Distress Tolerance as a Mechanism Linking Violence Exposure to Problematic Alcohol use in Adolescence

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Research on Child and Adolescent Psychopathology

https://doi.org/10.1007/s10802-021-00805-0

Distress Tolerance asaMechanism Linking Violence Exposure

toProblematic Alcohol use inAdolescence

CharlotteHeleniak

· ChinaR.Bolden

· ConnorJ.McCabe

· HilaryK.Lambert

· MayaL.Rosen

· KevinM.King

·

KathrynC.Monahan

· KatieA.McLaughlin

Accepted: 7 March 2021

Abstract

Adolescents exposed to violence are at elevated risk of developing most forms of psychopathology, including depression,

anxiety, and alcohol abuse. Prior research has identiﬁed emotional reactivity and diﬃculties with emotion regulation as core

mechanisms linking violence exposure with psychopathology. Scant research has examined behavioral responses to distress as

a mechanism in this association. This study examined the association of violence exposure with distress tolerance—the ability

to persist in the face of distress—and whether lower distress tolerance linked violence exposure with subsequent increases

in depression, anxiety, and alcohol abuse problems during adolescence. Data were collected prospectively in a sample of

287 adolescents aged 16–17 (44.3% male; 40.8% White). At Time 1, participants provided self-report of demographics, vio-

lence exposure, and psychopathology, and completed a behavioral measure of distress tolerance, the Paced Auditory Serial

AdditionTask. Four months later, participants (n = 237) repeated the psychopathology assessments. Violence exposure was

associated with lower distress tolerance (β = -.21 p = .009), and elevated concurrent psychopathology (β = .16-.45, p = .001-

.004). Low distress tolerance was prospectively associated with greater likelihood of abusing alcohol over time (OR = .63,

p = .021), and mediated the association between violence exposure and greater levels (β = .02, 95% CI [.001, .063]) and

likelihood (OR = .03, 95% CI [.006, .065]) of alcohol use over time. In contrast, low distress tolerance was not associated

concurrently or prospectively with internalizing symptoms. Results persisted after controlling forsocio-economic status.

Findings suggest that distress tolerance is shaped by early experiences of threat and plays a role in the association between

violence exposure and development of problematic alcohol use in adolescence.

Keywords Violence· Adversity· Distress tolerance· Alcohol· Internalizing· Adolescence

Exposure to interpersonal violence is common in children

and adolescents, with some estimates suggesting that nearly

half of U.S. adolescents have directly witnessed or been the

victim of violent assault in their lifetimes (Finkelhor etal.,

2013). These rates are concerning because exposure to inter-

personal violence in childhood is a potent risk factor for

many commonly occurring mental health problems, includ-

ing depression, anxiety, and alcohol abuse (Kessler etal.,

2005; Keyes etal., 2012; Klitzman & Freudenberg, 2003;

McLaughlin etal., 2012; Molnar etal., 2001; Ward etal.,

2001). Disruptions in emotional processing and emotion

regulation have frequently been posited to be a key mecha-

nism underlying the association between violence exposure

and psychopathology (McLaughlin, 2016; McLaughlin &

Lambert, 2017). Here, we examine whether reductions in

distress tolerance—the ability to persist in the face of emo-

tional distress or frustration (Daughters etal., 2009)-explains

the association between violence exposure and symptoms

of alcohol abuse, depression, and anxiety in adolescence.

Adverse childhood experiences, defined as circum-

stances that deviate from the expectable environment and

* Charlotte Heleniak

[email protected]

Department ofPsychology, Columbia University, 1190

Amsterdam Ave, NewYork, NY10027, USA

School ofPsychology, Family, andCommunity, Seattle

Paciﬁc University, Seattle, Washington, USA

Department ofPsychology, University ofWashington,

Guthrie Hall (GTH), Seattle, WA119A98195-1525, USA

Department ofPsychology, University ofPittsburgh,

Pittsburgh, PA15260, USA

Department ofPsychology, Harvard University, 33 Kirkland

St, Cambridge, MA02138, USA

Research on Child and Adolescent Psychopathology

1 3

that require signiﬁcant psychological, social, or neuro-

biological adaptation, are associated with increased risk

for virtually all forms of psychopathology (McLaughlin,

2016). Recent conceptual models suggest the need to

distinguish between experiences of threat that involve

harm or threat of harm (i.e., exposure to violence, physi-

cal abuse) and experiences of deprivation that involve an

absence of expected social and cognitive inputs from the

environment (i.e., neglect, institutional rearing) when

studying their downstream consequences on developmen-

tal outcomes (McLaughlin & Sheridan, 2016; McLaughlin

etal., 2014). Here, we focus on environmental experiences

that share the common feature of being a potential threat to

the child’s safety, including physical abuse, sexual abuse,

and violence exposure in the community.

Experiences of threat are likely to have strong inﬂu-

ences on emotional processing across development, lead-

ing to lasting changes in emotional reactivity and the

ability to modulate responses to negative emotion. Spe-

ciﬁcally, evidence from behavioral and neuroimaging stud-

ies suggest that childhood violence exposure is associ-

ated with increased emotional reactivity as measured by

self-report both concurrently (Heleniak etal., 2017) and

longitudinally (Heleniak etal., 2015), and in neuroimag-

ing measures of amygdala response to negative emotional

stimuli (McCrory etal., 2011, 2013; McLaughlin etal.,

2015). Heightened emotional responses to potential threats

likely represent a positive adaptation to living in a danger-

ous environment, as they facilitate early identiﬁcation of

threat and may promote safety-seeking behavior. In addi-

tion to heightened emotional reactivity, children who have

experienced violence also experience diﬃculty modulat-

ing emotional reactions and disengaging from negative

stimuli. This has been demonstrated for multiple forms of

emotion regulation, including engagement in rumination—

a strategy that is strongly linked to persistent distress and

risk for psychopathology (Nolen-Hoeksema etal., 2008),

adaptation to emotional conﬂict—an implicit form of emo-

tion regulation that has been consistently linked to risk for

psychopathology (Etkin & Schatzberg, 2011; Etkin etal.,

2006; Gyurak etal., 2011), and cognitive reappraisal—

an explicit or eﬀortful form of emotion regulation with

strong associations with psychopathology (Ochsner &

Gross, 2005). Children with histories of exposure to vio-

lence demonstrate higher levels of rumination (Heleniak

etal., 2015, 2017), diﬃculty adapting to emotional conﬂict

(Lambert etal., 2017; Marusak etal., 2015), and exhibit

greater recruitment of the prefrontal cortex (PFC) during

cognitive reappraisal, suggesting that the process is more

eﬀortful or diﬃcult for them (McLaughlin etal., 2015).

