Journal of Adolescence 37 (2014) 945e951

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Journal of Adolescence

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Alcohol use among adolescents, aggressive behaviour, andinternalizing problems

Petri Kivim€aki a, *, Virve Kekkonen b, Hannu Valtonen c, Tommi Tolmunen a, b,Kirsi Honkalampi d, Ulrich Tacke a, e, Jukka Hintikka f, g, Soili M. Lehto a, h,Eila Laukkanen a, b

a School of Medicine, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finlandb Department of Adolescent Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finlandc Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finlandd School of Educational Sciences and Psychology, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finlande Department of Addiction Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finlandf School of Medicine, University of Tampere, FI-33014 University of Tampere, Finlandg Department of Psychiatry, P€aij€at-H€ame Central Hospital, Keskussairaalankatu 7, FI-15850 Lahti, Finlandh Department of Psychiatry, Kuopio University Hospital, P.O. Box 1777, FI-70211 Kuopio, Finland

Keywords:AdolescenceAlcohol useAggressive behaviourAUDIT-CASEBA-YSR

* Corresponding author. Tel.: þ358 44 7175106; fE-mail addresses: petri.kivimaki@iki.fi, petri.kivi

http://dx.doi.org/10.1016/j.adolescence.2014.06.0110140-1971/© 2014 The Foundation for Professionals

a b s t r a c t

Alcohol use is common among adolescents, but its association with behavioural andemotional problems is not well understood. This study aimed to investigate how self-reported psychosocial problems were associated with the use of alcohol in a communitysample consisting of 4074 Finnish adolescents aged 13e18 years. Aggressive behaviourassociated with alcohol use and a high level of alcohol consumption, while internalizingproblems did not associate with alcohol use. Having problems in social relationshipsassociated with abstinence and lower alcohol consumption. Tobacco smoking, earlymenarche and attention problems also associated with alcohol use.© 2014 The Foundation for Professionals in Services for Adolescents. Published by Elsevier

Ltd. All rights reserved.

Introduction

Typically, alcohol drinking starts in adolescence, followed by increasing consumption in the early twenties (Chen &Kandel, 1995). The consumption of large quantities of alcohol on a single occasion (binge drinking) is common amongyouths (Miller, Naimi, Brewer, & Jones, 2007). Early adolescent alcohol use is a predictor of alcohol dependence as well asother mental health problems and delinquency. Furthermore, adolescence is a unique developmental period, and it has beenshown that excessive alcohol use may cause abnormalities in brain development, as well as neuropsychological conditionspossibly as a consequence of neural damage (Ezzati, Lopez, Rodgers, & Murray, 2004, chap. 12; Harper & Matsumoto, 2005)and degradation of white matter in the brain (Bühler & Mann, 2011). There appear to be gender-related differences in theseproblems (Giedd, 2004; Medina et al., 2008).

Studies have revealed a comorbidity of alcohol use disorders with mood and disruptive disorders among adolescents(Armstrong & Costello, 2002; Deas & Brown, 2012). A relationship between conduct problems in childhood and alcohol

ax: þ358 17 173 599.maki@uef.fi (P. Kivim€aki).

in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951946

problems in later life has been demonstrated in boys (Niemel€a et al., 2006), with an earlier start and a more rapid increase inconsumption than in controls (McArdle, 2008). In an Australian longitudinal study (N¼ 1590), peer aggression at the age of 14associated with later mental health and substance use problems (Moore et al., 2014). Motives for binge drinking amongadolescents are mainly associated with either positive outcome expectations or the regulation of negative affect (Stolle, Sack,& Thomasius, 2009). Poor coping with negative emotions is associated with harmful drinking habits (Blumenthal, Leen-Feldner, Frala, Badour, & Ham, 2010; Kuntsche, Knibbe, Gmel, & Engels, 2006). According to the self-medication hypothe-sis, adolescents can learn to use alcohol to alleviate their depressive symptoms and social anxiety (Tomlinson& Brown, 2012).Biological factors may also be associated with an early initiation of alcohol use (Kaltiala-Heino, Marttunen, Rantanen, &Rimpel€a, 2003).

