Child abuse exposure, emotion regulation, and drinking refusal self-efficacy: an analysis of problem drinking in college students.

http://informahealthcare.com/ada ISSN: 0095-2990 (print), 1097-9891 (electronic) Am J Drug Alcohol Abuse, 2015; 41(2): 188–196 ! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/00952990.2014.998365

ORIGINAL ARTICLE

Child abuse exposure, emotion regulation, and drinking refusal self-efficacy: an analysis of problem drinking in college students

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Alicia K. Klanecky, PhD, Erin O. Woolman, BA, and Madelyn M. Becker, BA Psychology Department, Creighton University, Omaha, NE, USA

Abstract

Keywords

Background: Problem drinking in college is a longstanding problem with potentially severe consequences. More recently, problem drinking has been linked to emotion regulation difficulties. However, these results are mixed and emphasize the need to examine moderating variables that may strengthen the problem drinking/emotion regulation relationship. Two such variables are child/adolescent sexual abuse (CASA) and drinking refusal self-efficacy (DRSE). Objectives: The current study hypothesized that the relations between emotion regulation difficulties and problem drinking would be most salient for college students with increased CASA exposure and decreased DRSE. Secondary analyses examined the hypothesis taking into consideration cumulative child/adolescent trauma exposure. Methods: Undergraduate students (n ¼ 200) completed a large survey battery for course credit. Results: Three-way interactions across the CASA and cumulative trauma models were significant and in a similar direction. Results indicated that for students without trauma exposure, problem drinking was the greatest for those with decreased DRSE and increased emotion regulation difficulties. As trauma exposure increased, problem drinking was the greatest for those with decreased DRSE and decreased emotion regulation difficulties (or superior perceived regulatory abilities). Conclusion: Discussion highlights the importance of considering DRSE and the possibility of reduced insight in trauma-exposed students, who may perceive alcohol use as an adaptive regulatory strategy.

Child abuse, college, drinking refusal self-efficacy, early life stress, emotion regulation, problem drinking, sexual abuse

Introduction Rates of college problem drinking have remained stable over the last 20 years and generally exceed those of non-college young adults (1). In the last two weeks, between 39.1 and 51.5% of students reported binge drinking, defined as consuming five or more consecutive drinks for men and four or more drinks for women in one setting (2,3). Consequences and risks associated with problem drinking are numerous, including alcohol-induced blackouts, hangovers, legal violations, impaired academic functioning, risky sexual behaviors, sexual assault, alcohol use disorders, injuries and fatalities (4–9). Such prevalence and potentially severe consequences underscore the importance of better understanding problem drinking in college environments. Problem drinking in college is increasingly being examined in the context of emotion regulation, defined as a ‘‘process by which individuals influence which emotions they have, when they have them, and how they experience and Address correspondence to Alicia Klanecky, PhD, Psychology Department, 2500 California Plaza, Creighton University, Omaha, NE 68178, USA. Tel: +1 402 280 2146. Fax: +1 402 280 4748. E-mail: [email protected]

History Received 7 August 2014 Revised 17 November 2014 Accepted 9 December 2014 Published online 20 February 2015

express these emotions’’ (10 p. 275). Some research indicated that difficulties in emotion regulation were associated with increased problem drinking in college students (11–14). Gottfredson and Hussong (14) reported that students’ daily levels of affect were not related to alcohol consumption, consistent with most (15–17) but not all previous findings (18,19). Rather, it was positive and negative affect variability that related to increased drinking (14). Plausibly, college students with more frequent and intense emotional lability consume alcohol as a method of regulating their emotional experiences, consistent with motivational models of alcohol use (20). However, not all research has found significant relations between emotion regulation and alcohol consumption (17,21), and reported effect sizes tend to be variable (r’s ¼ 0.04–0.41) (12,21). The relations between problem drinking and emotion regulation difficulties are likely strengthened for individuals with a history of child/adolescent sexual abuse (CASA). Prior research has theorized that child maltreatment including CASA alters developmental processes including emotion regulation capabilities (22–24). Numerous studies have reported emotion regulation deficits in children and adults with a history of CASA (25–30). Such emotion dysregulation