Finally, children exposed to violence exhibit reduced rest-

ing-state functional connectivity between the amygdala

and medial PFC (Herringa etal., 2013; Marusak etal.,

2015; Thomason etal., 2015), a circuit with a known role

in multiple forms of emotion regulation.

A second area of research has focused on elucidating on

how violence disrupts the processing of social information

and shapes normative beliefs in ways that increase risk spe-

ciﬁcally for antisocial behavior. Physically abused children

are more likely to overidentify anger in others using less per-

ceptual information (Pollak & Sinha, 2002), and to interpret

socially ambiguous contexts as hostile (Dodge etal., 1990).

When deciding how to react to perceived social threat, these

children generate a smaller range of potential responses,

select responses that are more aggressive, and foresee fewer

negative consequences to responses that are antisocial

(Guerra & Slaby, 1990; Perry etal., 1986). This pattern of

cognitive biases has been widely studied as a mechanism

linking violence with the development of aggressive behav-

ior (Guerra & Huesmann, 2004; Haegerich & Tolan, 2008).

Yet relatively little is known about how violence may shape

more subtle behavioral responses to everyday stressors and

frustrations. Heightened emotional reactivity, diﬃculty regu-

lating negative emotions, and cognitive biases may make it

more diﬃcult for children exposed to violence to persist dur-

ing diﬃcult and frustrating tasks. We are unaware of prior

research examining whether violence exposure inﬂuences

distress tolerance in children and adolescents. The vast

majority of research on distress tolerance has conceptual-

ized it as trait-like (for reviews, see (Leyro etal., 2010) and

(Zvolensky etal., 2010)). However, initial evidence from

adult studies suggest that a history of violence exposure is

associated with lower distress tolerance (Gratz etal., 2007;

Vujanovic etal., 2011). Furthermore, Bernstein and col-

leagues (2008) found that a stress induction decreased the

ability of adults to withstand distress while persisting in

goal-related behavior. These studies highlight the plausible

role that environmental factors play in the development of

distress tolerance, particularly experiences of threat-related

adversity.

Numerous cross-sectional studies have identiﬁed low

distress tolerance as a vulnerability factor for substance use

problems among adults (Buckner etal., 2007; Gorka etal.,

2012; Marshall-Berenz etal., 2011; Simons & Gaher, 2005),

and among adolescents (Daughters etal., 2009; MacPherson

etal., 2010). Individuals who are prone to escaping rather

than persisting through challenging negative emotional

and physical states may be particularly vulnerable for the

immediate physiological relief provided by alcohol and other

substances (King etal., 2018a, 2018b). Although there has

long been a focus on identifying internalizing predictors

of adolescent substance use (e.g., Hussong etal., 2011),

remarkably few studies have examined distress tolerance as a

prospective predictor of the onset of substance use problems.

It is surprising that this association has yet to be examined

prospectively during the developmental period when most

Research on Child and Adolescent Psychopathology

1 3

individuals initiate use (Johnston etal., 2016). For adoles-

cents with low distress tolerance, relying on alcohol may be

a particularly attractive method for avoiding the discomfort

generated by the interpersonal stressors that occur more fre-

quently during adolescence and are more likely to trigger

negative aﬀect than in prior developmental periods (Larson

& Ham, 1992; Larson & Lampman-Petraitis, 1989; Rudolph

& Hammen, 1999). Of course, a variety of other risk factors

for adolescent alcohol abuse have been identiﬁed, including

environmental factors such as parenting (e.g. low monitor-

ing, high permission), peer and sibling drinking, and soci-

odemographic factors including race/ethnicity, religion, and

gender (Barnes etal., 2005; Donovan, 2004; Hopfer etal.,

2003). Parental alcohol use has gained attention as a predic-

tor of adolescent problem drinking because it can serve as

both a genetic marker of risk for alcohol problems, as well

as provide a social learning model for the child (Lee etal.,

2014). Another prominent pathway to alcohol problems in

adolescence has been positive alcohol expectancies and

motives for drinking (McBride etal., 2014; Patrick etal.,

2010). Yet, the risks associated with distress tolerance and

other impulsivity-related behaviors (Stautz etal., 2013) are

poorly understood in adolescents. We focus here on this rela-

tively understudied pathway that may be uniquely important

in that distress tolerance may continue to confer risk for

alcohol problems into adulthood and presents a clear target

for intervention, unlike many environmental and sociode-

mographic risk factors (e.g., poverty, parental alcohol use).

While existing evidence indicates that low distress toler-

ance is a risk factor for substance use problems, relatively few

studies have examined whether low distress tolerance may be

better characterized as a transdiagnostic risk factor underlying

the onset and maintenance of a wider range of mental health

problems, including anxiety and depression. Yet theoretical

support from the ﬁeld of personality research has converged

around the related idea that a tendency for impulsive avoid-

ance places individuals at risk for psychopathology of many

kinds (Barlow etal., 2014; Cyders & Smith, 2008; Johnson

etal., 2013). Indeed, low distress tolerance has been associ-

ated with anxiety symptoms and disorders in cross-sectional

studies (Boelen & Reijntjes, 2009; Bonn-Miller etal., 2009;

Buckner etal., 2007; Daughters etal., 2009). However, both

low distress tolerance and anxiety disorders are characterized

by greater attention and sensitivity to negative arousal and

behavioral avoidance of distressing contexts. It is therefore

possible that low distress tolerance does not precede anxiety

symptoms but simply reﬂects their presence. Similarly, it is

diﬃcult to disentangle the relation between low distress toler-

ance and depression. It is possible that the low persistence in

the face of negative emotions may lead to social withdrawal

and hopelessness, key features of depression. Yet it is also

possible the perseverative focus on negative emotional infor-

mation and diﬃculty persisting in goal-directed behavior

observed in depression (Joormann & Gotlib, 2010; Nolen-

Hoeksema etal., 2008) may lead people to perform poorly on

tasks of distress tolerance. A large body of research has exam-

ined a variety of factors that predict adolescent depression,

including negative peer and school experiences (Lu, 2019;

Reinherz etal., 2000), parenting factors like family conﬂict

(Rueter etal., 1999), and parental depression (Beardslee etal.,

1998; Jellinek & Snyder, 1998), and cognitive factors like

self-criticism, rumination and a negative attributional style

(Abramson etal., 1989; Auerbach etal., 2014; Beck etal.,

1983; Nolen-Hoeksema, 2000). However, we are aware of

only one study that has examined the role of distress tolerance

predicting growth in anxiety and depression symptoms longi-

tudinally across late childhood/early adolescence. Cummings

and colleagues (2013) found that distress tolerance, though

associated with internalizing problems concurrently, did not

predict growth in these symptoms across four years. This

study provides initial evidence that low distress tolerance may

be a consequence rather than risk factor for internalizing prob-

lems. Yet it is clear that more research is needed to understand

whether low distress tolerance heightens vulnerability for the

onset of anxiety and depression symptoms, particularly during

adolescence when these problems most commonly emerge.