Although alcohol use disorder (AUD) has been associated with psychiatric conditions, adolescent alcohol use or problembehaviour does not usually meet the criteria for any disorder (Deas& Brown, 2012). To our best knowledge, only two previousstudies have evaluated the associations between adolescent alcohol use and dimensions of psychiatric symptoms measuredwith the Achenbach System of Empirically Based Assessment: Youth Self-Report for ages 11e18 years (ASEBA-YSR). In anAmerican study on 14- to 17-year-old adolescents (N ¼ 822), externalizing problems increased the likelihood of early alcoholinitiation, and problems in social relationships associated with fewer drinking friends (Kuperman et al., 2013). In a study on11,943 Taiwanese 15- to 18-year-old adolescents, attention and thought problems as well as somatic complaints in ASEBA-YSRassociated with more experience of alcohol use (Chen et al., 2008).

As drinking cultures vary between countries, we aimed to contribute to the previous literature by examining the asso-ciations between ASEBA-YSR scales and alcohol consumption in Finland, where binge drinking is quite common amongadolescents. In Finland, where the present study was conducted, there has been a threefold increase in per capita alcohol useover a 40-year period, themost significant increase being amongwomen. During this period, the level of alcohol consumptionhas increased 5.8-fold in women and 2.2-fold in men. Since 1976, heavy drinking episodes have become increasingly popularamong 15- to 29-year-old Finns, and the popularity of binge drinking is above the European average (M€akel€a, Tigerstedt, &Mustonen, 2012).

Based on the earlier literature, we hypothesised that symptoms of depression and anxiety as well as aggressive behaviourwould associate with increased alcohol consumption. Secondly, we hypothesised that an early onset of puberty and a largenumber of friends would associate with high alcohol consumption. Thirdly, we aimed to examine whether the associationsmentioned above would depend on gender. Our observations were based on a large and representative cross-sectionalsample of Finnish youths (N ¼ 4074) and the analyses were adjusted for various confounding variables.

Material and methods

Participants

For this study we used a dataset that had been collected from cohorts of 13- to 18-year-old pupils from all local schools(excluding schools for pupils with impaired cognitive skills) in Kuopio, a city in Eastern Finland with approximately 95,000inhabitants. The data were collected with structured self-report questionnaires, which were handed out in comprehensive,upper secondary and vocational schools. For pupils under 15 years of age, written consent was obtained from one of theirparents. Ethical approval was received from the Research Ethics Committee of Kuopio University Hospital and the Universityof Kuopio (now the University of Eastern Finland).

A total of 6421 adolescents met the inclusion criteria for the study. Among the 13- to 15-year-olds,1031 did not participate,and 666 of these did not receive consent from their parents. Among the 16- to 18-year-olds, a total of 1851 did not participatefor unknown reasons. As a result, 4214 (65.6%) adolescents participated in the study, although 140 of these had to be excludeddue to invalid data, leading to a final sample of 4074 participants (53% female). The types of school were comprehensiveschool for 1840, upper secondary school for 1474 and vocational school for 900 participants.

Alcohol use and tobacco smokingThe Alcohol Use Disorders Identification Test (AUDIT) is a structured questionnaire originally designed by the World

Health Organization for assessing adult alcohol use (Saunders, Aasland, Babor, la Fuente, & Grant, 1993). The instrument hasalso been tested in young people and its validity for detecting heavy alcohol use has been demonstrated. For 14- to 18-year-old adolescents (N ¼ 538) visiting medical clinics, a cut-off score of 2 for the complete 10-question AUDIT with maximumscore of 40 was optimal for identifying problematic alcohol use, and 3 for identifying alcohol use disorder (AUD), diagnosedaccording to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (Knight, Sherritt, Harris, Gates, & Chang,2003).

In this study we used a shortened version of AUDIT, AUDIT-C (items 1e3; range 0e12), which only includes the questionson the level of consumption (“How often do you have a drink containing alcohol?”, “Howmany drinks containing alcohol doyou have on a typical day when you are drinking?” and “How often do you have six or more drinks on one occasion?”) (Bush,Kivlahan, McDonell, Fihn, & Bradley, 1998). According to Kelly, Donovan, Chung, Bukstein, and Cornelius (2009), AUDIT-Cperforms well in screening 18- to 20-year-old adults for AUD with a cut-off point of 6 for males (77% sensitivity; 68%specificity) and 5 for females (77% sensitivity; 78% specificity). We screened current tobacco smoking by asking how often theparticipants smoked tobacco (“daily”, “occasionally” or “never”).

