of high-risk samples (e.g., adolescents receiving substance use treatment) experience at least one traumatic event before 18 years of age (Copeland, Keeler, Angold, & Costello, 2007; Deykin & Buka, 1997; McLaughlin et al., 2013). Although only a small percentage of trauma exposed individuals from the community go on to develop posttraumatic stress disorder (PTSD; 11.5–21.5%), a significant proportion continue to experience symptomatic responses (e.g., Alisic et al., 2014; Foa, Johnson, Feeny, & Treadwell, 2001). An extensive adult and adolescent literature underscores additional risk associated with traumatic event exposure and posttraumatic stress symptoms (PTSS), including elevated depression, anxiety and panic problems, risk-related substance use (e.g., binge drinking), and alcohol use problems in particular (Kar & Bastia, 2006; Oosterhoff, Kaplow, & Layne, 2016; Pietrzak, Goldstein, Southwick, & Grant, 2011; Read et al., 2012). In contrast to adolescents in the community, a disproportionately greater number of adolescents in treatment for alcohol use disorder or other substances also meet criteria for lifetime (29.6%) and current (19.2%) PTSD diagnoses (Deykin & Buka, 1997). Indeed, both PTSD and higher PTSS levels have been consistently linked to more frequent alcohol use, alcohol-related problems, and the diagnosis of an alcohol use disorder across adult and adolescent samples (Blumenthal et al., 2008; Debell et al., 2014; Read et al., 2012).

Evidence that trauma-exposed individuals may use alcohol as a means of coping with PTSS is presented across several studies of trauma-exposed adults with and without a PTSD diagnosis (e.g., battered women, veterans; Kaysen et al., 2007; Simpson et al., 2014; Stewart, 1996). For example, during intake interviews with military veterans, 85.3% of participants retrospectively reported that as their PTSS increased, so did their frequency of substance use; 61.8% reported that a decrease in PTSS was followed by a decrease in substance use (Back et al., 2014). Conversely, only 11.4% reported that a decrease in their substance use preceded a decrease in PTSS (Back et al., 2014). Additionally, findings from multiple cross-sectional studies with adults indicate that coping motives (i.e., drinking to alleviate negative affect) partially account for the relation between PTSS and markers of alcohol-related problems such as heavy episodic drinking and problems with relationships/important areas of life (Kaysen et al., 2007, Lehavot, Stappenbeck, Luterek, Kaysen, & Simpson, 2014; Ullman, Relyea, Peter-Hagene, & Vasquez, 2013). Support also is found in studies assessing daily and momentary PTSS and alcohol use. For example, in a daily assessment of PTSS and alcohol use among adults with co-occurring PTSD and alcohol use disorder diagnoses, PTSS severity was positively associated with both same-day and next-day alcohol use (Simpson et al., 2014). Despite this growing body of evidence, the majority of the work examining these relations has been conducted with adults, many of whom already meet criteria for PTSD, alcohol use disorder, or both.

Understanding the link between PTSS and alcohol use during adolescence is of particular concern for at least three reasons. Most notably, this distinct period is marked by (a) high rates of trauma exposure (e.g., up to 68%; Copeland et al., 2007; McLaughlin et al., 2013), (b) forming of initial beliefs about alcohol (Schell et al., 2005), and (c) elevated risk for more rapid transitions to problematic alcohol use compared to adults (Deas et al., 2000). Further, theoretical and empirical work demonstrates that adolescence is a unique period of development, meaning that processes underlying trauma- and substance-related pathology among adults might not exist or function in the same manner among adolescents. Indeed, simple “downward extension” of adult models to younger populations without empirical testing can be misleading (Blumenthal et al., 2008; Cicchetti & Rogosch, 2002). For example, implied within the Self-Medication model (i.e., alcohol is consumed to alleviate negative affect caused by PTSD) is that users have had a sufficient number of pairings between negative affect and relief from that negative affect following alcohol use in order to be motivated to use alcohol for coping purposes (Khantzian, 1997). Yet, by virtue of their age and legal status, adolescents typically have a more limited alcohol use history (i.e., fewer opportunities for pairings), as well as dangerous binge-drinking tendencies whenever consumption opportunities do arise (Miller, Naimi, Brewer, & Jones, 2007). The infrequent alcohol use more typical of non-clinical adolescent populations is predominately associated with environmental features (e.g., peers) and as a reaction to those environmental features (e.g., drinking to conform with peers; Teunissen et al., 2012). Thus, PTSS may not relate to coping motives among adolescents because they have yet to formulate any primary motives or, alternatively, because externally-based motives (e.g., conformity, social) are still predominant (Cooper, 1994). In contrast, PTSS may serve to expedite the process through which adolescents begin to use alcohol for coping purposes by increasing the number and severity of negative affect events that are paired with relief following alcohol consumption.