The present study addresses these gaps in the literature by

examining distress tolerance as a potential mechanism linking

exposure to interpersonal violence in childhood with symp-

toms of alcohol abuse, anxiety, and depression in a diverse,

community-based sample of adolescents. First, we examined

whether exposure to interpersonal violence was associated

with distress tolerance. We examined distress tolerance using a

behavioral task rather than questionnaire measure as self-report

relies heavily on subject self-awareness, is less ecologically

valid, and evidence suggests that self-report measures of dis-

tress tolerance are not correlated with actual distress tolerance

behavior (McHugh etal., 2013). Second, we evaluated whether

low distress tolerance was associated with adolescent psycho-

pathology—including symptoms of alcohol abuse, depression,

and anxiety—both concurrently and prospectively over a four-

month period. Third, we examined whether low distress toler-

ance mediated the association between interpersonal violence

exposure and increases in symptoms of psychopathology. We

expected that greaterexposure to interpersonal violence would be

associated with decreased tolerance for distress. We addition-

ally predicted that lower levels of distress tolerance would be

associated with problematic alcohol use and higher anxiety and

depression symptoms both concurrently and prospectively, and

would mediate the association between interpersonal violence

exposure and later psychopathology. Finally, we expected that

the associations of interpersonal violence with psychopathol-

ogy and distress tolerance would persist after controlling for

socio-economic status (SES), speciﬁcally poverty and mater-

nal education.

Research on Child and Adolescent Psychopathology

1 3

Method

This is the sixth paper from a large multi-site study on mech-

anisms linking childhood adversity with psychopathology.

Other papers from this data set examine associations of

adversity with automatic and eﬀortful regulation and psy-

chopathology (Adrian etal., 2019; Heleniak etal., 2017;

King, Feil, etal., 2018a, 2018b; King, McLaughlin, etal.,

2018a, 2018b; Lambert etal., 2017). This is the ﬁrst paper

using this dataset to examine distress tolerance in relation

to either violence exposure or alcohol use problems. This

study was conceived and executed (2011–2014) before the

current practice of publishing a study protocol or registering

an analysis plan was established.

Sample

Participants were drawn from a study of 287 adolescents

aged 16 -17years, recruited in 3 major metropolitan areas in

the U.S. (Seattle, Boston, and Pittsburgh). Recruitment was

focused in community centers and after-school programs,

including in low SES areas to ensure sample variation on

the basis of race and ethnicity, SES, and exposure to adver-

sity. Additionally, community mental health and education

organizations that provided services for trauma-exposed

youth were targeted. The ﬁnal study sample included 287

adolescents (54.4% female) and their parents. The sample

was racially and ethnically diverse (40.8% White; 20.6%

Black; 16.0% Asian; 6.3% Hispanic; and 14.6% Biracial

or other). Parental informed consent and youth assent were

required for participation.

Measures

Violence Exposure Participants completed the Childhood

Trauma Questionnaire (CTQ;Bernstein etal., 1994, 1997,

2003), which assesses frequency of exposure to abuse and

neglect during childhood and adolescence. Evidence to sup-

port the validity of the CTQ as a retrospective measure of child

abuse was provided by Bernstein and colleagues (1994, 1997)

by showing good internal consistency (α = 0.79-0.94), test–

retest reliability over a two to six month period (ICC = 0.88), as

well as discriminant validity when compared with therapist rat-

ings in an inpatient adolescent psychiatric setting (i.e. r = 0.46-

0.72, p < 0.0001). To assess violence exposure, scores on 15

items in the physical, emotional, and sexual abuse subscales

were summed to produce a total child abuse score, with higher

scores indicating greater exposure. These items demonstrated

good reliability in this sample (α = 0.88). Approximately

25.1% of the sample met criteria for exposure to child abuse

based on a previously validated cut-oﬀ (Walker, & etal, 1999).

The Screen for Adolescent Violence Exposure (SAVE;

Hastings & Kelley, 1997) is a 32-item measure which

assesses frequency of direct and indirect exposure to vio-

lence in school, home, and neighborhood settings. Respond-

ents rate the frequency of exposure to indirect community

violence (e.g., “I have seen someone get beat up”), trau-

matic community violence (e.g., “Someone has pulled a

knife on me”) and physical/verbal abuse (e.g., “Grownups

hit me”) on a ﬁve-point Likert scale. In their development

and validation study of the SAVE, Hastings and Kelley

(1997) found that the SAVE demonstrated good validity in

detecting violence exposure; it correctly classiﬁed 79.37%-

82.56% of high and low- violence groups and signiﬁcant

correlations with neighborhood crime data (r = 0.28-0.35,

p < 0.001), and had good internal consistency (α = 0.65-

0.95). The 12 items from the traumatic community violence

scale were summed to produce a direct community violence

exposure score. The traumatic community violence scale

of the SAVE demonstrated good reliability in this sample

(α = 0.87).

Child abuse and community violence each represent

experiences of threat that are hypothesized to inﬂuence

emotional processing in similar ways (McLaughlin etal.,

2014). We therefore calculated a continuous total violence

exposure score for each participant by ﬁrst standardizing

the total CTQ child abuse score and the SAVE traumatic

community violence score, and then summing these two

standardized scores to create a composite measure. A simi-

lar approach has been used in prior work with this sample

(Lambert etal., 2017).

Psychopathology We used three measures to assess prob-

lematic alcohol use and abuse, anxiety, and depression. The

Alcohol Use Disorders Identiﬁcation Test (AUDIT; Saunders

etal., 1993) is a 10-item self-report measure of problematic

alcohol use. Respondents answer questions regarding past-

year frequency of alcohol consumption (e.g. “How often do

you have six or more drinks on one occasion?”), problem-

atic drinking behavior (e.g. “How often during the last year

have you found that you were not able to stop drinking once

you had started?”), and adverse psychological reactions (e.g.

“How often during the last year have you had a feeling of guilt

or remorse after drinking?”) on a Likert scale from never (0)

to 4 or more times a week (4) as well as questions regarding

whether there have been alcohol-related injuries (e.g., “Have

you or someone else been injured as a result of your drink-

ing?”). These 10 items were used to calculate a total mean

AUDIT score. As is typical in substance use measurement,

the total scores on the AUDIT were not normally distributed

(Maisto etal., 2000). We addressed this by examining problem

drinking in two ways in all analyses examining alcohol use. To

examine problem drinking continuously, we log-transformed

the total mean AUDIT score for each individual subject. We

Research on Child and Adolescent Psychopathology

1 3

additionally created a binary AUDIT variable in order to com-

pare participants who did and did not engage in any problem

drinking behavior. Evidence to support the validity of the

AUDIT in the detection of harmful drinking was provided

by Bohn and colleagues (1995) by showing its signiﬁcant

correlation (i.e., r = 0.54-0.88, p < 0.01) with the MAST and

MacAndrew alcoholism screening tests in a sample of known

alcoholics and general medical patients.The AUDIT demon-

strated good reliability in this sample (α = 0.81).