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951 947

Psychosocial problemsSocial competence, adaptive functioning and psychosocial problems were assessed with the ASEBA-YSR, which is an in-

strument examining multiple aspects of adolescent behaviour and well-being (Achenbach & Rescorla, 2001). The ques-tionnaire consists of basic demographic questions and 20 competence items concerning participation in various activities,social relationships and schoolwork. The ASEBA-YSR has a total of 112 items measuring symptoms: internalizing problems(anxious/depressed, withdrawn/depressed, somatic complaints; 32 items), externalizing problems (rule-breaking behaviour,aggressive behaviour; 30 items), social problems (8 items), thought problems (7 items) and attention problems (9 items). Inthis study sample, Cronbach's a for the ASEBA-YSR scales was 0.82 for anxious/depressed, 0.71 for withdrawn/depressed, 0.83for aggressive behaviour, 0.70 for rule-breaking behaviour, 0.77 for somatic complaints, 0.70 for social problems, 0.76 forthought problems and 0.70 for attention problems.

One of the two externalizing problems subscales of the ASEBA-YSR (rule-breaking behaviour with 11 items) contains aquestion about substance use and therefore overlapped with AUDIT-C. Since regression analysis was applied, only the 19-itemaggressive behaviour subscale was used for statistical analysis.

Number of friends, parental marital status and onset of pubertyQuestions concerning the number of close friends and the marital status of the parents are included in the ASEBA-YSR

(Achenbach & Rescorla, 2001). The number of friends was elicited by asking “How many close friends do you have?” Fourresponse options were provided: “no friends”, “one friend”, “two to three friends” and “four friends or more”. Regarding themarital status of the parents, responses could be chosen from four options: “married”, “living with a partner”, “divorced” and“other”. Parental divorce was then recoded into a single dichotomous variable with values “divorced” or “not divorced”. Theonset of puberty was estimated to the nearest month according to the self-reported time of menarche in girls and the firstnocturnal emission in boys. Similar questions have been used in Finnish school health surveys and previous studies (Kaltiala-Heino et al., 2003).

Statistical analysis

Gender-related differences in age, the AUDIT-C score and ASEBA-YSR scales were assessed with the ManneWhitney U-testdue to the non-normal distributions. The onset of puberty was normally distributed and the differences were thereforeassessed with the Student's t-test.

In the regressionmodels, explanatory variables for theAUDIT-C scorewere theASEBA-YSR scores (i.e., aggressive behaviour,social problems, thought problems, attention problems and internalizing problems), age, type of school, the number of closefriends, smoking, parental divorce and timing of the onset of puberty. Tobacco smoking was recoded into a dichotomousvariable. The interactions between gender and other explanatory variables in explaining AUDIT-C were tested with level andslope dummy variables. There were statistically significant interactions with gender in both alcohol use (Wald test, p¼ 0.037)and the level of alcohol consumption (Wald test, p< 0.001). Being dependent on gender, themodelswere estimated separatelyfor females and males. The question concerning the onset of puberty was answered by 90% of females but only 46% of males.

The AUDIT-C responses were viewed as count datawith a skewed distribution. The Poisson distributionwould have been anatural choice for count data, but as the variance of the AUDIT-C scores was not equal to the mean (likelihood ratio test forover-dispersion, a ¼ 0: males p ¼ 0.072, females p ¼ 0.497), we used negative binomial regression models. Because a largeproportion (38.2%) of the study subjects did not drink alcohol, resulting in a large number of zero AUDIT-C scores, zero-inflated negative binomial (ZINB) regression models were chosen for the statistical analysis (Cameron & Trivedi, 2009). Asverification for the performance of the modelling, the abstinence parts of ZINB models were compared with logisticregression models and the level of consumption parts were compared with ordinary least squares (OLS) regression models.

As AUDIT-C had not been validated among the 13- to 17-year-olds, we aimed to test whether a single model could be usedfor the whole age span. Therefore, participants were divided into two age groups: the young teenage group of 13- to 15-year-old participants and the old teenage group of 16- to 18-year-old participants. Intercept and slope dummy variables were thenincluded in regression models to test the interaction between age and other explanatory variables. There were small butstatistically significant interactions between age and other covariates in the model for the level of male alcohol consumption.In other words, the association of alcohol use and age was non-linear, and to adjust the regression models for this, we addedan age2 variable to the models.

Multicollinearity was assessed by calculating the variance inflation factor (VIF) for each of the explanatory variables. Allthe VIF values were 3 or less which rules out multicollinearity. Misspecification was tested with the Ramsey RegressionEquation Specification Error Test (RESET) and no specification problems were found. The OLS model was tested for hetero-skedasticity with the Breusch-Pagan/CookeWeisberg test, and no heteroskedasticity was found. The estimated standarderrors were robust for heteroskedasticity. Vuong's closeness test verified that ZINB should be preferred over a negativebinomial distribution (males p < 0.001, females p < 0.001). With respect to the statistical significance and the sign of thecoefficients, the results from technically different logistic and OLS regression models were qualitatively the same for most ofthe variables. Thus, the results did not depend on the chosen statistical method.