The limited work conducted with adolescents provides preliminary support for the contention that trauma-exposed youth also may use alcohol as a means of coping with their trauma histories. For example, Topper, Castellanos-Ryan, Mackie, and Conrod (2011) found that adolescents (13–15 years) who were bullied at baseline reported greater rates of coping related alcohol use at a one year follow-up, which in turn accounted for greater alcohol problems. Another study on adolescents (14–17 years) who were in the welfare system and had a history of child maltreatment found that anxiety symptoms were associated with greater alcohol problems for those reporting higher coping motives for alcohol use (Goldstein, Vilhena-Churchill, Stewart, & Wekerle, 2012). Dixon and colleagues (2009) reported that PTSS were positively related to frequency of coping motives, but not conformity, social, or enhancement motives, providing initial support for the specific relation between PTSS and coping-motivated drinking among adolescents entered into a residential treatment program. However, these findings do not provide a complete picture regarding the association between PTSS and coping motives across samples. More specifically, the studies of community adolescents (e.g., Topper et al., 2011) were not specifically focused on PTSS. Further, the few studies that did examine PTSS had notable methodological limitations, either (a) only included youth exposed to a specific type of trauma (e.g., maltreatment/neglect; Goldstein et al., 2012) or (b) included youths already in a treatment programs, where large proportion also presented with a substance use disorder (e.g., Dixon et al., 2009).

Notably, a recent study of community-recruited adolescents found that tension-reduction alcohol expectancies significantly mediated the relation between trauma exposure and alcohol use frequency, suggesting that the increased alcohol use observed among trauma-exposed youth is related to the expectation that alcohol will reduce negative affect (Blumenthal, Leen-Feldner, Knapp, Badour, & Boals, 2015). However, expecting alcohol to reduce tension does not necessarily mean that is why an adolescent chooses to use alcohol, and trauma exposure does not necessarily lead to PTSS (Cronin, 1997; Foa et al., 2001; Kuntsche, Knibbe, Gmel, & Engels, 2005). There remains a need to examine the relation between PTSS and coping related alcohol use across the spectrum of PTSS severity, particularly among adolescents before meeting clinical criteria for alcohol or stress-related diagnoses. Importantly, examining these relations across at-risk adolescent samples allows for the consideration of theorized etiological processes while also limiting potential confounding effects of concurrent clinical conditions (e.g., Zvolensky, Lejuez, Stuart, & Curtin, 2001). Clearly delineating these theoretical processes will, in turn, help inform meaningful intervention-and prevention-oriented programming efforts (Blumenthal et al., 2008; Clark, Lesnick, & Hegedus, 1997; Stewart, 1996).

Together, the aim of the current project was to replicate and extend prior findings linking PTSS and coping related alcohol use motives among adolescents. Drawing from existing work, PTSS severity was hypothesized to positively relate to coping, but not conformity, social, or enhancement alcohol use motives in a sample of youth entering residential treatment (Sample 1) and recruited from the community (Sample 2). Sample 1 was chosen to replicate existing work with adolescents in treatment (e.g., Dixon et al., 2013) while Sample 2 was chosen as an extension of the existing literature. Specifically, Sample 2 was recruited from the community to cross-validate results (e.g., ensure that findings were not confounded by the effects of pre-existing, related factors). Finally, the association between PTSS and coping motives was expected to be robust to the inclusion of demographic (i.e., chronological age, alcohol use frequency; Kuntsche et al., 2005; 2006; Tolin & Foa, 2006) and theoretical (e.g., days since trauma; other use motives) covariates. Of note, within the drinking motives literature, approaches for handling the anticipated shared variance across subscales varies widely (e.g., Cooper et al., 2016; Kuntsche et al. 2005). As such, we elected to run two sets of regression models to provide estimates that focus solely on covariates related to the specific construct (e.g., PTSS and coping motives), as well as constructs pertain to the broader topic of drinking motives, specificity (e.g., PTSS and coping motives, controlling for all other drinking motives).

