Alcohol and Alcoholism Advance Access originally published online on January 5, 2006
Alcohol and Alcoholism 2006 41(2):143-150; doi:10.1093/alcalc/agh261
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ADAPTIVE FUNCTIONING, PSYCHOPATHOLOGY AND SERVICE USE AMONG 18-YEAR-OLD BOYS WITH DRUNKENNESS-RELATED ALCOHOL USE
1 Addiction Clinic at Turku City Psychiatric Services, Kunnallissairaalantie 20, 20700 Turku, Finland, 2 Department of Child Psychiatry, 3 Department of Criminology and 4 Department of Biostatistics, Turku University, 20520 Turku, Finland, 5 Visiting Department of Child and Adolescent Psychiatry, Columbia University, NY, USA, 6 The Finnish Foundation for Alcohol Studies, PL 220 00531 Helsinki and 7 Archipelago Sea Naval Command PL 5, 20241 Turku, Finland
* Author to whom correspondence should be addressed at: Fax: +358 2 2692 478; E-mail: solja.niemela{at}utu.fi
(Received 23 September 2005; first review notified 22 November 2005; in revised form 16 December 2005; accepted 19 December 2005)
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Aims: To study the associations between drunkenness frequency and adaptive functioning, psychopathology and service use among 18-year-old Finnish boys in a nation-wide population-based study. Methods: Information about drunkenness frequency within the previous six months was collected from the Finnish boys born in 1981 (n = 2306) at the boys' obligatory military call-up in 1999. Self-report questionnaires were used to study demographic factors, adaptive functioning, risk behaviour, life events, and mental health service use. Psychopathology and adaptive functioning was assessed with the Young Adult Self-Report (YASR) questionnaire. Results: Of the boys, 85% reported drunkenness within the previous 6 months. Most of the subjects were occasionally drunk: 39% reported drunkenness less than a month, and 35% less than once a week, while 10% reported being frequently drunk once a week or more often. Occasional drunkenness was associated with better adaptive functioning and psychosocial well-being in general. Refraining from drunkenness was associated with suicidal ideation and internalizing problems in the YASR scale. Frequent drunkenness associated with daily smoking, illicit drug use, and externalizing problems in the YASR scale, especially delinquent behaviour. In the multivariate analysis, number of friends, having a regular relationship and cigarette smoking had a linear association with frequency of drunkenness, while drunkenness-related alcohol use was less common among those with poor friendship quality. Among the participants, entering substance use treatment was rare (0.2%). Frequent drunkenness was found to be common among mental health service users. Conclusions: Among late-adolescent boys, occasional drunkenness is a normative alcohol use pattern and associates with social competence and good psychosocial functioning. Late-adolescent boys refraining from drunkenness in addition to those with frequent drunkenness may be in a need of mental health assessment. As entering substance use treatment is infrequent, establishing integrated services with multi-professional co-operation for late-adolescent males with frequent drunkenness is emphasized.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Alcohol-use-related problems are one of the most prominent public health problems in Western countries (Room et al., 2005
). Among 18-year-old adolescents, the lifetime prevalence of alcohol use varies from 80.0 to 94.8% (Essau et al., 2002). Drinking style becomes drunkenness-orientated with age (Lintonen et al., 2000), while access to licensed premises at age 18 increases alcohol consumption (Casswell et al., 2002). Drinking habits tend to be maintained from late adolescence to adulthood (Jefferis et al., 2005). A common pattern of alcohol use among adolescents is heavy episodic drinking (Kuntsche et al., 2004), which is known to associate with a range of health risk behaviours (Settertobulte et al., 2001). Adolescent alcohol use is associated with educational and occupational problems, interpersonal and familial conflicts, unprotected sex, proneness to accidents, suicidality, and youth crime, especially violent offending (Maio et al., 1994; Ellickson et al., 2003; Esposito-Smythers and Spirito, 2004; Wells et al., 2004). Teenage alcohol use has been found to predict substance-use-related problems in young adulthood, including illicit drug use (Poikolainen et al., 2001; Ellickson et al., 2003). On the other hand, while some adolescents with alcohol-use-disorders manifest chronic alcohol dependence in adulthood, a substantial proportion overcome their alcohol problems and change to abstinence or normative drinking (Clark, 2004). Therefore, distinguishing those adolescents at risk of alcohol-related problems is clinically important.