Finally, the coefficients of the ZINB model (b) were expressed as odds ratios (OR) for any alcohol use (for the abstinencepart, OR ¼ e�b) and as incidence rate ratios (IRR), expressing the impact of a one-unit increase in cofactors (while othervariables remain constant) on the AUDIT-C score (for the level of consumption part, IRR ¼ eb; please see examples in Table 3).

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951948

P-values below 0.05 were interpreted as statistically significant. The software packages used for data analysis were SPSS(version 19) and STATA (version 11).

Results

Alcohol and tobacco use, psychosocial problems, parental divorce and the number of close friends

Alcohol use was high (Table 1). In the age cohorts of 17- and 18-year-old, males had higher AUDIT-C scores than fe-males, but there were otherwise no gender-related differences in alcohol consumption. Female adolescents had a greaterfrequency of self-reported internalizing and externalizing problems, as well as problems in attention, thinking and socialrelationships measured with the ASEBA-YSR (Table 2). Among females, occasional tobacco smoking was more commonthan among males, but no difference between genders was found in daily tobacco smoking. Female adolescents reportedtwo or three close friends more often than males, while male adolescents reported four or more close friends more oftenthan females.

Factors associated with alcohol use

Alcohol use and high alcohol consumption both associated with aggressive behaviour and tobacco smoking (Table 3).Abstinence from alcohol and low alcohol consumption both associated with problems in social relationships. Attentionproblems associated with alcohol use, but not with alcohol consumption. The level of alcohol consumption positivelyassociated with the number of close friends. There also were some gender-related differences in the models. Among females,an early onset of puberty and parental divorce were associated with an increased probability of alcohol use.

The models were also adjusted for age and the type of school. As age moderated the associations between alcohol con-sumption and some of the covariates in men, the models were also adjusted for the non-linear effect of age with the variableage2. Among older males, the negative association between the AUDIT-C score and problems in social relationships, as well asthe association between the AUDIT-C score and the number of close friends, were stronger and steeper than among youngermale adolescents. The association between the AUDIT-C score and smoking was stronger and steeper among the youngermales than the older male adolescents.

Discussion

Main findings

In this community sample of 13- to 18-year-old Finnish adolescents, aggressive behaviour, but not internalizing problems,associated with alcohol use and the level of alcohol consumption. Smoking associated with both alcohol use and the level ofalcohol consumption. A lack of problems in social relationships and a higher number of friends associated with drinkingamong the 13- to 18-year-olds.

Comparison with the existing literature

The association between aggressive behaviour and alcohol consumption is likely to be bi-directional. Unfortunately, wecould not distinguish the direction of causation in our cross-sectional study setting. This association may be pronounced inadolescence due to brain development. Brain areas responsible for impulse control are under development, and alcohol usemay be a distinct risk factor for adolescent aggressive behaviour (Stephens& Duka, 2008). Contrary to the previous literature,girls reportedmore aggressive behaviour than boys in our study (Rescorla et al., 2012). This is a novel finding that has not been

Table 1Alcohol use measured by the AUDIT-C score in a Finnish sample of 13- to 18-year-old male and female adolescents. AUDIT-C ¼ 0 indicates no alcohol use.

Age Male (N ¼ 1938) Female (N ¼ 2229) Differencebetweengenders (Z)b

AUDIT-C ¼ 0 AUDIT-C > 0 AUDIT-C ¼ 0 AUDIT-C > 0

N (%) N (%) Median (Q1eQ3)a N (%) N (%) Median (Q1eQ3)a

13 192 (81%) 44 (19%) 1 (1e2) 210 (79%) 55 (21%) 2 (1e3) �0.7514 165 (67%) 83 (33%) 2 (1e6) 174 (61%) 111 (39%) 4 (1e5) �1.2815 190 (43%) 248 (57%) 4 (1e6) 197 (40%) 297 (60%) 4 (2e5) �0.8216 136 (30%) 318 (70%) 5 (3e7) 127 (25%) 374 (75%) 4 (3e6) �1.6617 75 (21%) 277 (79%) 6 (4e8) 82 (19%) 343 (81%) 4 (3e6) �3.83***18 23 (11%) 187 (89%) 6 (4e8) 29 (11%) 230 (89%) 5 (3e6) �4.39***Total 781 (40%) 1157 (60%) 5 (2e7) 819 (37%) 1410 (63%) 4 (2e6) �1.54

*p < 0.05, **p < 0.01, ***p < 0.001.a The first quartile (Q1) and third quartile (Q3) are equal to the 25th and 75th percentiles, respectively.b The ManneWhitney U-test (Z) was used to test whether the distributions of the AUDIT-C scores differ between genders.