The Children’s Depression Inventory (CDI; Kovacs,

1992) is a widely used self-report measure of depression

within youth aged 7 to 17. The CDI includes 27 items con-

sisting of three statements (e.g., “Nothing will ever work

out for me”, “I am not sure if things will work out for me”,

“Things will work out for me OK”) representing diﬀerent

levels of severity of a speciﬁc symptom of depression. The

item pertaining to suicidal ideation was removed. The 26

remaining items were summed for a total score. In a large

community sample, Smucker etal. (1986) demonstrated that

the CDI has good internal consistency (i.e. α = 0.84-0.89),

and in their sample of pediatric hospital patients, Allgaier

and colleagues (2012) demonstrated that the CDI had both

good sensitivity (83.3%) and speciﬁcity (82.7%). The CDI

demonstrated good reliability in this sample (α = 0.86).

The Multidimensional Anxiety Scale for Children

(MASC; March etal., 1997) is a 39-item measure of child

anxiety. The MASC assesses physical symptoms of anxi-

ety (e.g., “I’m jumpy”), harm avoidance (e.g., “I keep my

eyes open for danger”), social anxiety (e.g., “I worry about

getting called on in class”), and separation anxiety (e.g.,

“I get scared when my parents go away”) and is appropri-

ate for youth ages 8 to 19years. Respondents indicate how

often they experience each item using a 4-point Likert scale

ranging from never true (0) to very true (3). The MASC

total score was calculated as the mean response across all

39 items. In two separate school-based population studies

conducted by March and colleagues (1997), the MASC

demonstrated good test–retest reliability (i.e. ICC = 0.79-

0.93) and evidence to support the validity of the MASC in

the detection of child anxiety was demonstrated by showing

its signiﬁcant correlation (i.e., r = 0.62 p < 0.01) with the

RCMAS. The MASC demonstrated high reliability in this

sample (α = 0.89).

Poverty A parent or guardian provided information regard-

ing their current annual household income. The income-

to-needs ratio was calculated by dividing total household

income by the 2012 U.S. census-deﬁned poverty line for a

family of their individual size (based on the year data were

collected). A lower value than one indicated a family was

living below the poverty line. This ratio was used to cre-

ate a dichotomous poverty variable, such that families were

grouped into those who were and were not living in poverty.

Parent-reported SES data were available on a smaller pro-

portion of the sample (n = 147).

Maternal Education A parent or guardian provided infor-

mation regarding highest level of education achieved by

the participant’s mother. Response options were rated on

a 10-point scale from “8

grade or less” (1) to “graduate/

professional school” (10). Maternal education was normally

distributed in the study sample, with approximately 25% of

mothers reporting a high school education or less.

Behavioral Task

Distress Tolerance To assess distress tolerance, we used

thePaced Auditory Serial Addition Task (PASAT), a per-

formance-based computer task that is designed to measure

attentional and behavioral persistence on a diﬃcult task

that creates frustration and emotional distress (Daughters

etal., 2005; Lejuez etal., 2003). Participants view a series

of numbers sequentially ﬂashed on a computer screen, and

are instructed to add each new number to the previously

presented number (not the running total) before the subse-

quent number appears on the screen. The task consists of

three blocks. The ﬁrst block lasted 3min, the second block

lasted 5min, and the third block lasted 7min. In block 1,

the latency between stimuli was three seconds (60 trials), in

block 2, two seconds (72 trials), and in block three, latency

was one second (92 trials). Shorter latencies between stimuli

increase the diﬃculty of the task on each subsequent block.

Participants were told that they could terminate the task at

any time once they reached the ﬁnal block of the task. Par-

ticipants were unaware of the task length. Distress tolerance

was measured continuously as the latency (in seconds) to

termination in the third block of the task, consistent with

prior research (Daughters etal., 2005; Lejuez etal., 2003).

A binary distress tolerance variable was also created to com-

pare participants who did and did not elect to quit the task.

Procedure

Participants were recruited, consented and assented to com-

plete a battery of task and psychological assessments. At

Time 1 (T1), participants provided demographic information

and completed measures of violence exposure and psycho-

pathology. Each participant also completed the PASAT and

time-to-quit was recorded. At each of the sites, adolescents

completed the PASAT in a small assessment room with the

experimenter. The PASAT was programmed in E-prime to

ensure that the administration was identical for all partici-

pants. The experimenter used a scoring sheet that displayed

Research on Child and Adolescent Psychopathology

1 3

the correct answer for each trial and scored the task as the

participant completed it. The task was also audio-recorded

to allow for scoring to be checked if the experimenter missed

a trial or was unsure about a particular response. This pro-

cedure ensured that there were no site variations in task

administration, and indeed no signiﬁcant eﬀect of site was

observed on task performance for the three site locations

(F(2, 281) = 0.16, p = 0.852).

At Time 2 (T2), four months following T1

(M = 120.28days), participants (n = 237) repeated the psy-

chopathology assessments in an online format. We selected

this period of time to reduce attrition as much as possible.

Furthermore, as almost half of our sample were high school

seniors at T1, it was important to conduct our follow up

assessment before any participants left their home environ-

ments to begin college or full-time employment, experiences

that would introduce a range of other risk factors for psycho-

pathology and alcohol abuse.

Subjects were compensated $35 for participating in the

T1 study visit, and $25 for completing the T2 online assess-

ment. Participants in the research described in this paper

were treated in accordance with APA ethical standards, and

the study was approved by the Institutional Review Boards

at University of Washington, Boston Children’s Hospital,

and University of Pittsburgh.

Statistical Analyses

We used a combination of linear and logistic regression to

examine each pathway of our indirect eﬀect models (Baron

& Kenny, 1986; Mackinnon etal., 2007). First, we exam-

ined associations of violence exposure with psychopa-

thology at T1 and at T2, controlling for T1 levels. Next,

we determined whether violence exposure was associated

with distress tolerance, the potential mediator, using linear

regression to examine time to quit on the PASAT and using

logistic regression to examine the log-odds of quitting the

PASAT. Then, we examined associations between distress

tolerance and psychopathology at T1 and at T2, controlling

for T1 psychopathology. Finally, we estimated a mediation

model to determine whether there was an indirect eﬀect of

violence exposure on change in psychopathology from T1

to T2 through lower distress tolerance. We evaluated preci-

sion in this estimate using a bootstrapping approach that

provides 95% conﬁdence intervals for indirect eﬀects in

statistical mediation estimated from 1000 resamples of the

data (Preacher & Hayes, 2008). All regression and media-

tion analyses were conducted in MPlus, Version 8 (Muthén

& Muthén, 2017), using full-information maximum likeli-

hood (FIML) estimation to handle missing data (Schafer &

Graham, 2002).