Only a few studies on adolescent substance use and mental health service use have been carried out in a nationwide sample (Wu et al., 2002). It has been indicated that there is a considerable gap between substance use disorders and referral to appropriate services, especially among young people (McLellan and Meyers, 2004). Furthermore, 
60–80% of youths with substance use, abuse or dependence have some form of comorbid diagnosis, most commonly conduct disorder and depression (Armstrong and Costello, 2002). In the USA, about one-fourth of the 16–18-year-old boys involved in publicly funded youth serving agencies had a past-year diagnosis of alcohol-use-disorder (Aarons et al., 2001). Of the adolescents entering substance abuse treatment, 60% had a high level of mental health problems, but only few received mental health treatment (Jaycox et al., 2003).
The aim of this study is to examine the frequency of drunkenness-related alcohol use and the family characteristics, life events, adaptive functioning, psychopathology and other substance use (smoking and use of illicit drugs) among 18-year-old males attending their obligatory military call-up. Furthermore, the aim was to shed some light on the associations between mental health service use and drunkenness frequency. The large number of participants gave us an opportunity to study self-reported drunkenness frequency during the previous 6 months as a four-class variable: never, once a month or less, less than once a week, and at least once a week. For preventive purposes, it is important to recognize those late-adolescent boys at possible risk of later alcohol-use-related problems. Clinically, the group of adolescents who are drunk once a week or more often are obviously different from those who are drunk only, for example, once a month. However, the issue of the degree to which background risk factors differ in those adolescents who are drunk frequently versus those who are drunk occasionally has not been sufficiently addressed in previous population-based studies. It is important to distinguish between different levels of involvement with alcohol since alcohol use is normative in our society and in this age group in particular. We hypothesized that risky behaviours and poor adaptive functioning associate only with frequent drunkenness occurring at least once a week, while occasional drunkenness is normative behaviour in this age group of males without marked psychosocial adversities.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Subjects
This investigation is part of the nationwide ‘From a Boy to a Man’ study, a 10-year follow-up study included in the Epidemiological Multicenter Child Psychiatric Study in Finland (Almqvist et al., 1999
). The research plan was approved by the Joint Commission on Ethics of Turku University and Turku University Central Hospital. The original study sample was drawn from the total population of Finnish children born during 1981 (n = 60 007). Of the selected 10% (n = 6017), 96.6% took part in the study in 1989. Of these 5813 children, 2946 were boys. In 1999, 2599 (88.2%) boys from the original sample were reached at their obligatory military call-up. Of these boys, 2348 (90.3%) filled in the given questionnaires. The drop-out group from the original study population—those who took part in the study in 1989 but did not fill in the questionnaire in 1999—was more closely studied. The drop-outs had a significantly higher level of psychopathological features at age eight, and their family structure was more often other than two biological parents (Haavisto et al., 2004). A more detailed description of this study has been published previously (Multimaki et al., 2005). Information about alcohol use was obtained from 2306 boys; 78.3% of the original study group at age eight, 88.7% of those attending military call-up, and 98.2% of those filling in the questionnaire. At military call-up, the respondents returned the questionnaires in sealed envelopes to avoid reporting bias. The participants were informed by the researchers that the military personnel or any other authority has no access to the collected data. Furthermore, it was informed that the collected data is analysed anonymously. Therefore, from the adolescent's perspective, the reports of, for example, alcohol use, use of services, or behavioural problems did not affect the decisions made by the military call-up authorities.
Outcome variable
The outcome variable was the self-reported frequency of drunkenness during the preceding six months prior to the military call-up. The frequency of drunkenness was studied by the question: ‘how many times have you been drunk during the past six months?’ This question is part of the Young Adult Self-Report questionnaire (YASR) (Achenbach, 1997). A four-point scale in the YASR questionnaire was: 1 = never; 2 = once a month or less; 3 = less than once a week; and 4 = once a week or more often. Those who reported refraining from drunkenness within the past 6 months were chosen as a reference group. The group reporting drunkenness once a week or more often was referred to as frequent drunkenness group.
Instruments
The psychopathology and adaptive functioning of the subjects were studied using the YASR, a self-report questionnaire for subjects aged 18–30 years (Achenbach, 1997). It contains 110 problem items that can be scored on a total problem scale, two subscales, and eight syndromes; withdrawn, anxious/depressed (together constituting the internalizing scale); delinquent behaviour, aggressive behaviour, intrusive behaviour (together constituting the externalizing scale); somatic complaints, attention problems, and thought problems. The YASR competence scales investigate adaptive functioning in five life areas: family, friends, education, spouse/partner, and occupation. The 90th percentile cut-off point based on the distribution of scores in the present sample was considered to depict poor adaptive functioning in each of these scales. The questions concerning substance use in the YASR delinquency item were removed before the statistical analysis.