Table 2Descriptive statistics for age, onset of puberty, symptoms of psychosocial problems measured with the Youth Self-Report questionnaire, smoking andnumber of friends in a Finnish sample of 13- to 18-year-old adolescents.

Male (N ¼ 1897) Female (N ¼ 2177) Differencebetweengenders (Z/t)

Median (Q1eQ2)/Mean(SD)/Proportion

Median (Q1eQ2)/Mean(SD)/Proportion

Agea 16 (15e17) 16 (15e17) �0.82Onset of pubertyb 12.8 (1.5) 12.4 (1.1) 8.14***Youth Self-Report- Internalizing problemsa 5 (3e10) 11 (6e17) �22.95***- Aggressive behavioura 6 (3e9) 7 (5e11) �10.66***- Social problemsa 2 (1e3) 2 (1e3) �6.15***- Thought problemsa 1 (0e2) 2 (0e3) �10.00***- Attention problemsa 4 (2e6) 6 (4e7.75) �14.25***Number of friends- No close friends (%)c 0.4 0.6 �1.02- One close friend (%)c 6.8 7.9 �1.31- Two or three (%)c 32.9 45.9 �8.20***- Four or more (%)c 58.0 44.7 �8.88***Smoking- No smoking (%)c 71.3 66.5 �3.91***- Occasional smoking (%)c 10.9 15.6 �4.20***- Daily smoking (%)c 15.0 16.2 �0.93Divorced parents (%)c 24.2 28.8 �2.97**

a Showing median, first quartile (Q1), second quartile (Q2) and differences between genders assessed with the ManneWhitney U-test (Z).b Showing mean, standard deviation (SD) and differences between genders assessed with the Student's t-test (t).c Showing proportions and differences between genders assessed with the ManneWhitney U-test (Z).

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951 949

reported earlier, and may reflect some new trend in behaviour among girls in a similar way to their increasing level of alcoholconsumption.

For thosewith problems in social relationships, alcohol may be harder to obtain. Selling alcohol to, or possessing alcohol asindividuals under 18 years of age is illegal in Finland. One possible explanation for the relationship between alcohol con-sumption and the number of friends could be that people with more friends are more likely to have friends who drink. Olderfriends may supply alcohol to their younger peers.

In this study, alcohol use was slightly less common than in previous national surveys (Kinnunen et al., 2013, chap. 4), butthe level of alcohol consumption was high. Median AUDIT-C scores for the age cohorts of 14 years old and older were 4 orabove, and as a matter of fact, any alcohol use between the ages of 12 and 15 years can be a signal of alcohol-related problems(Chung et al., 2012). No association was found between alcohol use and internalizing problems. Consequently, our results did

Table 3A zero-inflated negative binomial regression model (ZINB) explaining alcohol use (AUDIT-C > 0) and the level of alcohol consumption (AUDIT-C score) in aFinnish sample of 13- to 18-year-old male and female adolescents.

Odds ratios for any alcohol use, the inflatepart of the model

Incidence rate ratioa for a change in AUDIT-C score,the negative binomial part of the model

Male (N ¼ 1773) Female (N ¼ 1929) Male (N ¼ 1773) Female (N ¼ 1929)

OR 95% CI OR 95% CI IRR 95% CI IRR 95% CI

Ageb 6.59 1.06e41.14***, c 8.19 1.21e55.49**, c 4.98 2.67e9.26***, c 1.61 0.94e2.75***, c

