Journal of Addiction & Prevention
The Role of Impulsivity, Anger, Verbal Ability, and Abstract Reasoning in Emerging Adults’ Treatment Outcomes
Sarah W. Feldstein Ewing1,2*, Jon M. Houck1, Dustin Truitt1 and Amber D. McEachern3
- 1University of New Mexico Center on Alcoholism, Substance Abuse and Addictions (UNM CASAA), 1 University of New Mexico, MSC11 6280, Albuquerque, NM 87131, USA
- 2University of New Mexico, University Honors College, 1 University of Mexico, MSC06 3890, Albuquerque, NM 87131, USA
- 3The Mind Research Network, 1101 Yale Blvd NE, Albuquerque, NM 87106, USA
*Address for Correspondence: Sarah W. Feldstein Ewing , Ph.D., Assistant Professor, University of New Mexico, University Honors College/UNM CASAA, 1 University of New Mexico, MSC06 3890, Albuquerque, NM 87131, USA, Tel: +1-505-277- 4315; Fax: +1-505-277-4271; E-mail: email@example.com
Citation: Feldstein Ewing SW, Houck JM, Truitt D, McEachern AD. The Role of Impulsivity, Anger, Verbal Ability, and Abstract Reasoning In Emerging Adults’ Treatment Outcomes. J Addiction Prevention. 2013;1(2): 5.
Copyright © 2013 Feldstein Ewing SW, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Addiction & Prevention| ISSN: 2330-2178 | Volume: 1, Issue: 2
Submission: 13 August 2013 | Accepted: 06 September 2013 | Published: 16 September 2013
AbstractMotivational interviewing (MI), a brief, client-centered intervention, has shown promise in reducing problem drinking. However, many questions remain regarding how to improve effectiveness of this intervention. Based on prior work indicating the importance of individual difference factors in response to MI interventions, this study explicitly evaluated the influence of empirically-indicated and theoretically-indicated individual difference factors (i.e., impulsivity, anger, verbal ability, abstract reasoning) in predicting treatment response. The sample included 53 problem drinkers (58.5% female; 54.9% Caucasian; 29.4% Hispanic; M age = 20.02 years). Multiple regression analyses indicated that verbal ability, anger, and impulsivity predicted reductions in quantity of drinking (drinks per drinking day) at the one month follow-up. Specifically, we observed a three-way interaction between verbal ability, anger, and impulsivity, whereby youth with either high or low verbal ability benefitted from treatment, with anger and impulsivity serving as limiting factors. Together, these data highlight the complex relationship between salient and indicated individual difference factors (impulsivity, anger, abstract reasoning, and verbal ability) in terms of treatment outcomes, as well as the relevance of examining these relationships directly with younger samples.
KeywordsAlcohol; Motivational interviewing; Verbal ability; Anger; Impulsivity
IntroductionAcross the lifespan, emerging adults (age 18-25) have the highest rates of hazardous drinking, with as many as 71% using alcohol, 49% engaging in binge drinking (4+ drinks per episode/females, and 5+ drinks per episode/males; , and 31% meeting criteria for alcohol use disorders . While these rates are alarming, they are not a new trend; the rates of hazardous drinking among this age group have maintained historical consistency throughout the past five decades [3,4].
In contrast with older adults’ drinking patterns, emerging adult drinking does not tend to cause harm through consistent, steady rates of excess. Rather, emerging adult problem drinking frequently manifests itself as “dumb drinking” , single occasions of excessive consumption that lead to sadly irrevocable outcomes, such as the accidents, injuries, and fatalities that may result from drinking and driving. Moreover, emerging drinking not only affects the drinker, but often the entire community, resulting in increased levels of property damage, sexual assault, and interpersonal victimization .