Method

Data for this study were drawn from two samples: adolescents entering residential treatment program and adolescents recruited from the community. Details about the participants and methods specific to each sample are described below and in Table 1. Prior to collecting data from both samples, approval was obtained from the University of Arkansas Institutional Review Board. Verbal and written informed parental consent for child participation as well as written adolescent assent were obtained prior to enrolling participants.

Table 1.

Sample Demographics

Variable Sample 1 (N = 41) Sample 2 (N = 55)
    Age M (SD) 15.8 (1.1) 15.6 (1.3)
    Gender % a
        Female 70.3% 45.5%
        Male 29.7% 54.5%
    Race/Ethnicity (%) a
        Hispanic 1.6% 10.9%
        Non-Hispanic White 82.8% 74.5%
        African American 3.1% 3.6%
        Asian 3.1% 1.8%
        Native American/Alaskan 1.6% 0.0%
        Other/Multiple 3.1% 3.6%
    Number of Trauma Types M (SD) 1.9 (1.4)
    Trauma Type
        Sick/Hurt 11.4% 18.2%
        Witness Death/Injury 25.0% 20.0%
        Accident/Fire 6.8% 14.5%
        Natural Disaster 4.5% 10.9%
        Robbed/Attacked 2.3% 5.4%
        Sexual Assault/Touched 25.0% 16.4%
        Sexual Assault/Touched Other 0% 0%
        Physical Assault/Domestic Abuse 13.6%% 7.3%
        Abandoned/Kidnapped 2.3% 0%
        Other 9.1% 7.3%
    Days Since Event 832.12 (1192.4) 1608.3 (1310.8)
PTSD Diagnosis 55.8% 7.3%
Parent Income (Median) $100,000a $43,500b
YSR Internalizing 30.6% 16.4%
YSR Externalizing 23.6% 16.4%
DMQ-Coping M(SD) 11.42 (5.8) 11.02 (5.2)
DMQ-Social M(SD) 12.3 (6.3) 15.0 (5.8)
DMQ-Conformity M(SD) 7.0 (3.6) 7.6 (3.7)
DMQ-Enhance M(SD) 13.7 (6.34) 15.6 (6.3)
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Note. YSR: Youth Self Report - % meeting clinical cutoffs (Achenbach & Rescorla, 2001); DMQ: Drinking Motives Questionnaire subscale sum

a

n = 37

b

n = 32

Participants

Sample 1

Sample 1 (n = 44) was drawn from an ongoing assessment of a group based residential treatment program for adolescents (ages 9–19). Of the 594 adolescents approached for participation, 384 agreed to participate (64.6%). Of those who agreed, 196 had usable Time 1 data – the most common reasons for unusable data were: participant refusal, program error (e.g., missed the window for pre-treatment assessment), and researcher error (e.g., technological errors when uploading data from tablets to computers). Of those with usable data, cases were selected for the current analyses if they were less than 18 years of age, met DSM-IV-TR criteria for trauma exposure (American Psychiatric Association, 2000), reported current alcohol use, and had complete data on the primary measures. Excluding youth who were 18 years or older (n = 1), non-trauma exposed (n = 103), and/or were not current drinkers (n = 115) from the larger sample1, resulted in a final sample of 44 adolescents aged 13–17 years.

Participants were assessed at entry to the program (i.e. prior to intervention), presenting with a variety of internalizing and externalizing forms of psychopathology. Adolescents entered treatment via community-based referrals or self-referrals from the program website. Program staff approached parents of potential participants to obtain parental consent and adolescent assent. Parents provided participant demographic (e.g., age, gender) and their own education and income for descriptive purposes. Adolescent participants completed all primary measures with computerized self-report measures. Participants and parents completed self-report indices in a quiet, private place with trained research personnel on hand to answer any questions. Finally, participants were compensated with a lottery enrollment where they could win $50 or $100.

Sample 2

Sample 2 (n = 56) was drawn from a larger study examining adolescent health behaviours among community youth ages 12–17 years.2 As part of the larger study, eligibility criteria included age 12–17 years, consumption of at least one standard alcoholic beverage in the past 6 months, not currently pregnant (girls only) or actively suicidal, and ability to provide written informed consent/assent; participants included in the current analyses also needed to endorse at least one DSM-IV Criteria A1 defined traumatic experience (APA, 2000). Of the 688 adolescents and/or guardians who contacted the laboratory and were informed about the study, 73 adolescents and/or guardians declined (e.g., sibling not eligible, no time, not comfortable with materials), 16 did not fall within the required age range, 392 reported never having consumed a standard alcoholic beverage, 60 had not consumed a full beverage in the past 6 months, and 51 met eligibility criteria but did not attend scheduled appointments (at least three times before no further attempts were made). Of the 88 eligible adolescents who participated in the laboratory appointment, 31 reported no lifetime DSM-IV defined traumatic events, and 5 did not complete the primary interviews, resulting in a final sample of 56 participants aged 12–17 years to serve as a community comparison sample to those in Sample 1 who were currently seeking treatment.