Tobacco use was studied with the YASR question: ‘how often have you been smoking cigarettes during the past six months?’ with the alternatives 1 = never; 2 = occasionally; 3 = 1–5 cigarettes a day; 4 = 6–10 cigarettes a day; and 5 = >10 cigarettes a day. Tobacco use was studied as a three-class variable with the categories ‘non-smoker’, ‘occasional smoker’, and ‘daily smoker’, Options 3, 4, and 5 being pooled. Self-report of illicit drug use was studied with the question: ‘how often have you used drugs during the past 6 months (such as cannabis, amphetamine, intoxicating drugs)?’ with alternatives 1 = never; 2 = once a month or less; 3 = less than once a week; and 4 = once a week or more often. Illicit drug use by self-report was dichotomized to ‘no’ and ‘yes’.
Suicidal ideation was studied in the YASR with the question ‘I think about killing myself’, and suicidal acts with the question: ‘I deliberately try to hurt or kill myself’. According to the answers to these questions, suicidality was divided into three categories: those not having suicidal thought or acts (referred to as ‘not suicidal’), those having suicidal thoughts only (referred to as ‘suicidal ideation’), and those with suicidal acts or deliberate self-harm, including those with suicidal ideation as well (referred to as ‘suicidality/deliberate self-harm’).
Global perceived psychological problems were studied with the question ‘do you have emotional, behavioural or relational problems?’ with the alternatives 1 = no; 2 = mild problems; 3 = moderate problems; 4 = severe problems. Options 3 and 4 were pooled, and this variable was studied as a three-class variable: ‘no mental health problems’, ‘minor problems’, and ‘severe problems’.
The self-reported use of mental health services during the preceding 12 months was studied with the question: ‘have you sought help or have you been referred for assessment because of behavioural, emotional or relational problems during the last 12 months?’ The questionnaire mentioned possible sources of help (e.g. psychiatric outpatient and inpatient unit, child guidance clinic, school psychologist, substance use treatment, youth clinic, private doctor). Adolescents were included in the service use group, if they had been in contact with mental health services during the 12-month period. Use of mental health services was studied as a dichotomous response variable with the categories ‘yes’ and ‘no’.
Additionally, the boys were asked about their health problems with a YASR question ‘Do you have any illness, disability or handicap?’ with alternatives ‘yes’ and ‘no’. Information about social environment was also collected with questions concerning family structure (biological parents/other family structure), living place (urban/rural), moving away from home, parental divorce, parental severe illness, parental death, and number of friends (one at most/two or more), These variables were dichotomized for the analysis.
Statistical methods
Multinomial logistic regression analysis was used to examine the univariate associations between drunkenness frequency and the explanatory variables. With multinomial logistic regression analysis, it is possible to study polytomous response variables. The multinomial technique gives one overall P-value for the association between each explanatory variable and the response variable (Agresti, 2002).The strength of associations was expressed as odds ratios (OR) and their 95% confidence intervals (95% CI). P-values of <0.05 were considered statistically significant. The Wald test was used for statistical purposes. All statistically significant explanatory variables from the univariate analysis were entered in the final multivariate logistic regression analysis, stepwise method. The model included YASR syndrome scales, family characteristics and life events, adaptive functioning, substance use other than alcohol, suicidality, and mental health service use. As the YASR syndromes scales are included in YASR total score and the subscales, only the model with YASR syndrome scales is reported. Two-sided interactions between the statistically significant variables from the multivariate analysis (i.e. having more than one friend, having a regular relationship, poor friendship quality, smoking, illicit drug use, and delinquent behaviour) were tested using models with forward and backward selection. No clear interactions were detected, as there was a notable instability between the models. All tests were two-tailed. Statistical computations were performed using the SAS system for Windows, release 8.2/2000.
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RESULTS |
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Prevalence of drunkenness
Of the subjects, 85.0% reported drunkenness during the previous 6 months, while 15.0% had not been drunk by self-report. Most of the subjects were occasionally drunk: 39.3% reported being drunk less than once a month, and 35.4% less than once a week. Of all the boys, 10.4% reported being drunk once a week or more often. This group was referred to as the ‘frequent drunkenness’ group.
Univariate associations
Family characteristics and life events
As shown in Table 1, parental divorce and living apart from parents associated with drunkenness less than once a week, and frequent drunkenness. Serious illness of a parent associated with refraining from drunkenness and frequent drunkenness.
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Adaptive functioning Educational and occupational problems were associated with frequent but not with occasional drunkenness. Drunkenness-related alcohol use was more common among those with more than one friend and a regular relationship with a linear trend. Refraining from drunkenness was associated with occupational problems. Furthermore, the refrainers reported more peer-related problems than those with drunkenness-related alcohol use in general (Table 1).