Age2b 0.96 0.91e1.02 0.95 0.89e1.01 0.96 0.94e0.97*** 0.99 0.97e1.00Internalizing problems 1.00 0.97e1.03 1.02 0.99e1.04 1.00 0.99e1.01 1.00 1.00e1.01Aggressive behaviour 1.09 1.05e1.13*** 1.11 1.06e1.16*** 1.03 1.02e1.04*** 1.02 1.01e1.02***Problems in social relationships 0.75 0.68e0.83*** 0.75 0.68e0.83*** 0.93 0.91e0.96*** 0.95 0.93e0.97***Thought problems 1.06 0.98e1.15 1.04 0.97e1.12 1.02 1.00e1.03 0.99 0.98e1.01Attention problems 1.08 1.00e1.16* 1.09 1.01e1.18* 1.00 0.99e1.02 1.01 1.00e1.03Number of close friends 1.15 0.94e1.40 1.33 1.08e1.64** 1.15 1.09e1.21*** 1.07 1.02e1.12**Smoking 7.70 5.07e11.71*** 8.49 5.48ee13.14*** 1.40 1.32e1.49*** 1.60 1.51e1.70***Divorced parents 1.29 0.96e1.73 1.93 1.40e2.65*** 1.02 0.96e1.09 1.07 1.01e1.13*Age at puberty onset 0.80 0.70e0.90*** 1.01 0.99e1.04Upper secondary school 1.11 0.73e1.68 1.65 1.07e2.55* 1.26 1.12e1.41*** 1.06 0.95e1.19Vocational school 0.89 0.57e1.38 1.97 1.17e3.32* 1.25 1.11e1.40*** 1.24 1.11e1.39***

*p < 0.05, **p < 0.01, ***p < 0.001.a For binary variables, e.g. the boys who smoke have an AUDIT-C score 1.22 points higher than those who do not, when all other variables in the model

remain constant. For continuous variables, e.g. when problems in social relationships increase by one unit, the expected value of AUDIT-C is multiplied by0.94, which equals a 6% decrease.

b Due to the non-linear association of age and AUDIT-C scores, the model is adjusted for both Age and Age2 variables.c Significance is the joint significance of the variables Age and Age2.

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951950

not support the hypothesis of self-medicationwith alcohol, whichmay not occur until an older age is reached. Tomlinson andBrown (2012) speculated in their study that individuals with social anxiety may develop alcohol-related problems if theylearn to use alcohol as a social lubricant.

In girls, the association of alcohol use with the parents being divorced and the onset of puberty may be mediated byvarious factors such as a dysfunctional family, conflicts in the family, a lack of parental support, parental alcohol problems, andfinancial and psychosocial stressors in general. Moreover, early-maturing adolescents face additional psychosocial stress dueto the adult role models and peer feedback. Parental divorce and early maturation may both involve interpersonal psycho-logical stressors, which have amore adverse impact onwell-being in girls than boys (Oldehinkel& Bouma, 2011). On the otherhand, in the study of Niemel€a et al. (2006), teachers in Finland reported that drunkenness in older teenage boys associatedwith a non-intact family and externalising problems in childhood.

Strengths and limitations

This study had a large sample and a high participation rate, considering that the participants were teenagers. The samplecovered over 65% of the age groups from 13 to 18 years in the Kuopio area. Moreover, the questionnaire mainly utilized well-validated measures, and the observations were confirmed through multiple statistical approaches.

There were also some limitations in this study. First, the cross-sectional study setting did not allow the examination ofcausality or trajectories for alcohol use. Second, no data other than marital status was collected concerning the researchsubjects' families, although the number of older siblings, the home neighbourhood and the parenting style, mental health,alcohol use and income of the parents could also have affected the alcohol use of their offspring. Third, adolescent self-reportquestionnaires were used, which may have caused method bias in the results. Using a personal interview would haveimproved the precision of our observations regarding alcohol use. Fourth, AUDITand AUDIT-Cwere not designed for assessingalcohol consumption specifically among adolescents, and AUDIT-C has not been validated among 13- to 18-year-olds. Thevalidity of the puberty onset question is also unknown, although it is used in school surveys in Finland and has been used inother questionnaire based studies (Kaltiala-Heino et al., 2003; Kaltiala-Heino, Koivisto, Marttunen, & Fr€ojd, 2011). A moreaccurate assessment of pubertal status could only have been obtained by examining past school health care registers. Fifth,among the male subjects, there was a low response rate for the pubertal onset question.

Conclusions

Aggressive behaviour, smoking and social relationships associated with both alcohol use and the level of alcohol con-sumption in this study. However, alcohol use among adolescents did not associate with internalizing problems. Many un-derage adolescents use alcohol and some of themuse it very heavily. Interventions targeted at alcohol use should start early aspart of the school health care system, involving both teenagers and their parents.

Acknowledgements

The authors report no conflicts of interest.All authors have contributed to and approved the final manuscript.Petri Kivim€aki was supported by Kuopio University Hospital EVO funding (Research ID 5702804).Roy Siddall revised the language of the article.