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has also been reported in college populations (31–34). For example, using a mood induction paradigm, Luterek et al. (34) reported that CASA-exposed college women evidenced deficits in emotional responding including experiencing reduced positive affect, disclosing fewer negative emotionrelated words during written disclosure, and showing less facial expressions compared to non-CASA individuals (34). Such an alteration in emotion regulation following CASA likely increases alcohol use, with drinking presumably used as a means of regulating affect. Multiple findings have shown that CASA exposure is associated with an increased risk for problem drinking and alcohol use disorders (33,35–40). A desire to enhance positive affect and cope with negative affect mediated the relations between CASA history and alcohol consumption in a general sample of women (35). Moreover, sexually abused adolescents reported an increased likelihood of using alcohol, drinking to cope with painful emotions, and drinking to escape problems compared to their non-abused peers (41). In working to understand the CASA and alcohol use relationship, prior research has focused less on regulatory constructs; rather, symptoms of post-traumatic stress disorder (PTSD) have been emphasized. Alcohol use is conceptualized as a method of alleviating symptoms of PTSD following trauma (42,43). While less research has directly compared emotion regulation difficulties and PTSD, findings indicate that emotion regulation difficulties are an underlying factor that may lend to PTSD symptom development (44). In a recent study utilizing adult women (with over 65% attending at least some college), the direct effect of childhood abuse on PTSD symptoms was not significant. Rather, child abuse was related to PTSD symptoms indirectly through emotion regulation difficulties (45). After accounting for PTSD symptoms, reports indicated that emotion dysregulation contributes uniquely to impairment (22), and CASA survivors experience greater emotion regulation difficulties compared to non-childhood trauma survivors (46,47). Further, most college women with a history of trauma who experience emotion dysregulation do not have PTSD (48). Coupled with low rates of PTSD symptoms in college populations (10–15%) (49), research suggests that emotion regulation difficulties confer risk for problem drinking following CASA, independent of PTSD symptom development. A cognitive mechanism which may also contribute to the relationship between emotion regulation difficulties and risk for problem drinking is drinking refusal self-efficacy (DRSE). As conceptualized by Bandura (50,51), perceptions of selfefficacy are a primary mechanism of human agency. Perceived self-efficacy guides future behavior directly and indirectly, via goals, perceived impediments, and outcome expectancies. Self-efficacy in drinking refusal is defined as one’s perceived ability to resist alcohol consumption (52). DRSE has theoretically and empirically been identified as a risk factor for increased drinking and a mechanism for reducing drinking behavior (53,54). For college students, DRSE is negatively correlated with quantity and frequency of alcohol consumption (r’s ¼ 0.16–0.49) (55–59), measures of problem drinking (r’s ¼ 0.32–0.48) (60), and alcohol-related problems (r’s ¼ 0.50–0.54) (56,61). Undergraduate participants experiencing depressive affect endorsed lower DRSE

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ratings in depression-related hypothetical contexts with a trend toward reporting lower DRSE scores across alternative negative affect contexts (62). Findings imply that emotional experiences may weaken some students’ perceived ability to resist alcohol, which may increase risk for problem drinking. While DRSE has yet to be explicitly examined in those with CASA exposure, one study found that reduced DRSE was related to increased trauma symptoms and a history of assaultive violence in college students (61). Leading from prior research, it is possible that individuals with a history of CASA who are less able to regulate affective experiences may be more susceptible to problem drinking if they perceive themselves as less able to refuse alcohol. The primary aim of the current study was to examine the moderating potential of CASA and DRSE on the relations between emotion regulation difficulties and problem drinking via a three-way interaction, after accounting for PTSD symptoms. It was hypothesized that the relations between emotion regulation difficulties and problem drinking would be most salient for college students with increased CASA exposure and decreased DRSE. College students are a particularly relevant population to examine the research question given that college environments support problem drinking (1), CASA experiences are reported by college men and women (63), and college environments provide a unique opportunity for intervention (64). Last, while a sizeable amount of research has focused specifically on CASA, some evidence indicates that the cumulative experience of child/ adolescent trauma is associated with an increased risk for problematic alcohol use (65,66). Additionally, alternative forms of childhood trauma (e.g. child physical abuse) have been linked to increased emotion regulation difficulties (32,67) and reduced self-efficacy (68). Accordingly, a secondary aim of the study sought to replicate the three-way interaction with cumulative child/adolescent trauma exposure.