Adolescents completed the self-report assessments in a private space with a trained researcher on hand to answer questions, followed by a series of laboratory tasks not relevant to the current study (e.g., voluntary hyperventilation). Parents accompanying their child to the laboratory visit also were asked to report on their own education and income for descriptive purposes (66.7% of sample). Finally, participants were debriefed and compensated $40 and $5 for adolescents and parents, respectively.

Please see Table 1 for additional descriptives on Samples 1 and 2, including the percentage of youth meeting ‘clinical cut-offs’ on the Youth Self Report internalizing and externalizing subscales (i.e., T-score ≥ 70; Achenbach & Rescorla, 2001).

Measures

Post-Traumatic Stress Symptoms (PTSS).

Self-reported trauma exposure and PTSD symptoms were assessed with the computer (Sample 1) or the interview (Sample 2) version of the Child PTSD Symptom Scale (CPSS; Foa et al., 2001). Across both samples and versions, the trauma had to have been experienced by the participant and the participants had to endorse fear, helplessness, or horror in response to the index trauma (i.e., Criterion A). Sample 1 described their most distressing lifetime event, then rated the severity of their symptoms from the past two weeks. Symptoms were rated across 17 items on a 0 (“Not at All”) to 3 (“5+ times per week/Almost Always”) scale and summed to create a total score with a possible range of 0–51. Higher scores indicate greater severity of symptoms, with a score of 15 suggesting possible PTSD diagnosis (Nixon et al., 2013). For Sample 2, trained interviewers administered the Anxiety Disorders Interview Schedule for DSM-IV: Child Version (Silverman & Albano, 1996) to index traumatic event exposure, including direct inquiries about experiencing eight specific events (e.g., physical or sexual assault), as well as any other upsetting events not listed. Affirmative responses were probed to determine whether significant threat and emotional response were present. The most distressing event identified by the youth and researcher (e.g., meeting DSM-IV-TR criteria) was then assessed for lifetime PTSS with the CPSS interview (Foa et al., 2001). In contrast to Sample 1, symptoms were assessed as present (coded 1) or absent (coded 0), then summed to create a total score with a possible range of 0–17. Additional interference ratings allowed for the ascertainment of possible lifetime PTSD as defined by the DSM-IV-TR (for exclusionary purposes only).

The CPSS is a sensitive and widely used measure of PTSS validated for use in youth with and without a clinical diagnosis of PTSD (Foa et al., 2001; Nixon et al., 2013). The CPSS also has adequate test-retest reliability among youth with recent and distal trauma exposures (Foa et al., 2001; Nixon et al., 2013). The CPSS evidenced adequate internal consistency in both Sample 1 (e.g., current Cronbach’s α= .92) and Sample 2 (e.g., Cronbach’s α= .81).

Alcohol use motives.

Both samples completed the Drinking Motives Questionnaire–Revised (DMQ-R; Cooper, 1994) to assess motives for alcohol use. This 20-item self-report measure is rated on a Likert-type scale indicating how often participants use alcohol for the listed reason ranging from 1 (almost never/never) to 5 (almost always/always). The measure includes five questions reflecting each of the four alcohol use motives categories: coping (“to relax”, “to forget your worries”, “because you feel more self-confident or sure of yourself”, “because it helps when you feel depressed or nervous”, “to cheer up when you’re in a bad mood”), conformity (“because your friends pressure you to drink”, “so that others won’t kid you about not drinking”, “to fit in with a group you like”, “to be liked”, “so you won’t feel left out”), social (“because it helps you enjoy a party”, “to be sociable”, “because it makes social gatherings more fun”, “because it improves parties and celebrations”, “to celebrate a special occasion with friends”), and enhancement (e.g., “because you like the feeling”, “because it’s exciting”, “to get drunk”, “because it’s fun”, “because it gives you a pleasant feeling”). Subscale scores have each been shown to uniquely and prospectively predict different alcohol-related outcomes (e.g., frequency, drinking contexts, problems; Cooper, 1994; Kuntsche et al., 2005; 2006). All subscales evidenced adequate internal reliabilities in Sample 1 (coping: α = .88; conformity: α = .89; social: α = .93; enhancement: α = .90) and Sample 2 (coping: α = .77; conformity: α = .89; social: α = .88; enhancement: α = .90).