Following analysis of our three main models, we con-

ducted two sensitivity analyses to evaluate whether ﬁndings

remained signiﬁcant after controlling forSES. We examined

whether associations between violence and T1 psychopa-

thology, change in psychopathology from T1 to T2, distress

tolerance, and indirect eﬀects of violence on change in psy-

chopathology through distress tolerance, remained signiﬁ-

cant after controlling for SES. Our ﬁrst sensitivity analy-

sis controlled for poverty. Due to the high level of missing

data on family income (n = 140 subjects did not provide

this information), reducing our sample size considerably,

we conducted a second sensitivity analysis examining the

eﬀects of violence over and above maternal education (95%

item response rate).

In all models, predictors were mean-centered to facilitate

the interpretation of model coeﬃcients. We controlled for

T1 psychopathology in all longitudinal models to estimate

predictor eﬀects on change from T1 to T2. Sex was included

as a covariate in all models.

Results

Descriptive Statistics

Table1 provides means and standard deviations of all vari-

ables. Table2 depicts bivariate correlations among all vari-

ables. Means and standard deviations of CTQ and SAVE

subscales that comprise our cumulative violence measure

are provided in TableS1 within the Supplemental Materials.

Violence Exposure andPsychopathology

First, we examined the association between violence expo-

sure and each measure of psychopathology at T1. Higher

scores on the composite measure of violence exposure were

positively associated with higher levels of depression (β = 0.45,

p < 0.001, 95% CI [0.33, 0.58]), anxiety (β = 0.16, p = 0.004,

95% CI [0.05, 0.26]), and alcohol abuse (β = 0.31, p = 0.001,

95% CI [0.13, 0.49]) as well as greater odds of abusing alcohol

(OR = 1.42, p = 0.004, 95% CI [1.16, 1.74]), after adjusting

for sex. Next, we investigated the relationship between vio-

lence exposure and change in psychopathology over time. We

found no signiﬁcant associations between violence exposure

and change in depression, anxiety, alcohol abuse, or likelihood

of abusing alcohol from T1 to T2, indicating that violence

exposure was associated with higher overall levels of psycho-

pathology at T1 but not change in psychopathology over the

relatively short time scale of the present study.

Research on Child and Adolescent Psychopathology

1 3

Violence Exposure andDistress Tolerance

Greater violence exposure was associated with lower dis-

tress tolerance evidenced by a faster time to quit (β = -0.21

p = 0.009, 95% CI [-0.37, -0.05]) and greater odds of quitting

(OR = 1.23, p = 0.022, 95% CI [1.05, 1.44]) on the PASAT.

Distress Tolerance andPsychopathology

Lower levels of distress tolerance were not associated with

concurrent symptoms of depression, anxiety, alcohol abuse,

or likelihood of abusing alcohol at T1. However, when we

examined the eﬀects of distress tolerance on psychopa-

thology over time we found that a one standard-deviation

decrease in time on the PASAT (i.e. lower distress toler-

ance) was associated with a 37.0% increase in the odds of

abusing alcohol at T2 (OR = 0.63 p = 0.021, 95% CI [0.04,

0.94]), controlling for T1 alcohol abuse. The association

with increased alcohol abuse symptoms did not reach statis-

tical signiﬁcance at T2 (β = -0.11 p = 0.064, 95% CI [-0.23,

0.01]), controlling for T1 alcohol abuse. Distress tolerance

was not associated with an increase in depression or anxiety

symptoms from T1 to T2.

Mediation Analysis

Given signiﬁcant associations between violence exposure

and distress tolerance with changes in alcohol abuse, we

investigated whether lower distress tolerance mediated the

association between violence exposure and increased alco-

hol abuse using a non-parametric bootstrapping test of

mediation that derives conﬁdence intervals from indirect

eﬀects estimated across 1000 resamples of data (Preacher

& Hayes, 2008). Modern approaches to statistical mediation

do notrequire a signiﬁcant association in the direct path (i.e.,

violence exposure to changes in alcohol abuse symptoms)

toexamine the signiﬁcance of the indirect eﬀect (Hayes,

2013; MacKinnon etal., 2007).

Lower distress tolerance during the PASAT mediated the

association between violence exposure and increased abuse

of alcohol from T1 to T2, β = 0.02, 95% CI [0.01, 0.06].

Lower distress tolerance during the PASAT also mediated

the association between violence exposure and greater like-

lihood of alcohol abuse from T1 to T2, OR = 0.03, 95% CI

[0.01, 0.07].

Sensitivity Analyses

Poverty. To determine whether violence exposure was asso-

ciated with distress tolerance and psychopathology over and

above the eﬀects ofSES, we conducted a sensitivity analysis

in which we adjusted for poverty. Adjusting for poverty had

little impact on the associations of violence exposure with

distress tolerance or psychopathology or of distress toler-

ance with changes in alcohol abuse. In the small subsample

that provided information on income (n = 147), the eﬀects

of the associations between violence exposure and distress

tolerance measured in seconds to quit and likelihood of

quitting the task remained similar but shifted to trend-level

signiﬁcance (p = 0.080-0.100), and the association between

distress tolerance and increased alcohol abuse at T2 reached

statistical signiﬁcance (p = 0.045). All other associations that

were signiﬁcant without inclusion of poverty as a covariate

remained statistically signiﬁcant.

Maternal Education. We additionally conducted a sensi-

tivity analysis in which we adjusted for maternal education,

a second indicator of SES. Adjusting for maternal education

had no impact on the signiﬁcant associations of violence

Table 1 Means and standard deviations of violence exposure, distress

tolerance, psychopathology symptoms, and SES

Violence = Total exposure to interpersonal violence, calculated by

summing the standardized composites of the Childhood Trauma

Questionnaire Total Child Abuse scale and the Screen for Adoles-

cent Violence Exposure Traumatic Violence scale; PASAT Quit

Total = distress tolerance measured as time in seconds to quit the third

block of the PASAT task; PASAT Quit Bin = the binary distress tol-

erance measure indicating whether a participant elected to quit the

PASAT task; T1 AUDIT Total = Alcohol Use Disorders Identiﬁca-

tion Test total mean score at Time 1; T2 AUDIT Total = Alcohol Use

Disorders Identiﬁcation Test total mean score at Time 2; T1 AUDIT

Bin = Alcohol Use Disorders Identiﬁcation Test binary score indicat-

ing whether a participant did or did not endorse alcohol problems at

Time 1; T2 AUDIT Bin = Alcohol Use Disorders Identiﬁcation Test

binary score indicating whether a participant did or did not endorse

alcohol problems at Time 2; T1 CDI Total = Children’s Depression

Inventory total score at Time 1; T2 CDI Total = Children’s Depres-

sion Inventory total score at Time 2; T1 MASC Total = Multidimen-

sional Anxiety Scale for Children mean symptom score at Time 1; T2

MASC Total = Multidimensional Anxiety Scale for Children mean

symptom score at Time 2

Measure Mean (SD)