References

Achenbach, T., & Rescorla, L. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermount, Research Center for Children,Youth & Families.

Armstrong, T. D., & Costello, E. J. (2002). Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Journal ofConsulting and Clinical Psychology, 70(6), 1224e1239. http://dx.doi.org/10.1037/0022-006X.70.6.1224.

Blumenthal, H., Leen-Feldner, E. W., Frala, J. L., Badour, C. L., & Ham, L. S. (2010). Social anxiety and motives for alcohol use among adolescents. Psychology ofAddictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 24(3), 529e534. http://dx.doi.org/10.1037/a0019794.

Bühler, M., & Mann, K. (2011). Alcohol and the human brain: a systematic review of different neuroimaging methods. Alcoholism, Clinical and ExperimentalResearch, 35(10), 1771e1793. http://dx.doi.org/10.1111/j.1530-0277.2011.01540.x.

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective briefscreening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives ofInternal Medicine, 158(16), 1789e1795.

Cameron, A. C., & Trivedi, P. K. (2009). Microeconometrics using Stata. Stata Press.Chen, K., & Kandel, D. B. (1995). The natural history of drug use from adolescence to the mid-thirties in a general population sample. American Journal of

Public Health, 85(1), 41e47.Chen, C.-Y., Storr, C. L., Tang, G.-M., Huang, S.-L., Hsiao, C. K., & Chen, W. J. (2008). Early alcohol experiences and adolescent mental health: a population-

based study in Taiwan. Drug and Alcohol Dependence, 95(3), 209e218. http://dx.doi.org/10.1016/j.drugalcdep.2008.01.018.Chung, T., Smith, G. T., Donovan, J. E., Windle, M., Faden, V. B., Chen, C. M., et al. (2012). Drinking frequency as a brief screen for adolescent alcohol problems.

Pediatrics, 129(2), 205e212. http://dx.doi.org/10.1542/peds.2011-1828.Deas, D., & Brown, E. S. (2012). Adolescent substance abuse and psychiatric comorbidities. The Journal of Clinical Psychiatry, 67(7), e02.Ezzati, M., Lopez, A. D., Rodgers, A., & Murray, C. J. L. (2004). Comparative quantification of health risks: Global and regional burden of disease attributable to

selected major risk factors (Vol. 1). Geneva: World Health Organization.

P. Kivim€aki et al. / Journal of Adolescence 37 (2014) 945e951 951

Giedd, J. N. (2004). Structural magnetic resonance imaging of the adolescent brain. Annals of the New York Academy of Sciences, 1021, 77e85. http://dx.doi.org/10.1196/annals.1308.009.

Harper, C., & Matsumoto, I. (2005). Ethanol and brain damage. Current Opinion in Pharmacology, 5(1), 73e78. http://dx.doi.org/10.1016/j.coph.2004.06.011.Kaltiala-Heino, R., Koivisto, A.-M., Marttunen, M., & Fr€ojd, S. (2011). Pubertal timing and substance use in middle adolescence: a 2-year follow-up study.

Journal of Youth and Adolescence, 40(10), 1288e1301. http://dx.doi.org/10.1007/s10964-011-9667-1.Kaltiala-Heino, R., Marttunen, M., Rantanen, P., & Rimpel€a, M. (2003). Early puberty is associated with mental health problems in middle adolescence. Social

Science & Medicine, 57(6), 1055e1064.Kelly, T. M., Donovan, J. E., Chung, T., Bukstein, O. G., & Cornelius, J. R. (2009). Brief screens for detecting alcohol use disorder among 18-20 year old young

adults in emergency departments: comparing AUDIT-C, CRAFFT, RAPS4-QF, FAST, RUFT-Cut, and DSM-IV 2-Item Scale. Addictive Behaviors, 34(8),668e674. http://dx.doi.org/10.1016/j.addbeh.2009.03.038.