Smoking and illicit drug use Of those boys reporting daily smoking, 22.4% also reported being drunk at least once a week. Of the boys using illicit drug by self-report, 47.9% had also been drunk at least once a week during the previous 6 months. The relationship between drunkenness frequency and tobacco smoking or illicit drug use was linear. Both occasional and daily smoking was associated with frequent drunkenness.
Psychopathology and suicidality As shown in Table 2, boys reporting occasional drunkenness had less self-reported psychological deviance in general compared to those with frequent drunkenness or those refraining from drunkenness. The groups reporting occasional drunkenness, i.e. less than once a month or less than once a week, did not significantly differ from each other. Only intrusive behaviour in the YASR syndrome scale associated with drunkenness less than once a week, but not with drunkenness occurring less than once a month. Refraining from drunkenness was associated with suicidal ideation, severe global perceived psychological problems, mental health service use, YASR total score, and YASR internalizing problems. Furthermore, withdrawal, anxiousness and depressive symptoms, thought problems and somatic complaints according to the YASR syndrome scales associated with refraining from drunkenness. Frequent drunkenness was associated with suicidal ideation and suicidal acts, minor and severe global perceived psychological problems, and mental health service use. YASR total score, externalizing and internalizing YASR subscale, and every syndrome in the YASR syndrome scales.
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Service use for mental health problems Overall service use for mental health problems during the previous 12 months was 2.1%. Only five subjects (0.2%) reported help-seeking from substance use treatment settings. Of those frequently drunk, 6.8% reported help-seeking for their psychic distress. Help-seeking associated only with frequent drunkenness. Of the help-seekers, 33.3% reported frequent drunkenness.
The multivariate associations Table 3 shows the results of the multivariate analysis after controlling for the effects of other significant explanatory variables, i.e. YASR syndrome scales, family characteristics and life events, adaptive functioning, smoking and illicit drug use, suicidality, and mental health service use. Smoking and illicit drug use independently associated with drunkenness-related alcohol use in general, the association being most evident with frequent drunkenness. Delinquent behaviour associated exclusively with frequent drunkenness. Having a regular relationship had a linear connection with drunkenness frequency, while having at least one friend associated with drunkenness less than once a week and frequent drunkenness. Poor friendship quality was less common among those with occasional drunkenness.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Drunkenness frequency
Drunkenness as a drinking habit seems to be culturally normative among 18-year-old Finnish boys. Three out of four were occasionally drunk, i.e. less than weekly. One out of ten was drunk at least once a week. Of all the boys, 15% reported refraining from drunkenness. Figures on prevalence of self-reported drunkenness are consistent with other studies done in Finland and elsewhere (Lintonen et al., 2000
; Andersen et al., 2003).
Adaptive functioning
Our results indicate that occasional drunkenness among late-adolescent males is associated with better adaptive functioning than refraining from alcohol or frequent drunkenness. Socializing with others, having friends and a regular relationship associated independently with drunkenness-related alcohol use, especially with frequent drunkenness. Drunkenness was less common among boys with poor friendship quality. It has been previously postulated that adolescents with moderate and heavy alcohol consumption are more sociable (Hoel et al., 2004) and high friendship quality accelerates substance use (Urberg et al., 2003). Leifman et al. (1995) hypothesized that poor sociability could be a consequence of abstaining at a young age when abstinence is uncommon. These findings indicate that drunkenness-related alcohol use among late-adolescent boys associates with social competence, while drunkenness appears to be less common among those with fewer social skills.
Smoking and illicit drug use
Both occasional and regular smoking and illicit drug use were parallel to drunkenness frequency with a linear trend. After adjusting for other variables, illicit drug use associated only with frequent drunkenness. Alcohol use and smoking have been found to associate with each other reciprocally among adolescents (Wetzels et al., 2003). Illicit drug use and positive drug attitudes have been found to be more common among adolescents who both drink and smoke regularly (Best et al., 2000). For preventive purposes, screening for smoking and illicit drug use is highlighted when drunkenness-related alcohol use, particularly on a weekly basis, is reported.
