Rethink your drink... The bidirectional relation between automatic and controlled processes and the development of drinking behavior in at-risk adolescents

Recent theories suggest that behavioral control is a very important aspect in the drinking behavior of adolescents, and differences in the capacity to control one’s own responses are assumed to underlie the escalation from relatively normal drinking patterns to more severe drinking in adults and adolescents. The development of the behavioral control coincides together with the maturation of the prefrontal cortex and it is not until late adolescence that these brain areas are fully grown. This ongoing maturation process during adolescence has been identified as vulnerable marker for the neurotoxic effects of alcohol. Alcohol use during adolescence could contribute to delay in development and impairment of cognitive functions and differences in brain functioning. At the same time, impairments in cognitive functioning have been found to predict increase in drinking behavior in adolescents. This raises the question of directionality of the relationship and suggests a bidirectional relation between cognitive functioning and adolescents’ drinking behavior. Some cognitive impairments might result from heavy alcohol use, while other cognitive impairments found in heavy drinking adolescents, have been present before adolescents started with drinking. In this thesis, the influence of executive functioning, important functions for behavioral control, have been examined in relation to adolescents’ alcohol use. Besides behavioral control, more automatic and motivational processes (e.g. wanting, craving, expectancies) also appear to play an important role in drinking behavior. These automatic processes can be assessed trough alcohol cognitions (e.g. implicit cognitions) or biases in attention (e.g. attentional bias) or motivational orientation (i.e. approach bias) towards alcohol. It is hypothesized that behavioral decisions to drink are influenced by the strength of automatic processes in combination with the ability and motivation to control these automatic processes. This theory has frequently been tested in adult drinkers and addicts, but less often in young adolescents who just start with drinking. Adolescents from mainstream education (a Dutch and English sample) as well as a high risk sample of adolescents (e.g. adolescents with externalizing behavior problems) were included in the studies and followed over a period of two years. Several measures of executive functioning and measures to assess automatic processes were completed by the participants. The findings of these thesis suggest that both controlled as well as automatic processes play a significant role in the drinking behavior of adolescents cross-sectionally as well as longitudinally. Impairments in executive functions predicted increase in, as well as the onset of, drinking behavior of adolescents. In addition, strong automatic processes also elevated alcohol use among at-risk adolescents, with even stronger influences when executive functions were relatively weak. In sum, weaknesses in executive functioning appear to precede the onset of drinking and heavy drinking in adolescents. Prolonged use of alcohol might further impair these functions, resulting in a vicious circle in which behavioral control problems, either by itself or in combination with automatic processes, increase alcohol use, and heavy drinking further impairs these cognitive functions.