Similar to adolescents [e.g., 7], emerging adults do not tend to be treatment-seeking. Rather, despite the prevalence of alcohol use disorders in this age group, few emerging adults receive needed interventions . The rare receipt of treatment persists despite the generally positive outcomes observed for emerging adults across brief interventions, particularly those that permit youths’ ambivalence around changing their behavior (e.g., motivational interviewing; MI; [9,10]). While MI shows promise for this age group, the small (d=0.16) to medium (d=0.67) effect sizes found across MI (e.g., ) indicate the need to explore potential contributing individual difference factors, in order to guide and improve treatment effectiveness.
Salient individual difference factorsSeveral individual difference factors have been linked to risk for problem drinking, as well as treatment response. However, few studies have coordinated examinations of these individual difference factors with emerging adults. To that end, impulsivity (e.g., [12,13]) and anger (e.g., ) have been linked to greater rates of problem drinking and poorer treatment outcomes throughout the broader addictions literature. In the context of MI, emerging adults with lower levels of impulsivity have responded better to MI interventions . In addition, results from Project MATCH indicated that adults high in anger reported better treatment outcomes with MI (more days abstinent and fewer drinks per drinking day) .
In terms of relevant neuropsychological factors, verbal ability and abstract reasoning have also been implicated in treatment response. In general, lower verbal ability has been associated with greater alcohol problems , and difficulties with abstract reasoning have been associated with greater alcohol use . Further, while it has not been previously examined, some suggest that individuals with greater verbal ability may be more likely to respond to talk-based treatments like MI, as they may be better able to access and utilize language to describe their feelings and emotions, as required in MI interventions . Similarly, individuals with greater abstract reasoning skills may respond better to MI, as they may be better able to engage in some of the requisite tasks, including simultaneously considering one’s own behavior and how that behavior fits with one’s goals .
This study sought to build upon and extend previous work by utilizing an integrative approach (behavioral with neuropsychological) to evaluate salient individual difference factors that may modulate response to a psychosocial alcohol intervention (MI). Based on the literature, it was hypothesized that greater levels of impulsivity and anger would be related to poorer MI outcomes (smaller reductions in post-treatment drinking). In addition, we predicted that greater verbal ability and abstract reasoning would result in better MI outcomes (larger reductions in follow-up drinking).
Materials and MethodsParticipants
Following other studies with young drinkers, introductory psychology students were invited to participate in return for class credit . All study procedures were approved by the university institutional review board and conducted with a federal Certificate of Confidentiality. Participants were required to be ages 18 to 25 (e.g., [22,23]), report current binge drinking (≥4 past month binge drinking episodes, defined as ≥4 drinks/occasion for females; ≥5 drinks/occasion for men) , provide written consent, evidence a breath alcohol level of 0 prior to all study components, and meet fMRI safety criteria (for the parent study)(e.g., ). Participants received $60 for participation.
This study was part of a larger investigation (PI: first author). For this component of the evaluation, participants completed a psychosocial and neuropsychological assessment, two MI sessions focused on reducing binge drinking and a behavioral follow-up at one month. All individuals completed the assessment and the first MI session during their first appointment. One week later, all participants completed their second MI session. One month after the second MI, all participants completed their final behavioral follow-up.
At the assessment session, participants completed measures of demographics, alcohol use, and individual difference factors. Past month alcohol use (drinks per drinking day; DDD) was evaluated using the Time Line Follow-Back Interview (TLFB; ) at both the initial assessment and the one-month follow-up. Change scores were calculated by subtracting their initial average DDD reported from the follow-up average DDD, and multiplying that number by -1 (so that higher scores indicated greater drinking reductions). In terms of individual difference factors, we evaluated impulsivity with the Impulsive Sensation Seeking scale (ImpSS; ), a nineteen item, dichotomous self-report measure. Anger was measured using the State-Trait Anger Expression Inventory – 2 Children & Adolescents (STAXI-2 C/A; 27), a thirty-five item self-report measure using a threepoint Likert scale. Finally, to assess our proposed neuropsychological factors, participants were administered vocabulary (verbal ability) and matrix reasoning (abstract reasoning) subtests of the Wechsler Abbreviated Scale of Intelligence (WASI; ).