1. Violence 0.00 1.61

2. PASAT Quit Total 104.56 46.32

3. PASAT Quit Bin 0.37 0.49

4. T1 AUDIT Total 1.23 0.41

5. T2 AUDIT Total 1.19 0.30

6. T1 AUDIT Bin 0.50 0.50

7. T2 AUDIT Bin 0.49 0.50

8. T1 CDI Total 10.40 6.89

9. T2 CDI Total 9.87 7.37

10. T1 MASC Total 1.99 0.40

11. T2 MASC Total 2.09 0.41

12. Poverty 0.10 0.30

13. Maternal Education 6.71 2.78

Research on Child and Adolescent Psychopathology

1 3

exposure with distress tolerance or psychopathology, dis-

tress tolerance with changes in alcohol abuse, or mediation

analyses.

Discussion

Consistentevidence suggests that violence exposure in

childhood is associated with the onset and persistence of psy-

chopathology, including substance abuse, anxiety, and depres-

sion (Kessler etal., 2005; Keyes etal., 2012; Klitzman &

Freudenberg, 2003; McLaughlin etal., 2012; Molnar etal.,

2001; Ward etal., 2001). Although disruptions in emotion

regulation are frequently posited to be a central mechanism

linking violence exposure with multiple forms of psycho-

pathology (Heleniak etal., 2015; McLaughlin & Lambert,

2017), we are unaware of previous studies that have examined

distress tolerance as a potential transdiagnostic mechanism

linking violence exposure with heightened risk for psychopa-

thology during adolescence. We provide novel evidence from

a longitudinal community-based study indicating that expo-

sure to interpersonal violence is associated with diminished

ability to tolerate distress in order to persist in goal-related

behavior in adolescence. Longitudinal analyses revealed that

distress tolerance was associated with a speciﬁc pattern of

risk for psychopathology, such that low distress tolerance was

associated with increased likelihood of problematic alcohol

use over time, and mediated the association between violence

exposure severityand problematic alcohol use. However, low

distress tolerance was not associated with concurrent or later

symptoms of anxiety and depression. These ﬁndings suggest

that distress tolerance is shaped by experiences of threat, spe-

ciﬁcally exposure to interpersonal violence, and may play a

speciﬁc role in the development of problematic alcohol use

in adolescence.

Consistent with our hypotheses and prior studies on child-

hood violence exposure (Lansford etal., 2002; McLaughlin

etal., 2012), we found signiﬁcant moderate associations

between the degree ofexposure to interpersonal violence

and concurrent substance use, anxiety and depression symp-

toms. In the longitudinal analyses, we were additionally able

to examine violence exposure and increased symptoms of

psychopathology across a four month period of time. In con-

trast with our baseline results, we found that although the

severity ofviolence exposure was associated with overall

initial level of psychopathology, it did not predict changes

in alcohol abuse or internalizing symptoms over time. This

ﬁnding may seem surprising because adolescence is a period

of heightened vulnerability for the ﬁrst onset of these men-

tal health problems. But prior work also suggests that vio-

lence exposure is associated with earlier age of ﬁrst onset of

symptoms (Briggs-Gowan etal., 2010; Kessler etal., 2007;

Table 2 Correlations of violence exposure, distress tolerance, and psychopathology symptoms

Violence = Total exposure to interpersonal violence, calculated by summing the standardized composites of the Childhood Trauma Question-

naire Total Child Abuse scale and the Screen for Adolescent Violence Exposure Traumatic Violence scale; PASAT Quit Total = distress toler-

ance measured as time in seconds to quit the third block of the PASAT task; PASAT Quit Bin = the binary distress tolerance measure indicating

whether a participant elected to quit the PASAT task; T1 AUDIT Total = Alcohol Use Disorders Identiﬁcation Test total mean score at Time 1;

T2 AUDIT Total = Alcohol Use Disorders Identiﬁcation Test total mean score at Time 2; T1 AUDIT Bin = Alcohol Use Disorders Identiﬁcation

Test binary score indicating whether a participant did or did not endorse alcohol problems at Time 1; T2 AUDIT Bin = Alcohol Use Disorders

Identiﬁcation Test binary score indicating whether a participant did or did not endorse alcohol problems at Time 2; T1 CDI Total = Children’s

Depression Inventory total score at Time 1; T2 CDI Total = Children’s Depression Inventory total score at Time 2; T1 MASC Total = Multidi-

mensional Anxiety Scale for Children mean symptom score at Time 1; T2 MASC Total = Multidimensional Anxiety Scale for Children mean

symptom score at Time 2

p < 0.05, **p < 0.01

1 2 3 4 5 6 7 8 9 10 11 12 13

1. Violence __

2. PASAT Quit Total -0.21** __

3. PASAT Quit Bin 0.16** -0.93** __

4. T1 AUDIT Total 0.31** -0.05 0.02 __

5. T2 AUDIT Total 0.18** -0.08 0.07 0.65** __

6. T1 AUDIT Bin 0.22** 0.01 0.01 0.67** 0.57** __

7. T2 AUDIT Bin 0.19** -0.09 0.10 0.55** 0.73** 0.67** __

8. T1 CDI Total 0.45** -0.06 0.02 0.12 0.18** 0.13* 0.17** __

9. T2 CDI Total 0.38** -0.04 0.03 0.11 0.16* 0.10 0.15* 0.73** __

10. T1 MASC Total 0.15** 0.06 -0.08 0.03 -0.09 -0.03 -0.12 0.39** 0.31** __

11. T2 MASC Total 0.06 0.03 -0.02 0.01 0.01 -0.05 -0.04 0.33** 0.43** 0.60** __

12. Poverty 0.01 -0.14 .16* -0.14 -0.17* -0.17* -.18* -0.09 0.00 -0.10 -0.09 __

13. Maternal Education -0.11 0.09 -0.07 0.00 0.00 0.09 0.05 -0.04 -0.06 0.10 0.02 -0.40** __

Research on Child and Adolescent Psychopathology

1 3

Mandelli etal., 2011), meaning that the eﬀects of violence

on risk for psychopathology were already present by the

time of our baseline assessment in later adolescence. It is

also possible that the four-month span between our baseline

and follow up assessments did not grant suﬃcient time to

capture meaningful changes in psychopathology related to

prior experiences of violence.