Kinnunen, J. M., Lindfors, P., Pere, L., Ollila, H., Samposalo, H., & Rimpel€a, A. (2013). Nuorten terveystapatutkimus 2013. Helsinki: Sosiaali- ja terveysministeri€o.Knight, J. R., Sherritt, L., Harris, S. K., Gates, E. C., & Chang, G. (2003). Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT,

POSIT, CAGE, and CRAFFT. Alcoholism, Clinical and Experimental Research, 27(1), 67e73. http://dx.doi.org/10.1097/01.ALC.0000046598.59317.3A.Kuntsche, E., Knibbe, R., Gmel, G., & Engels, R. (2006). Who drinks and why? A review of socio-demographic, personality, and contextual issues behind the

drinking motives in young people. Addictive Behaviors, 31(10), 1844e1857. http://dx.doi.org/10.1016/j.addbeh.2005.12.028.Kuperman, S., Chan, G., Kramer, J. R., Wetherill, L., Bucholz, K. K., Dick, D., et al. (2013). A model to determine the likely age of an Adolescent's first drink of

alcohol. Pediatrics, 131(2), 242e248. http://dx.doi.org/10.1542/peds.2012-0880.M€akel€a, P., Tigerstedt, C., & Mustonen, H. (2012). The Finnish drinking culture: change and continuity in the past 40 years. Drug and Alcohol Review, 31(7),

831e840. http://dx.doi.org/10.1111/j.1465-3362.2012.00479.x.McArdle, P. (2008). Alcohol abuse in adolescents. Archives of Disease in Childhood, 93(6), 524e527. http://dx.doi.org/10.1136/adc.2007.115840.Medina, K. L., McQueeny, T., Nagel, B. J., Hanson, K. L., Schweinsburg, A. D., & Tapert, S. F. (2008). Prefrontal cortex volumes in adolescents with alcohol use

disorders: unique gender effects. Alcoholism, Clinical and Experimental Research, 32(3), 386e394. http://dx.doi.org/10.1111/j.1530-0277.2007.00602.x.Miller, J. W., Naimi, T. S., Brewer, R. D., & Jones, S. E. (2007). Binge drinking and associated health risk behaviors among high school students. Pediatrics,

119(1), 76e85. http://dx.doi.org/10.1542/peds.2006-1517.Moore, S. E., Norman, R. E., Sly, P. D., Whitehouse, A. J. O., Zubrick, S. R., & Scott, J. (2014). Adolescent peer aggression and its association with mental health

and substance use in an Australian cohort. Journal of Adolescence, 37(1), 11e21. http://dx.doi.org/10.1016/j.adolescence.2013.10.006.Niemel€a, S., Sourander, A., Poikolainen, K., Helenius, H., Sillanm€aki, L., Parkkola, K., et al. (2006). Childhood predictors of drunkenness in late adolescence

among males: a 10-year population-based follow-up study. Addiction, 101(4), 512e521. http://dx.doi.org/10.1111/j.1360-0443.2006.01381.x.Oldehinkel, A. J., & Bouma, E. M. C. (2011). Sensitivity to the depressogenic effect of stress and HPA-axis reactivity in adolescence: a review of gender

differences. Neuroscience and Biobehavioral Reviews, 35(8), 1757e1770. http://dx.doi.org/10.1016/j.neubiorev.2010.10.013.Rescorla, L., Ivanova, M. Y., Achenbach, T. M., Begovac, I., Chahed, M., Drugli, M. B., et al. (2012). International epidemiology of child and

adolescent psychopathology ii: integration and applications of dimensional findings from 44 societies. Journal of the American Academy ofChild and Adolescent Psychiatry, 51(12), 1273e1283.e8. http://dx.doi.org/10.1016/j.jaac.2012.09.012. http://www.ncbi.nlm.nih.gov/pubmed/?term¼InternationalþEpidemiologyþofþChildþandþAdolescentþPsychopathologyþII%3AþIntegrationþandþApplicationsþofþDimensionalþFindingsþFromþ44þSocieties.

Saunders, J. B., Aasland, O. G., Babor, T. F., la Fuente, de, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHOcollaborative project on early detection of persons with harmful alcohol consumptioneII. Addiction, 88(6), 791e804.

Stephens, D. N., & Duka, T. (2008). Cognitive and emotional consequences of binge drinking: role of amygdala and prefrontal cortex. Philosophical Trans-actions of the Royal Society of London. Series B, Biological Sciences, 363(1507), 3169e3179. http://dx.doi.org/10.1098/rstb.2008.0097.

Stolle, M., Sack, P.-M., & Thomasius, R. (2009). Binge drinking in childhood and adolescence: epidemiology, consequences, and interventions. Deutsches€Arzteblatt International, 106(19), 323e328. http://dx.doi.org/10.3238/arztebl.2009.0323.

Tomlinson, K. L., & Brown, S. A. (2012). Self-medication or social learning? A comparison of models to predict early adolescent drinking. Addictive Behaviors,37(2), 179e186. http://dx.doi.org/10.1016/j.addbeh.2011.09.016.