ResultsThis sample (N = 53; 58.5% female; M age = 20.02, SD = 1.90) was ethnically diverse (54.9% of participants self identified as Caucasian, 29.4% Hispanic, 2.0% African-American, 2.0% Asian, 2.0% Native- American, and 9.8% bi- or multi-racial).
Individual difference factors and treatment response
Two distinct multiple regression analyses were used to examine the contribution of impulsivity, anger, verbal ability, and abstract reasoning in predicting post-treatment changes in drinks per drinking day (DDD). Regression analysis was performed using the PROCESS macro  in SPSS. The results of these regression analyses are presented in Table 1. As expected, scores for verbal ability and abstract reasoning were correlated (r = 0.35, p = 0.015).
In the first regression analysis, post-treatment changes in DDD were regressed on verbal ability, anger, impulsivity, and their interactions. This set of predictors accounted for 46.9% of the variance in post-treatment changes in DDD [F(7,33) = 4.16, p = 0.0022]. In this analysis, impulsivity was predictive of changes in drinking behavior (b = 56.07, SE = 18.36, t(40)= 3.05, p = 0.0044). Neither verbal ability (b = 2.77, t(40) = 1.73, p = 0.12) nor anger (b = 8.79, t(40)= 1.03, p = 0.31) were significant direct predictors of post-treatment changes in DDD. However, the anger × verbal ability × impulsivity interaction was a significant predictor of post-intervention reductions in DDD (F(1,33) = 7.64, R2 change = 0.12, p = 0.009). Among participants with lower verbal ability, those with both low anger and high impulsivity showed greater reductions in drinking than did those with high anger and low impulsivity. Among participants with high verbal ability, those with both high anger and high impulsivity had greaterreductions in drinking than did those with either high anger and low impulsivity or low anger and high impulsivity (see Figure 1 ).
In the second regression analysis, post-intervention changes in DDD were regressed on abstract reasoning, anger, impulsivity, and their interactions. This set of predictors accounted for 42.3% of the variance in post-intervention changes in DDD [F(7,33) = 3.45, p = 0.0069]. In this analysis, neither abstract reasoning (b = -3.69, t(40)= -1.81, p =0.08), nor impulsivity (b = -53.53, t(40) = -1.74, p = 0.09), nor anger (b = -24.79, t(40)= -1.97, p = 0.06) were significant direct predictors of post-intervention changes in DDD, nor was the anger × abstract reasoning ×impulsivity interaction (F1,33 = 3.88, R2 change = 0.07, p = 0.06) predictive of treatment response.
DiscussionThis study offered an opportunity to examine salient individual difference factors and their relationship to young drinkers’ response to a widely-disseminated brief intervention, motivational interviewing (MI) . Examination of individual difference factors is important as it provides an opportunity to evaluate individual-level constructs that may influence not only MI intervention response, but also the persistence of alcohol use behaviors (e.g., ). Based on prior work, we were particularly interested in the potential influence of empirically- and theoretically-indicated individual difference factors (e.g., impulsivity, anger, verbal ability, abstract reasoning), and their relationships with post-treatment changes in alcohol use behavior (drinkers per drinking day). Based on prior work, we hypothesized that greater levels of impulsivity and anger would be related to smaller reductions in drinking [15,16]. And, higher verbal ability and abstract reasoning would result in better MI outcomes (larger reductions in post-treatment drinking) (e.g., [19,20]).
In contrast with predictions, our results were slightly more complicated than anticipated. To that end, we found that verbal ability, anger, and impulsivity predicted better treatment outcomes at the one month follow-up (significant reductions in drinks per drinking day). To that end, youth with both high and low verbal ability benefitted from treatment, with anger and impulsivity serving as limiting factors. In other words, we found that youth who had lower verbal ability, lower anger, and higher impulsivity showed better treatment outcomes in this MI intervention. Similarly, youth with higher verbal ability, higher anger and higher impulsivity performed well in this treatment approach.