Covariates

Age, number of drinking days, and number of days since trauma were selected as potential demographic covariates. Age for Sample 1 was reported by parents during intake, and by adolescents on a demographic questionnaire in Sample 2. In Sample 1, total number of drinking days within the preceding 30 days (i.e., 30-day alcohol use frequency) was assessed using a single, open-ended-item from the Youth Risk Behavior Survey (Center for Disease Control and Prevention, 2006): “During the past month (30 days), on how many days did you have at least drink of alcohol?”). Self-generated responses ranged from 0 to 30. If a non-numeric response was provided, clear responses (e.g., ‘None’ = 0, ‘Everyday’= 30) were recoded into numeric values and unclear responses (e.g., ‘Yes’) were treated as missing. In Sample 2, total number of drinking days within the preceding six-months was assessed with a Timeline Followback interview (Sobell & Sobell, 1996). During the Timeline Followback, the interviewer obtains daily drinking estimates that are summed to create a continuous estimate of the total number of drinking days (i.e., days consumed at least one full standard alcoholic beverage) in the past six-months. In Sample 1 and Sample 2, time since trauma was asked as part of the CPSS, following the assessment of the index trauma. Specifically, participants were asked what their most distressing event was, then asked to report the length of time since the event. As an open-response format, participants were able to report the duration of time in days, weeks, or years – all responses were recoded into days.

Data Analytic Plan

In Sample 1 there were two cases missing data on PTSS (4.5%), and one case missing data on time since trauma (2.3%). All available cases were used for each analysis resulting in slightly different sample sizes (n’s = 36 – 42) in the preliminary analyses depending on the variable of interest and are described in Table Notes. Because Little’s MCAR test indicted the data were Missing Completely at Random [χ2 = 6.85, (df = 7, p = .445)] and the percent of missingness present in the variables selected for the regression models fell below accepted thresholds (e.g., 8–10%; Widamen, 2006), listwise deletion was used on the final regression analyses (Final n = 41). In Sample 2, one case (1.7% of sample) had missing data on the PTSS – because PTSS was the primary predictor of interest, the overall percent of missingness fell below accepted thresholds, and Little’s MCAR test indicted the data were Missing Completely at Random [χ2 = 8.62, (df = 5, p = .125)], listwise deletion was used on all analyses resulting in a final sample of 55.

Identical analyses were conducted across samples with the exception that Sample 1 included 30-day alcohol use frequency and Sample 2 included six-month alcohol use frequency as a covariate. To facilitate comparisons across samples, the results are summarized in the same sections and tables. First, zero-order Pearson correlations were conducted to examine bivariate relations among primary variables (see Table 2). An online calculator from Lee and Preacher (2013) was used to test the equality of statistically significant correlation coefficients between PTSS and each of the drinking motives subscales (Steiger, 1980). Second, hierarchical linear regression analyses were conducted to test the main hypothesis that PTSS would predict coping motives for alcohol use above and beyond relevant covariates. Two regression models were conducted for each sample – the first models included demographic covariates only and are summarized in text. The second, more conservative models also controlled for other alcohol use motives (presented in Table 3).

Table 2.

Bivariate Relations Among Drinking Motives, PTSS, and Demographics

Variable 1 2 3 4 5 6 7 8 9
1. Coping - .18 .36** .49** .26 .091 −.166 .33* −.11
2. Conformity .38** - .12 −.10 .11 −.10 −.08 .04 .07
3. Social .56** .46** - .71** −.28* .26 .35** .31* .15
4. Enhancement .67** .32* .65** - −.22 .26 .22 .21 .01
5. PTSS Total .58** .38* .27 .23 - .11 −.39** −.04 −.10
6. Chronological Age .17 .10 .36** .34* .09 - .08 .04 .30*
7. Gender (male)a −.18 −.01 −.17 .05 −.25 .02 - −.06 .05
8. Alc. Frequency .67** .41* .43** .56** .21 .24 −.07 - −.16
9. Time Since Trauma −.35* −.13 −.23 −.31* −.22 −.06 .39*b −.30* -
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Note. Correlations for Sample 1 are presented below the diagonal (N = 42); Correlations for Sample 2 are presented above the diagonal (N = 55). PTSS Total: Post-Traumatic Stress Symptom total score. Alc. Frequency: total number of drinking days in preceding 30 days (Sample 1) or six-months (Sample 2).