Psychopathology and suicidality
According to our results, late-adolescent boys getting occasionally drunk report more well-being than those with non-normative drunkenness-related alcohol use, i.e. refraining from drunkenness or getting frequently drunk. As hypothesized, boys reporting frequent drunkenness had significantly more psychopathological deviance, especially externalizing syndromes and suicidality. Interestingly, refraining from drunkenness was found to associate with a variety of psychological problems, especially internalizing problems. It has been estimated that non-drinkers as well as hazardous drinkers experience higher levels of distress than moderate drinkers (Caldwell et al., 2002). However, in the multivariate analysis, only delinquent behaviour had an independent association with frequent drunkenness. The association between alcohol use and antisocial behaviour has been well established in previous studies (Fergusson and Horwood, 2000; Swahn and Donovan, 2004). Among young binge drinkers, frequency of drunkenness was found to be a better predictor of offending behaviour than frequency of drinking per se (Richardson and Budd, 2003). Accordingly, delinquency is associated specifically with frequent drunkenness, while risk-taking behaviours are less common among boys getting occasionally drunk and those refraining from drunkenness. It can be postulated that avoiding risk-taking behaviours, for example, drunkenness-related alcohol use, associates with internalizing problems in late adolescence. Therefore, risk-taking behaviours, especially delinquency and suicidal acts should be actively screened, if an 18-year-old boy reports drunkenness on a weekly basis. In addition, among those who refrain from drunkenness, more attention should be paid for internalizing problems in late adolescence, such as withdrawal and suicidal ideation.
Service use
Help-seeking was more common among those with frequent drunkenness, and a substantial portion of the service users reported frequent drunkenness. However, only 10% of service users had had contact with specialized services for substance use treatment. Therefore, the majority of the help seekers with frequent drunkenness had had contact only with general mental health services. Most likely, the late-adolescent males with frequent drunkenness do not receive alcohol treatment. It has been estimated that substance use problems among adolescents entering specialized services, for example, the mental health system, are overlooked (Aarons et al., 2001). Therefore, drunkenness-related alcohol use might be a candidate for screening in the mental health care system. The rate of receiving alcohol treatment among adolescents with alcohol problems has been found to be low in previous studies as well (Wu et al., 2002; McLellan and Meyers, 2004). It has been estimated that alcohol abuse and dependence have the widest treatment gap of all mental health problems (Kohn et al., 2004). As entering a substance use treatment setting was found to be extremely rare, integrating a substance use treatment perspective with other services where late-adolescent males are encountered is emphasized. On the other hand, drunkenness-related alcohol use is culturally normative and there are no firm results on the effectiveness of primary prevention interventions concerning alcohol misuse among young people (Foxcroft et al., 2003). Therefore, offering alcohol misuse interventions to late-adolescent males may be challenging.
Limitations
The sample was representative of a whole age cohort collected nationwide in Finland. The findings of this report have been collected in a cross-sectional setting, thus causalities between the explanatory variables and drunkenness frequency cannot be shown. The drop-out group from the original study population had a somewhat higher level of psychopathological features at age eight and their family structure was more often other than two biological parents, which may affect the present findings (Haavisto et al., 2004). The large sample size gave us an opportunity to study drunkenness frequency as a four-class variable, but unfortunately, the quantity of alcohol consumed has not been specified. Furthermore, information about alcohol use was based solely on self-reports. However, recent research supports the assertion that subjects provide accurate reports about their drinking and associated consequences (Lintonen et al., 2004). The questionnaire does not give any information about alcohol-use-related problems in particular, for example, alcohol overdoses, drunk driving, suicidal acts, and antisocial behaviour while intoxicated. Additionally, we are not able to control for parental and peer influence, nor the onset of alcohol intake or other substance use. Finally, the degree of alcohol use severity, problematic use or dependency, is not studied. On the other hand, frequent reported episodes of drunkenness are an indicator of hazardous alcohol use. Among young adults, frequency of drunkenness has been suggested to be the single best indicator of problem drinking (Bailey, 1999). Moreover, a thorough assessment of regular alcohol consumption and mean drinking frequency as predictor variables for adolescent alcohol misuse and alcohol-related problems is still lacking (Foxcroft et al., 2003).
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Drunkenness-related alcohol use among Finnish 18-year-old boys is culturally normative and associates with social competence, while drunkenness is less common among those with fewer social skills. Poor adaptive functioning and psychological problems are connected with non-normative orientation to drunkenness, not with drunkenness-related alcohol use per se. Late-adolescent boys refraining from drunkenness in addition to those with frequent drunkenness may also be in need of mental health assessment. Frequent drunkenness is common among late-adolescent mental health service users, while entering substance use treatment is almost non-existent. Accordingly, a need for integrated services with multi-professional co-operation including substance use prevention, crime prevention, and mental health prevention is emphasized.
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ACKNOWLEDGEMENTS |
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The Sigrid Juselius Foundation, The Finnish Pediatric Research Foundation and MATINE.
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