These findings are clinically relevant, as despite predictions that high levels of verbal ability might be needed for positive MI treatment outcomes, in this study youth with a range of verbal ability showed positive treatment outcomes (reductions in drinking behavior). This stands in contrast to prior studies, which have suggested that youth might need to have a certain level of verbal development in order to be able to actively participate in an MI session . Our findings indicate that, youth may be able to participate in, and benefit from MI regardless of level of their level of verbal ability. However, it is important to note that other factors, specifically anger and impulsivity, moderated this treatment response.
To that end, while previous work has suggested that individuals high in anger may uniquely respond to the empathic and nonjudgmental approach of MI (e.g., [16,32]), we found that anger did not directly predict post-treatment reductions in drinking. Rather, youth with both lower levels of anger (and low verbal ability/high impulsivity), as well as higher levels of anger (and high verbal ability/ impulsivity) reported greater post-treatment change. This suggests that anger may be a contributing, and slightly more complicated, factor in MI treatment response for young drinkers. These results are in line with other developmental studies in MI [33,34], which have found that factors important in adult MI treatment response do not directly map on to youth treatment response patterns. Further, these developmental studies highlight the importance of explicitly evaluating salient active ingredients in MI with younger populations.
Similarly, while prior studies have indicated that impulsivity may interfere with positive MI treatment outcomes(e.g., ), our study found the opposite; not only did impulsivity directly predict treatment response (in the context of verbal ability), youth with greater impulsivity demonstrated better treatment outcomes in this MI intervention. There may be several reasons for this. First, a number of studies with high-risk youth and emerging adults have found excellent responses with MI (e.g., [35,36,37]). This is clinically relevant, as younger populations tend toward higher levels of impulsivity (e.g., ). Thus, it may be the case that MI provides a context wherein even developmentally-appropriate impulsive individuals can stop and consider their problematic drinking patterns, subsequently resulting in greater than expected reductions in drinking.
In addition, while prior studies have indicated that abstract reasoning skills may help facilitate youths’ ability to engage in, and respond to MI (e.g., ),we found no relationship between level of abstract reasoning and MI treatment response in this young sample. This finding suggests that youths’ ability to contemplate and consider hypothetical ideas, as is requisite in many MI sessions, may not be important to MI response in this age group. It is equally possible that our measure of abstract reasoning may not have been the best instrument to tap into these cognitive skills. Future work in our lab will assess whether alternative measures of abstract reasoning, such as the Ravens , or even measures of theory of mind , may better access this construct and related treatment outcomes with youth.
Ultimately, in terms of clinical implications, this study suggests that the following factors are important to consider when contemplating whether to conduct MI with young drinkers. Across the board, youth responded well to this intervention. Further, this intervention appeared to be a particularly good fit for youth with high levels of impulsivity, all levels of verbal ability (high and low), and all levels of anger (high and low). At this time, our data does not suggest that abstract reasoning should be included in decisions about whether or not to conduct MI with this age group.
This study has several strengths, including utilization of an integrative (behavioral with neuropsychological) measurement approach to evaluate predictors of treatment response in an MI intervention with a diverse sample of young drinkers. However, it is important to consider these findings in light of the following limitations. First, all participants were recruited from a university setting; future work must be done to evaluate outcomes in a community-based sample. Second, the results were detected in a relatively small sample; thus, it will be important to replicate these results with a larger sample. Third, this study relied on behavioral and neuropsychological measures of individual differences. Reexamination with other approaches, such as functional neuroimaging (e.g., fMRI), would strengthen the observed results. Fourth, without a control group, it is not possible at this time to evaluate how much and whether the observed improvements reflect regression to the mean.
Ultimately, our results suggest the promise of MI, as well as the critical and complex contributing role of salient individual difference factors in intervention response. These findings indicate the importance of continuing to apply multi-level and integrative approaches to examine response to MI using multiple methodologies across developmental groups [33,34].