In support of our primary hypothesis, we found that

greaterexposure to interpersonal violence was associ-

ated with lower ability to persist in the face of distress.

Diminished ability to withstand uncomfortable emotional

states among violence-exposed adolescents could reﬂect

an adaptation to early experiences ofthreat. Heightened

attention and sensitivity to negative emotional cues are

adaptive responsesto being raised in a dangerousenvi-

ronment. This heightened salience of negative emotions

may become overwhelming for children who have experi-

enced violence by the time they reach adolescence, when

it is developmentally normative to experience negative

emotions more often and more strongly than in childhood

(Larson & Lampman-Petraitis, 1989; Larson etal., 2002).

As a result, adolescents who have experienced violencemay

be more likely to engage in escape behaviors to modulate

distress and reduce their persistence at diﬃcult and frus-

trating tasksthan adolescents who have not encountered

violence. Furthermore, adolescents who have experienced

violence may have learned that it is safer to leave distress-

ing situations immediately before evaluating whether the

potential threat signaled by distress was real or imagined.

As a result, violence-exposed youth have diﬃculty dis-

criminating between cues of threat and safety (McLaughlin

etal., 2016; Pollak etal., 2000; Pollak & Sinha, 2002).

Although it may be safer for children to immediately escape

distressing activities in dangerous environments, it may

result in fewer opportunities to practice persisting through

diﬃcult tasks that are challenging but present no threat to

personal safety. Although we do not have information spe-

ciﬁcally on the chronicity of violence exposure within our

sample(i.e., when in development these experiences started

and ended), we would expect there to be a wide distribution

rangingfrom single episodes to years-long abuse experi-

ences. Indeed, youth in our study endorsed a range of violent

experiences from discrete attacks within their communities

to subtypes of abuse that tend to be more chronic such as

physical abuse. If lower distress tolerance emerges from a

pattern of learned safety seeking behavior following vio-

lence, we would expect chronicity of violence to strengthen

this relationship over time. On the other hand, exposure to

a few recent and discrete instances of violence could have

a weaker eﬀect on children’s behavior, and may explain our

small eﬀect sizes. Indeed, larger eﬀects on distress toler-

ance have been observed among adults with moderate to

severe histories of child abuse (Gratz etal., 2007)and here

we observe that increased severity of violence exposure was

associated with worse distress tolerance. Together with ﬁnd-

ings from adult studies that also report associations between

violence exposure and distress tolerance (Gratz etal., 2007;

Vujanovic etal., 2011), our pattern of results raises ques-

tions about the conceptualization of distress tolerance as a

stable trait insensitive to environmental input.

If violence exposure in childhood makes it more diﬃ-

cultto tolerate negative emotional states, low distress tol-

erance represents one plausible pathway linking violence

exposure with increased symptoms of psychopathology.

Indeed, we found that low distress tolerance was associated

with a small but signiﬁcantly increased likelihood of abus-

ing alcohol over several months. These ﬁndings suggest that

low distress tolerance may represent a vulnerability factor

for the development of alcohol use problems during a time

when most adolescents are ﬁrst experimenting with alcohol

(Johnston etal., 2016). This is concerning because alco-

hol abuse in adolescence is associated with a wide range

of deleterious behavioral, academic, social, and health con-

sequences (Bonomo etal., 2001; Donovan & Jessor, 1985;

Meropol etal., 1995; Valois etal., 1999) including alcohol

and substance abuse in adulthood (Englund etal., 2008).

Our ﬁndings are consistent with the large body of literature

demonstrating that low distress tolerance is concurrently

associated with substance problems in adults (Buckner

etal., 2007; Gorka etal., 2012; Marshall-Berenz etal., 2011;

Simons & Gaher, 2005). We extend prior work in this area

by demonstrating that low distress tolerance is associated

with increased engagement in problematic use of alco-

hol during adolescence. Of course, our ﬁnding should be

considered in the context of a large body of research that

has identiﬁed other potent risk and protective factors for

alcohol problems in adolescence. For example, belonging

to a religious community and parental monitoring are key

environmental factors that are known to buﬀer teens from

initiating and maintaining alcohol abuse by restricting ado-

lescent access to alcohol (Brown etal., 2001; Carroll etal.,

2016). On the other hand, parental alcohol use is likely to be

associated with both child maltreatment and heightened risk

for adolescent alcohol problems (Lee etal., 2014). Under-

standing the complex interplay of these and other risk and

protective factors for adolescent alcohol use problems will

not be possible until we have developed a better understand-

ing of behavioral risk factors, such asdistress tolerance, for

alcohol problems. As adolescents age and navigatethe world

independently, low distress tolerance may be one factor that

contributes tohigher risk of drinking problems once access

to alcohol is unrestricted in early adulthood. Overall, our

ﬁndings underscore the importance of understanding risks

associated with low distress tolerance in adolescence, and

determining whether early interventions that target distress

tolerance speciﬁcally before the age of peak vulnerability

Research on Child and Adolescent Psychopathology

1 3

for alcohol problems might be eﬀective at preventing prob-

lematic use.

In contrast, we found that low distress tolerance in ado-

lescence was not associated with current levels or changes

in anxiety or depression symptoms. These ﬁndings are con-

sistent with the only prior study we are aware of that has

examined associations between distress tolerance, inter-

nalizing, and externalizing psychopathology over time in

a sample of children and early adolescents. Cummings and

colleagues (2013) reported that although low distress tol-

erance predicted internalizing symptoms in children age

9–13, it was not associated with internalizing symptoms by

middle adolescence or growth in internalizing symptoms

across middle adolescence. In contrast, low distress toler-

ance did predict growth in externalizing symptoms over this

time period. Together, these ﬁndings and ours suggest that

low distress tolerance is not a transdiagnostic risk factor in

adolescence but instead a speciﬁc vulnerability for disorders

characterized by low behavioral regulation, such as alcohol

abuse. Given mixed ﬁndings on the association between

distress tolerance and anxiety and depression symptoms in

adolescent and adult populations (Leyro etal., 2010), an

important step for future research will be elucidating the

stability of this relationship across the lifespan. While rates

of alcohol increase from early to late adolescence, evidence

suggests that internalizing symptoms may peak by early ado-

lescence, with depression symptoms remaining stable and

anxiety symptoms actually declining by middle-adolescence

(McLaughlin & King, 2015). Therefore, it may be impor-

tant for future research to examine the association between

distress tolerance and internalizing symptoms earlier in

adolescence.

Overall, our study suggests that low distress tolerance

represents a plausible mechanism underlying the association

between violence exposure and problematic substance use

during adolescence. Indeed, mediation analyses revealed a

small but signiﬁcant indirect eﬀect of interpersonal violence

exposure on later problematic alcohol use through low dis-

tress tolerance. This builds on prior work identifying other

aspects of emotion regulation, such as emotional reactivity

and rumination, as mechanisms linking violence exposure

with internalizing psychopathology (Heleniak etal.,2015).