a

Females=0, males=1; thus positive correlations reflect higher scores among males and negative correlations higher scores among females; missing gender data resulted in n = 37 for Sample 1 on all pairwise correlations

b

n = 36

*

p < .05

**

p < .01

Table 3.

Hierarchical Multiple Regression Analyses Predicting DMQ-Coping Motives

Variable ΔR2 β rs2 p
Sample 1 (Treatment Sample)
Step 1 .61 < .001
Age −.09 0.01 .361
Alc. Frequency .42 0.58 .001
Time Since Trauma −.01 0.14 .888
Conformity −.14 0.17 .194
Social .21 0.41 .120
Enhancement .26 0.57 .054
Step 2 .15
PTSS .43 0.46 <.001
Sample 2 (Community Sample)
Step 1 .35 .001
Age −.06 0.02 .601
Alc. Frequency .22 0.22 .062
Time Since Trauma −.04 0.02 .757
Conformity .18 0.07 .119
Social .00 0.25 .998
Enhancement .56 0.46 .001
Step 2 .12
PTSS .37 0.13 .002
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Note. Sample 1 n = 41; Sample 2 n = 55. β = standardized beta. rs2=squared structure coefficient. DMQ: Drinking Motives Questionnaire.

Results

Preliminary Analyses

Sample 1

Adolescents in Sample 1 endorsed a mean PTSS severity of 16.76 (SD = 13.48) with 50.0% meeting the cut off for possible PTSD diagnosis. Adolescents drank an average of 5.4 (SD = 8.4) days out of the past 30 days. Zero-order correlations indicated PTSS was positively correlated with Coping (p < .001) and Conformity (p = .012) motives, but not Social (p = .090) or Enhancement (p = .142) motives. Tests comparing the equality of correlation coefficients (Lee & Preacher, 2013) indicated that the correlation between PTSS and Coping motives was stronger than the correlations between PTSS and Social (p = .045) or Enhancement (p = .029) motives, but similar in magnitude to the correlations between PTSS and Conformity (p = .123) motives. In terms of potential covariates, Coping motives were positively associated with alcohol frequency (p <.001) and negatively associated with days since trauma (p = .022) but not associated with age (p = .280).

Sample 2

Adolescents in Sample 2 endorsed a mean PTSS severity of 4.7 (SD = 3.9) with four cases meeting the cut off for possible PTSD diagnosis. Adolescents drank an average of 2.1 (SD = 2.7) days out of the past 30 days and 7.8 (SD = 12.3) days out of the past six months. Zero-order correlations indicated that PTSS was positively related to Coping motives (p = .057), negatively related to Social motives (p =.039), and unrelated to Conformity (p=.409) and Enhancement (p =.102) motives. Similar to Sample 1, Coping motives were positively associated with alcohol frequency (p = .013) and not statistically related to age (p = .510). However, unlike Sample 1, Coping motives was not related to days since trauma (p = .435).

Primary Analyses

Sample 1

In the first regression, demographic covariates (age, 30-day alcohol use frequency, time since trauma) were entered in step one followed by PTSS total scores in step two. The overall model accounted for 64.9% total variance in Coping motives for alcohol use and was statistically significant (F[4, 40] = 16.66, p < .001). Covariates accounted for 45.5% variance and PTSS contributed 19.4% unique variance to Coping motives. The second regression included demographic covariates as well as Conformity, Social, and Enhancement motives in step one followed by PTSS in step two. Again, the overall model was statistically significant (F[7, 40] = 14.29, p < .001) accounting for 75.2% variance in total and PTSS remained a significant predictor (Please see Table 3 for predictor level data)3.

Sample 2

In the first regression, age, six-month alcohol use frequency, and time since trauma were entered into step one, followed by PTSS total scores in step two. The overall model accounted for 18.9% total variance in Coping motives for alcohol use and was statistically significant (F[4, 50] = 2.80, p = .030). At the predictor level, PTSS accounted for 6.8% variance and was statistically significant (p = .046). The second regression also included Conformity, Social, and Enhancement motives with the demographic covariates in step one, and PTSS included in step two. Overall, this model was statistically significant (F[7, 47] = 5.94, p <.001), accounting for 46.9% variance in total and PTSS remained a significant predictor (Please see Table 3 for predictor level data).