AcknowledgmentsThis study was supported by DE-FG02-08ER64581, PI: Feldstein Ewing. The authors would like to thank Liana Rivera BA, Lindsay Chandler BA, Shirley Smith MS, Tom Chavez MA, and Erin Tooley MS, for their assistance with this study.
- SAMHSA (2006) Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration. Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194.
- Knight KM, Bundy C, Morris R, Higgs JF, Jameson RA, et al. (2003) The effects of group motivational interviewing with externalizing conversations for adolescents with Type-I diabetes. Psychol Health Med 8: 149-157.
- O'Malley PM, Johnston LD (2002) Epidemiology of alcohol and other drug use among American college students. J Stud Alcohol Suppl 14: 23-39.
- Schulenberg JE, Maggs JL (2002) A developmental perspective on alcohol use and heavy drinking during adolescence and the transition to young adulthood. J Stud Alcohol Suppl 14: 54-70.
- 5. Miller WR, Munoz RF (2005) Controlling your drinking. New York, Guilford Press.
- Wechsler H, Lee JE, Nelson TF, Kuo M (2002) Underage college students' drinking behavior, access to alcohol, and the influence of deterrence policies. Findings from the Harvard School of Public Health College Alcohol Study. J Am Coll Health 50: 223-236.
- Chung T, Maisto SA (2006) Relapse to alcohol and other drug use in treated adolescents: Review and reconsideration of relapse as a change point in clinical course. Clin Psychol Rev 26: 149-161.
- Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, et al. (2008) Mental health of college students and their non-college-attending peers: results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiatry 65: 1429-1437.
- Carey KB, Scott-Sheldon LAJ, Carey MP, DeMartini KS (2007) Individual-level interventions to reduce college student drinking: A meta-analytic review. Addict Behav 32: 2469-2494.
- Larimer ME, Cronce JM (2007) Identification, prevention, and treatment revisited: Individual-focused college drinking prevention strategies 1999-2006. Addict Behav 32: 2439-2468.
- Moyer A, Finney JW, Swearingen CE, Vergun P (2002) Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non-treatment seeking populations. Addiction 97: 279-292.
- Camatta CD, Nagoshi CT (1995) Stress, depression, irrational beliefs, and alcohol use and problems in a college student sample. Alcohol Clin Exp Res 19: 142-146.
- MacKillop J, Mattson RE, Anderson MacKillop EJ, Castelda BA, Donovick PJ (2007) Multidimensional assessment of impulsivity in undergraduate hazardous drinkers and controls. J Stud Alcohol Drugs 68: 785-788.
- Ciesla JA, Dickson KS, Anderson NL, Neal DJ (2011) Negative repetitive thought and college drinking: Angry rumination, depression rumination, co-rumination, and worry. Cognitive Therapy and Research 35: 142-50.
- Feldstein Ewing SW, LaChance HA, Bryan AD, Hutchison KE (2009) Do genetic and individual risk factors moderate the efficacy of motivational enhancement therapy? Drinking outcomes with an emerging adult sample. Addict Biol 14: 356-365.
- (1997) Project MATCH secondary a priori hypotheses. Project MATCH Research Group Addiction 92: 1671-1698.
- Latvala A, Tuulio-Henriksson A, Dick DM, Vuoksimaa E, Viken RJ, et al. (2011) Genetic origins of the association between verbal ability and alcohol dependence symptoms in young adulthood. Psychol Med 41: 641-651.
- Cunha PJ, Nicastri S, de Andrade AG, Bolla KI (2010) The frontal assessment battery (FAB) reveals neurocognitive dysfunction in substance-dependent individuals in distinct executive domains: Abstract reasoning, motor programming, and cognitive flexibility. Addict Behav 35: 875-881.