Methods Participants and procedures Undergraduate students (n ¼ 200) from a private Midwestern university completed a large survey battery. All study procedures were approved by the University’s Institutional Review Board, and study completion was voluntary. Students were recruited via the Psychology Department’s online research system. At the onset of the survey battery, students received details concerning the rights of participants and completed informed consent procedures. Survey instruments were completed in one setting, and in a location and time of students’ choosing. The study took approximately 45–60 min to complete. The order of survey presentation was randomized to minimize the effects of response bias on the data. All participants received course credit for study completion. Overall, participants completing the study were 19.45 years old (SD ¼ 1.62), and 62% were female. The majority identified as European American (72.2%) with 11.3% identifying as Asian American, 5.2% Hispanic/Latino, 4.1% African American, and 7.0% ‘‘Other’’. Most participants were either freshmen or sophomores in college (77.0%). Questionnaires within the battery assessed alcohol use behaviors as well as a range of related factors. Survey

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instruments pertinent to the current research question included: Measures


Alcohol Use Disorders Identification Test (AUDIT) (69) The AUDIT is a widely-used 10-item questionnaire designed to measure severity of problem alcohol consumption. Items include ‘‘How often do you have a drink containing alcohol?’’ and ‘‘How often during the last year have you been unable to remember what happened the night before because of your drinking?’’ Utilizing a 5-point Likert scale, all items were summed to provide a continuous measure of problem drinking. A cut-off score of six has been used to identify problem drinking in college populations (70). The AUDIT has shown internal consistency across diverse samples and settings, including Cronbach’s a40.80 and test-retest reliability of 0.92 (71,72). Cronbach’s alpha for the current study was 0.86. Demographic information Demographic data were collected via a comprehensive questionnaire asking participants to provide information such as age, gender, race/ethnicity, year in school, academic performance variables, and living arrangements.

Am J Drug Alcohol Abuse, 2015; 41(2): 188–196

including physical, sexual, emotional, and general (e.g. witnessing trauma, natural disasters). Each subscale outlines potentially traumatic and/or abusive events prior to age 18 and across a range of severity. The sexual trauma subscale provided the current measure of CASA, consistent with conceptualizations of CASA in previous studies (34,77–80). Items include questions such as, ‘‘Were you ever touched in an intimate or private part of your body (e.g. breast, thigh, genitals) in a way that surprised you or made you feel uncomfortable?’’ and ‘‘Did anyone ever have genital sex with you against your will?’’ The six CASA items were averaged to provide a continuous score with higher scores indicative of greater CASA exposure. To examine cumulative child/ adolescent trauma exposure, items across all subscales were averaged. Example items include: ‘‘Were you ever burned with hot water, a cigarette or something else?’’ ‘‘Did you ever witness violence towards others, including family members?’’ and ‘‘Were you often ignored or made to feel that you didn’t count?’’ Again, higher scores were indicative of greater trauma exposure. The ETI-SR-SF evidenced good construct validity with the Clinician Administered PTSD Scale and internal consistency (Cronbach’s a ¼ 0.87) (76). Cronbach’s alphas for the CASA subscale was 0.80, while alphas for the physical, emotional, and general subscales were 0.81, 0.85, and 0.64, respectively.

Difficulties in Emotion Regulation Scale (DERS) (73) The 36-item DERS was designed to provide a comprehensive measure of emotion regulation across six domains (i.e. nonacceptance, goals, impulse, awareness, strategies and clarity). Utilizing a 5-point Likert scale, questions include, ‘‘I pay attention to how I am feeling’’ and ‘‘When I’m upset, I have difficulty getting work done’’. Items were summed to provide a total score. Higher scores are interpreted as greater difficulty regulating emotions. In college student samples, high internal consistency has been reported for the DERS total score (Cronbach’s a ¼ 0.93) (73). Cronbach’s alpha in the current study was 0.91. Drinking Refusal Self-Efficacy Questionnaire – Revised (DRSE) (74) The DRSE is a 19-item measure, which assessed students’ perceived confidence in their ability to resist alcohol consumption across various situations. Utilizing a 6-point Likert scale, participants were asked to indicate ‘‘how sure’’ they are in their ability to resist drinking across items such as ‘‘when I am out at dinner’’ or ‘‘when I feel upset’’. The instrument includes three subscales (i.e. social pressure, emotional relief, and opportunistic self-efficacy), as well as a continuous total score, which was used in the current analyses. Higher scores are interpreted as stronger self-efficacy beliefs. The DRSE has evidenced good construct and concurrent validity as well as good internal consistency (a 0.84) (74,75). Cronbach’s alpha for the current study was 0.94. Early Trauma Inventory – Self Report – Short Form (ETI-SR-SF) (76) The ETI-SR-SF is a 29-item self-report questionnaire that measured four domains of childhood/adolescent trauma