Discussion

The present study was the first to examine the extent to which PTSS are related to coping motives for alcohol use among adolescents from both community and clinical settings. As hypothesized, across both samples PTSS was positively related to coping, but not social or enhancement alcohol use motives. In the clinical sample only, PTSS also were correlated with conformity motives, and alcohol use frequency was related to both coping motives and PTSS severity. Together, the current findings speak to the role of PTSS in coping-related drinking motives among adolescents with a range of responses to DSM-IV-defined traumatic events.

In both samples PTSS positively related to coping motives for alcohol use. Even after conducting a conservative test of the effects that included both demographic variables and other motives as covariates, PTSS remained a significant predictor. Further, the size of the PTSS effect in the community sample (r = .26) was nearly half that of the clinical sample (r = .58) in the preliminary analyses. This consistency highlights the relevance of PTSS in the development of coping motives even when youth are not currently expressing clinical PTSD or alcohol use disorder symptom levels. Of note, the adolescents entering treatment reported more frequent alcohol use than those from the community. Further, in the treatment seeking sample, 30-day alcohol use frequency was positively associated with all alcohol use motives, but evidenced the strongest association with coping motives. This provides some support for the idea that while increased frequency of alcohol use may lead to an increased level of alcohol use motives overall, specific risk factors, such as PTSS, may uniquely predict processes related to the development of alcohol problems (i.e., via negative reinforcement motives).

These findings replicate and extend previous work examining the association between PTSS and alcohol motives. To date, most studies included adult samples (e.g., Ullman et al., 2013) with only one reporting on adolescents (i.e., Dixon et al., 2009). Collectively, findings indicate that more severe PTSS following trauma are positively associated with coping motives for alcohol use across clinical and non-clinical samples, despite purposeful and meaningful variations in age, degree of alcohol use experience, and severity of other psychological and behavioural problems. The current data also support the contention that coping motives may precede – and, therefore, play a key role in – the development of subsequent alcohol use problems (Kuntsche et al., 2005; Topper et al., 2011). This is important, as empirical work indicates that earlier trauma exposure and more frequent alcohol use rates may place adolescents at particular risk for “telescoped” development of (i.e., faster progression to) alcohol problems as compared to adults or non-trauma exposed adolescents (e.g., Behrendt et al., 2010; Berenson, Wiemann, & McCombs, 2001). As adolescent alcohol use is often considered normative, it may be important for clinicians working with trauma-exposed youths to assess and target early reports of coping-related alcohol use as a means of preventing the development of problematic drinking behaviors.

Across almost all analyses, PTSS were uniquely related to coping motives. However, in the clinical sample PTSS also were positively correlated with conformity motives and in the community sample PTSS was negatively related to social motives. Although the PTSS-social motives effect was no longer statistically significant in the regression (ΔR2 = .01), the PTSS-conformity motives effect remained statistically significant when covariates were included in the model (ΔR2 = .09). Though the association between PTSS and conformity motives was unexpected, it is possible that in clinical populations PTSS leads to alcohol use for negative reinforcement motives more broadly. This association is generally consistent with the idea that, after controlling for use frequency, conformity motives are often associated with use related problems (Cooper, 1994). Nevertheless, these findings contradict several studies among adults (e.g., Vujanovic, Marshall-Berenz, & Zvolensky, 2011) and the one study conducted with another clinical population of adolescent alcohol users (Dixon et al., 2009) which have failed to identify associations between PTSS and conformity drinking motives. Future research is needed to resolve these discrepant findings.

Limitations and Future Research Directions

Importantly, while the analyses included adolescents with a range of trauma symptoms and alcohol use histories, both projects used cross-sectional designs and neither included an assessment of alcohol-related problems (e.g., Read et al., 2012). Thus, future adolescent work including each piece of the theoretical model (i.e., PTSS, coping motives, alcohol problems) in a longitudinal design is needed to parse apart the temporal sequencing of these processes. Experimental designs in particular could be used to isolate individual and situational risk factors as well as provide clearer targets for intervention (Kraemer, Yesavage, Taylor, & Kupfer, 2000), such as social support and rumination (Bokszczanin, 2007; Guay, Nachar, Lavoie, Marchand, & O’Connor, 2017; Szabo, Warnecke, Newton, & Valentine, 2017). Future work should also consider antecedent individual factors, such as coping styles and physiological stress reactivity before trauma exposure (e.g., disengagement coping; Gil, 2005; Pineles et al., 2013), although assessment of these constructs prior to trauma may be impractical given the nature of these experiences (i.e. often unexpected).