- Feldstein Ewing SW, Filbey FM, Hendershot CS, McEachern AD, Hutchison KE (2011) Proposed model of the neurobiolgocial mechanisms underlying psychosocial alcohol interventions: The example of motivational interviewing . J Stud Alcohol Drugs 72: 903-916.
- Christoff K, Prabhakaran V, Dorfman J, Zhao Z, Kroger JK, et al. (2001) Rostrolateral prefrontal cortex involvement in relational integration during reasoning. Neuroimage 14: 1136-1149.
- Walters ST, Vader AM, Harris TR, Field CA, Jouriles EN (2009) Dismantling motivational interviewing and feedback for college drinkers: A randomized clinical trial. J Consult Clin Psychol 77: 64-73.
- Carey KB, Henson JM, Carey MP, Maisto SA (2007) Which heavy drinking college students benefit from a brief motivational intervention? J Consult Clin Psychol 75: 663-669.
- Carey KB, Carey MP, Maisto SA, Henson JM (2006) Brief motivational interventions for heavy college drinkers: A randomized controlled trial. J Consult Clin Psychol 74: 943-954.
- Filbey FM, Claus E, Audette AR, Niculescu M, Banich MT, et al. (2008) Exposure to the taste of alcohol elicits activation of the mesocorticolimbic neurocircuitry. Neuropsychopharmacol 33: 1391-1401.
- Sobell LC, Sobell MB (1992) Time-line follow-back: A technique for assessing self-reported alcohol consumption. In: Litten RZ, Allen JP, editors. Measuring alcohol consumption, Totowa NJ, Humana Press 41-72.
- Zuckerman M (1994) Behavioral expressions and biosocial biases of sensation seeking. New York, Cambridge University Press.
- Brunner TM, Spielberger CD. State-Trait Anger Expression Inventory - 2, Children and Adolescent (STAXI-2 C/A), Professional Manual. Lutz, FL: Psychological Assessment Resources.
- Wechsler D (1999) Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: The Psychological Corporation.
- Hayes AF (2013) Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York, Guilford Press.
- Zucker RA, Heitzeg MM, Nigg JT (2011) Parsing the undercontrol/disinhibition pathway to substance use disorders: A multilevel developmental problem. Child Development Perspectives 5: 248-255.
- Erickson SJ, Gerstle M, Feldstein SW (2005) Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review. Arch Pediatr Adolesc Med 159: 1173-1180.
- Miller WR, Rollnick S (2002) Motivational interviewing: Preparing people for change (2nd Edition), New York, Guilford Press.
- Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, et al. (2011) Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. J Consult Clin Psychol 79: 433-440.
- Feldstein Ewing SW, McEachern AD, Yezhuvath U, Bryan AD, Hutchison KE, et al.(2013) Integrating brain and behavior: Evaluating adolescents' response to a cannabis intervention. Psychol Addict Behav 27: 510-525.
- Martin G, Copeland J (2008) The adolescent cannabis check-up: Randomized trial of a brief intervention for young cannabis users. J Subst Abuse Treat 34: 407-414.
- Schmiege SJ, Broaddus MR, Levin M, Bryan AD (2009) Randomized trial of group interventions to reduce HIV/STD risk and change theoretical mediators among detained adolescents. J Consult Clin Psychol 77: 38-50.
- McCambridge J, Strang J (2004) The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: Results from a multi-site cluster randomized trial. Addiction 99: 39-52.
- White JL, Moffitt TE, Caspi A, Bartusch DJ, Needles DJ, et al. (1994) Measuring impulsivity and examining its relationship to delinquency. J Abnorm Psychol 103: 192-205.
- Raven J, Raven JC, Court JH (2003) Manual for Raven's Progressive Matrices and Vocabulary Scales. San Antonio, TX: Harcourt Assessment.
- Vetter NC, Weigelt S, Dohnel K, Smolka MN, Kliegel M (2013) Ongoing neural development of affective theory of mind in adolescence. Soc Cogn Affect Neurosci. in press.