PTSD Checklist – Civilian (PCL-C) (81) The PCL-C is a brief, 17-item self-report instrument designed to measure severity of non-military-related post-traumatic stress disorder (PTSD) symptoms as outlined by the DSM-IV. For example, questions include ‘‘Avoiding activities or situations because they reminded you of a stressful experience?’’ The PCL-C uses a 5-point Likert scale, and items were summed to provide a continuous measure of symptom severity. The PCL-C has evidenced psychometric properties superior to alternative trauma related self-report instruments in college populations (82). Cronbach’s alpha for the current study was 0.90. Analytic plan Data were cleaned, and covariates were chosen based on their potential impact on the dependent (i.e. problem drinking) and independent variables (see Results section) (83). The hypothesis examining the moderating potential of CASA and DRSE on the relations between emotion regulation difficulties and problem drinking was tested via a three-way interaction, using multiple hierarchical regression analyses. Covariates were entered on Step 1, the independent and moderator variables on Step 2 (i.e. DERS, CASA, and DRSE), twoway interactions among the independent and moderator variables on Step 3 (i.e. DERS CASA, DERS DRSE, and CASA DRSE), and the three-way interaction on Step 4 (i.e. DERS CASA DRSE). All variables were centered or dummy coded to reduce unnecessary collinearity. Interaction patterns were examined using a simple slopes analysis with continuous variables examined on lines representing one standard deviation above and below the mean (e.g. high and low DERS) (84). Moderation analyses have effectively been applied to cross-sectional models although inferences of


DOI: 10.3109/00952990.2014.998365

causality and temporal ordering of variables are precluded (85,86).


Results Please see Table 1 for means, standard deviations, and bivariate statistics. Overall, 68.8% of students reported drinking in the last 30 days, consistent with national rates of college students (1). Reported levels of alcohol consumption were in the problem drinking range (AUDIT M ¼ 7.58, SD ¼ 6.27) (72). CASA was reported by 25.8% of students. Endorsement across items ranged from 3.5–19.7%, consistent with previous reports in college populations (63,87–90). Nearly 88% of college students reported exposure to at least one potentially traumatic event, consistent with previous research findings (e.g. 66–94%) (91,92). All significant correlations were in the expected direction. Increased problem drinking was associated with increased emotion regulation difficulties and decreased DRSE. Gender was included as a covariate. Previous research has reported gender differences in alcohol consumption (56,58), and gender was positively related to DRSE scores (r ¼ 0.18), consistent with past findings (55,58). As discussed above, PTSD was also included as a covariate. Bivariate statistics indicated a positive relationship between PTSD symptoms and emotion regulation difficulties (r ¼ 0.54), CASA (r ¼ 0.29), and cumulative trauma exposure (r ¼ 0.50). Primary analyses Results for the moderation analyses are shown in Table 2. After accounting for gender and PTSD symptoms (Step 1), the main effect of DRSE on problem drinking was significant (p50.01), such that decreased DRSE scores were associated with increased problem drinking. Results of the model containing the two-way interaction terms (Step 3) indicated that no two way interactions were statistically significant (p’s40.05). Results of the full model containing the three-way interaction among DERS, DRSE, and CASA on problem drinking was significant [DR2 ¼ 0.06, DF(1,155) ¼ 13.76, p50.01]. As shown in Figure 1, for participants without CASA exposure, problem drinking was the greatest for students reporting decreased DRSE and increased emotion regulation difficulties. As CASA exposure increased, problem drinking was the greatest for those with decreased DRSE and decreased emotion regulation

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difficulties. Said another way, CASA-exposed students reporting decreased DRSE and superior emotion regulation abilities evidenced the highest rates of problem drinking. Subscales of the DRSE were examined to investigate the possibility that a specific DRSE domain was accounting for the main and interaction effects. The model’s total DRSE score was replaced with individual subscale scores. For each subscale model, the direction and significance of the DRSE main effect as well as the three-way interaction (i.e. DERS CASA DRSE subscale) was replicated (p’s50.05). The only difference between the total DRSE model and the subscale models was a significant main effect for DERS. Increased emotion regulation difficulties were associated with increased problem drinking in the social pressure and opportunistic self-efficacy subscales (p’s50.05), and at a trend level in the emotional relief DRSE subscale (p ¼ 0.06). Secondary analyses Secondary analyses examined a three-way interaction, substituting CASA with cumulative child/adolescent trauma exposure. Results are shown in Table 3. After accounting for gender and PTSD symptoms (Step 1), the main effect of emotion regulation was significant at a trend level (p ¼ 0.08) such that increased emotion regulation difficulties were Table 2. Three-way interaction results for the model examining CASA exposure on problem drinking. Predictor

b

b (SE)