Here, we demonstrate that behavioral responses to distress-

ing emotional experiences vary as a function of the degree

ofchildhood exposure to violence, and are associated with

a small but signiﬁcant elevations inrisk for increased prob-

lematic alcohol use during adolescence. These ﬁndings

suggest the need for future research to examine distress

tolerance across development as a construct that is experi-

ence and state dependent, rather than an immutable trait.

Extensive evidence from treatment studies in children and

adults supports this characterization of distress tolerance as

a skill that can be improved. Indeed, ﬁndings from this study

suggest that improving distress tolerance skills should be a

speciﬁc treatment target for adolescents exposed to inter-

personal violence. Interventions such as Dialectical Behav-

ior Therapy (DBT; Linehan, 1993) and mindfulness-based

substance use disorder treatments (Zgierska etal., 2009)

that teach tools for remaining present, resisting urges and

tolerating distress (e.g. mindfulness and distress tolerance

skills), may be particularly eﬀective at reducing risk for

substance use disorders among adolescents exposed to vio-

lence. Preventive interventions that incorporate these skills

to address distress tolerance may be eﬀective for youths who

have experienced violence.

Several study limitations should be acknowledged. First,

we did not assess ADHD symptoms. Given evidence for a

relationship between low distress tolerance and attentional

control (Bardeen etal., 2015), it would be useful to control

for ADHD symptoms in models predicting psychopathol-

ogy symptoms. Second, we used a single behavioral task to

assess distress tolerance. Although there is a great deal of

literature supporting the validity of the PASAT in measur-

ing distress tolerance (for review, see Tombaugh, 2006), it

is possible that the adolescents who exhibited low distress

tolerance on this task may have been able to endure their

distress for a longer period of time had it been more relevant

to their personal interests and goals. Although our task is

the same as those used in prior work on distress tolerance,

future research should not only include self-report measures

of more trait-like general distress tolerance but should also

consider utilizing behavioral tasks with a variety of cogni-

tive (e.g. verbal rather than mathematical) and social goals

to establish whether distress tolerance varies by context

and the speciﬁcity of distress tolerance in these contexts

to psychopathology. Third, we selected the AUDIT as our

measure of alcohol abuse because of its excellent reliability

and validity and wide use as a screening tool for high-risk

drinking among a broad range of samples (Saunders etal.,

1993). However, the total score of this measure is weaker

at detecting binge drinking, a common use pattern among

adolescents (Cortes-Tomas etal., 2017). We addressed the

relative weakness of the audit total frequency score by calcu-

lating binary problematic alcohol use scores to better capture

sporadic but problematic use among our sample. Fourth, we

utilized self-report measures of alcohol abuse and depression

and anxiety symptomatology rather than administering struc-

tured diagnostic interviews of psychopathology. Although

administration of a structured interview to establish diag-

noses would represent a methodological improvement, the

validity of the youth report measures used in this study are

well-established (Kovacs, 1992; March etal., 1997; Muris

etal., 2002; Reynolds, 1994; Saunders etal., 1993; Saylor

etal., 1984), and the use of youth rather than parent report

is advantageous when assessing substance use and internal-

izing symptoms (Cantwell etal., 1997). Fifth, our mediation

Research on Child and Adolescent Psychopathology

1 3

analysis was modeled using two rather than three timepoints.

Although childhood experiencesof violence necessarily occurred

prior to the study assessments, both prior violenceexposure

and distress tolerance were measured at the same timepoint.

Replication of these ﬁndings in samples with multiple longi-

tudinal assessments is an important goal for future research.

Sixth, the focus of this paper was to examine distress toler-

ance as a behavioral phenotype linking threat-related adver-

sity with concurrent and subsequent psychopathology. Given

this focus, we adjusted for SES (i.e. poverty and maternal

education) in addition to sex. Of course, there are many other

co-morbid risks for psychopathology and alcohol abuse such

as genetic (parental psychopathology), cognitive (expectan-

cies and motivations), cultural (e.g. religious beliefs), and

environmental (e.g. parental monitoring, peer behavior) fac-

tors that were outside the focus of this study and that we did

not control for (because they were not assessed in our sam-

ple), which may limit generalizability of our results. While

such analyses would surely provide a more complex picture

of the sequential pathways to these mental health problems,

such analyses are beyond the scope of this paper, which was

to examine distress tolerance as an understudied potential

mechanism linking childhood violence exposure to ado-

lescent mental health problems. Finally, we conducted our

follow up assessments four months after the initial assess-

ment. It is possible that a longer follow-up period may have

revealed more meaningful associations as greater change in

our variables of interest might have been detected. However,

selection of a relatively short follow-up period allowed us

the opportunity to re-assess our sample before the signiﬁcant

proportion of high school seniors in our sample left for col-

lege, increasing risk of attrition and introducing new risks for

alcohol and internalizing symptoms. Furthermore, increasing

evidence suggests meaningful within-person variability in

symptoms of anxiety and depression (Jenness etal., 2019),

and in alcohol use (Cho etal., 2001) among individuals over

intervals of a similar length.

Exposure to interpersonal violence is associated with

reduced distress tolerance during adolescence using a behav-

ioral measure of persistence in the face of distress. Low dis-

tress tolerance, in turn, was prospectively associated with

increases in problematic alcohol use, but not internalizing

psychopathology, over several months and mediated the link

between violence exposure and increases in alcohol abuse

symptoms. Although future research is needed to further

disentangle how other established risks for alcohol problems

may inﬂuence this pathway, our ﬁndings highlight the poten-

tial role of distress tolerance as a risk factor for substance

use problems speciﬁcally shaped by early experiences of

threat-related adversity. Interventions that target distress

tolerance may be useful in reducing risk of substance use in

violence-exposed youth.

Supplementary Information The online version contains supplemen-

tary material available at https:// doi. org/ 10. 1007/ s10802- 021- 00805-0.

Funding This research was supported by a Doris Duke Fellowship

for the Promotion of Child Wellbeing to Charlotte Heleniak, by a

Young Scholars Award from the Klaus J. Jacobs Foundation to Katie

A. McLaughlin, Kevin M. King, and Kathryn C. Monahan, a grant

from the National Institute of Child Health and Human Development

to Maya L. Rosen (F32-HD089514), and by grants from the National

Institute of Mental Health to Charlotte Heleniak (F31-MH108245),

Hilary K. Lambert (F31-MH116559), and Katie A. McLaughlin

(R01-MH103291; R01-MH106482).

Compliance with Ethical Standard

Conflicts of Interest The authors declare that they have no conﬂicts

of interest.

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