Although findings generally supported our hypotheses and are consistent with the literature, it is important to note that, like previous studies in this area, the sample sizes of the current project were relatively small (Sample 1 n = 41; Sample 2 n = 55). Post-hoc power analyses conducted with G*Power (Erdfelder, Faul, & Buchner, 1996) – with power (1 - β) set at 0.80 and α = .05 for size of a single regression coefficient in a fixed linear multiple regression model – suggested that a slight increase in sample size for Sample 1 (required N = 46) and Sample 2 (required N = 59) would be needed to adequately detect unique effects for PTSS in a multiple regression. While statistically underpowered, the fact that effects were detected across two specialized adolescent populations (i.e., treatment-seeking and community-recruited) suggests that this may be a promising avenue for larger, more resource intensive investigations in the future.

Interpretation of these findings should be considered in light of additional limitations. First, despite the use of clinical and community samples being a notable methodological strength, both samples were relatively small and demographically homogenous (e.g., 80% Caucasian). Future work utilizing more diverse sampling strategies is needed (Weiss et al., 2017). Second, PTSS was assessed with different versions of the CPSS in Sample 1 (e.g., on a computer) and Sample 2 (e.g., interview format). On the one hand, the psychometric properties have been demonstrated for both versions (e.g., Foa et al., 2001), so the consistency of the results across samples provides greater confidence that the associations are not contingent on modes of measurement. On the other hand, these subtle differences limit the extent to which direct comparisons of the results might be drawn. Where possible, multi-modal assessments of PTSS within and across samples could be used to address possible invariance related to measurement. Third, the current study was underpowered to examine the role of gender (Kuntsche et al., 2006), specific symptom clusters (Ruggero et al., 2013), trauma type (Rosenkranz, Muller, & Henderson, 2012), or frequency of exposure (Brown & Shillington, 2017). Work designed to examine these and other key factors (e.g., depression; sleep disturbance; Meyer, McDonald, Douglas, & Scott, 2012; Vandrey, Babson, Herrmann, & Bonn-Miller, 2014) will be required to better understand the nature and boundaries of these relations. Lastly, the current project was conducted prior to the introduction of the DSM-5 (American Psychiatric Association, 2013); thus, conceptual replication, particularly in terms of addressing the role of specific symptom clusters (e.g., Ruggero et al., 2013) is required.

Conclusions

Despite these limitations, the current study is a unique extension to the extant literature and represents an important step in understanding the role of coping motivated alcohol use among trauma exposed youth. The current findings speak to the role of PTSS in coping-related drinking motives among adolescents with a range of responses to various traumatic events. This elevation in coping-related drinking motives may account for the later development of alcohol problems observed in this population. Together, existing data and the current findings highlight coping motives as an important target of future research aimed at understanding the etiology of co-occurring trauma- and alcohol-related disorders. Indeed, assessing the trajectory of coping related alcohol use as a function of PTSS may help inform developmentally-sensitive intervention and prevention efforts.

Acknowledgments:

This project was partially supported by a National Institute on Alcohol Abuse and Alcoholism National Research Service Award (F31 AA018589) awarded to the last author.

Footnotes

Disclosure of interest: The authors report no conflicts of interest.

Data Availability Statement: The data that support the findings of this study are available from the corresponding authors, [RMC or HB], upon reasonable request.

1.

Exclusion categories were not mutually exclusive

2.

Data are drawn from the same dataset used by Blumenthal, Leen-Feldner, Knapp, Badour, and Boals, (2015). Here, we directly examine PTSS (c.f., trauma exposure) and alcohol motives (c.f., expectancies) among only trauma exposed participants (c.f., trauma exposed and non-exposed).

3.

Because PTSS was positively associated with conformity motives at the zero order level (r=.38), similar post-hoc regression analyses were conducted examining PTSS as a predictor above and beyond other covariates. The overall model was statistically significant (F[7, 33] = 2.958, p = .016) and PTSS remained a unique predictor (ΔR2=.09, p = .04).

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