Step 1 Gender PTSD Step 2 DERS DRSE CASA Step 3 DERS CASA DRSE CASA DERS DRSE Step 4 DERS CASA DRSE

0.01 (0.96) 0.05 (0.05)

R2

DR2

DF

0.01

0.01

0.64

0.24

0.23

15.80**

0.24

0.00

0.21

0.30

0.06

13.76**

0.00 0.09

0.04 (0.02) 0.19 (0.03) 0.59 (0.42)

0.13 0.43** 0.10

0.02 (0.02) 0.00 (0.04) 0.00 (0.00)

0.06 0.01 0.01

0.01 (0.00)

0.44**

**p50.01; CASA, Child/Adolescent Sexual Abuse; DERS, Difficulties in Emotion Regulation Scale; DRSE, Drinking Refusal Self-Efficacy Questionnaire – Revised; PTSD, PTSD symptoms.

Table 1. Descriptive and bivariate statistics.

1. AUDIT 2. DERS 3. DRSE 4. CASA 5. Trauma 6. PTSD 7. Gender Mean (SD) or % endorsed

1. AUDIT

2. DERS

3. DRSE

4. CASA

5. Trauma

6. PTSD

7. Gender

– 0.26** 0.45** 0.11 0.03 0.06 0.04 7.58 (6.27)

– 0.29** 0.23** 0.12y 0.54** 0.02 77.18 (22.28)

– 0.07 0.05 0.15y 0.18* 103.22 (13.48)

– 0.52** 0.29** 0.10 0.54 (1.19)

– 0.50** 0.03 4.90 (4.35)

– 0.07 30.08 (10.17)

–

**p50.01, *p50.05, yp50.10; AUDIT, Alcohol Use Disorders Identification Test; CASA, Child/Adolescent Sexual Abuse; DERS, Difficulties in Emotion Regulation Scale; DRSE, Drinking Refusal Self-Efficacy Questionnaire – Revised; PTSD, PTSD symptoms; Trauma, Cumulative Child/ Adolescent Trauma Exposure; Please see results section for frequency (%) of CASA and Gender variables.



associated with increased problem drinking. The main effect of DRSE on problem drinking was significant (p50.01). Decreased DRSE scores were associated with increased problem drinking. Results of the model containing the twoway interaction terms (Step 3) indicated that the two-way interaction between total trauma and DRSE was significant (p ¼ 0.03). As trauma exposure increased, decreased DRSE was associated with increased problem drinking. Last, the model examining the three-way interaction among emotion regulation difficulties, total trauma, and DRSE was significant [DR2 ¼ 0.11, DF(1,150) ¼ 25.12, p50.01]. The direction of findings replicated the CASA model. Decreased DRSE and increased emotion regulation difficulties related to greater problem drinking for students without a history of trauma. However, as cumulative trauma exposure increased, decreased DRSE and decreased self-reported emotion regulation difficulties related to increased problem drinking (see Figure 2). The model was replicated, investigating individual DRSE subscales in place of the total DRSE score. For each subscale Figure 1. The three-way interaction among emotion regulation difficulties, CASA exposure, and DRSE on problem drinking (p50.01). For individuals without a history of CASA, decreased DRSE and increased emotion regulation difficulties related to greater problem drinking. As CASA exposure increased, decreased DRSE and decreased emotion regulation difficulties related to greater problem drinking; CASA, Child/ Adolescent Sexual Abuse; DERS, Difficulties in Emotion Regulation Scale; DRSE, Drinking Refusal Self-Efficacy Questionnaire – Revised.

model, the direction and significance of the DRSE main effect as well as the three-way interaction (i.e. DERS Trauma DRSE subscale) was replicated (p’s50.05). Similar to the CASA model, the main effect for DERS was also replicated. Across each subscale, increased emotion regulation difficulties were associated with increased problem drinking (p’s50.05). To eliminate the possibility that CASA exposure may be accounting for the cumulative trauma findings, a variable reflecting total trauma minus CASA was calculated and substituted within the model. The pattern of findings including direction and significance was replicated.

Discussion The current study sought to examine the moderating potential of CASA exposure and DRSE on the relations between emotion regulation difficulties and problem drinking in college students. It was hypothesized that the relations between emotion regulation difficulties and problem drinking would be most salient for college students with a history of

15 13

Problem Drinking


192

11

(1) High DRSE, High CASA

9

(2) High DRSE, Low CASA

7

(3) Low DRSE, High CASA

5

(4) Low DRSE, Low CASA

3 1 Low DERS

High DERS

Table 3. Three-way interaction results for the model examining cumulative trauma exposure on problem drinking. Predictor Step 1 Gender PTSD Step 2 DERS DRSE Trauma Step 3 DERS Trauma DRSE Trauma DERS DRSE Step 4 DERS Trauma DRSE

b (SE)

b

0.22 (0.76) 0.05 (0.05)

0.02 0.09

0.04 (0.02) 0.19 (0.03) 0.16 (0.12)

0.15y 0.44** 0.11

0.00 (0.01) 0.02 (0.01) 0.000 (0.00)

0.06 0.20* 0.12

0.00 (0.00)

R2

DR2

DF

0.01

0.01

0.59

0.24

0.24

15.95**

0.27

0.02

1.67

0.37

0.11

25.12**

0.45**

**p50.01, *p50.05, yp50.10; DERS, Difficulties in Emotion Regulation Scale; DRSE, Drinking Refusal Self-Efficacy Questionnaire – Revised; PTSD, PTSD symptoms; Trauma, Cumulative Child/Adolescent Trauma Exposure.


DOI: 10.3109/00952990.2014.998365


15 13

Problem Drinking

Figure 2. The three-way interaction among emotion regulation difficulties, cumulative child/adolescent trauma exposure, and DRSE on problem drinking (p50.01). The pattern of findings was similar to the CASA model. For individuals with decreased trauma exposure, decreased DRSE and increased emotion regulation difficulties related to increased problem drinking. As cumulative trauma exposure increased, decreased DRSE and decreased emotion regulation difficulties related to greater problem drinking; DERS, Difficulties in Emotion Regulation Scale; DRSE, Drinking Refusal Self-Efficacy Questionnaire – Revised; Trauma, Cumulative Child/Adolescent Trauma Exposure.

193

11

(1) High DRSE, High Trauma

9

(2) High DRSE, Low Trauma

7

(3) Low DRSE, High Trauma

5

(4) Low DRSE, Low Trauma

3 1 Low DERS

CASA and decreased DRSE. Secondary analyses examined if the study hypothesis would generalize to participants’ cumulative child/adolescent trauma exposure. Results of the study highlighted two overarching contributions to the literature. First, while bivariate and multivariate statistics pertaining to emotion regulation were in the expected direction, the direction of emotion regulation finding within the three-way interaction was unexpected. Trauma-exposed students who reported decreased DRSE and superior emotion regulation abilities (or decreased difficulties) were at the greatest risk for problem drinking. The Difficulties in Emotion Regulation Scale (73) is frequently used to examine emotion regulation across a range of populations. The assessment most accurately measures subjective appraisals or perceived regulatory abilities to ‘‘take into account the contextually dependent nature of adaptive regulation strategies’’ (73). For students with a history of abuse, the relations between perceived regulatory abilities and problem drinking may be blurred by a college context, which arguably promotes alcohol use as an adaptive regulatory mechanism. Nearly 70% of students drink at least monthly, and 40% have engaged in binge drinking in the past two weeks (1). Drinking to regulate affective experiences is reported by students with (93) and without (14,16) trauma exposure. Further, for CASA-exposed students, the result of maladaptive coping (including alcohol use) may be emotional support or validation from peers (63). Plausibly, the emphasis on and motives for alcohol use in college contexts reduces insight into adaptive emotion regulation abilities for traumaexposed students. This may reduce perceived efficacy in turning down alcohol, and increase problem drinking for regulatory purposes. The second contribution of the current study confirms the importance of considering the role of DRSE in college problem drinking regardless of trauma exposure. Decreased DRSE was associated with increased problem drinking in the CASA and cumulative trauma models, as hypothesized and consistent with prior literature (57–58,61). DRSE was devised from Bandura’s (94) identification of efficacy and outcome expectancies. DRSE is conceptualized as the intervening

High DERS

variable between outcome expectancies and alcohol consumption (52,95). According to alcohol expectancy theory, contextual cues can become associated with one’s perceived ability to resist drinking and actual drinking behavior (52). Drinking behavior is more likely to occur in the presence of cues that signal a low perceived ability to resist alcohol. Such contextual cues may be particularly salient in college environments (e.g. alcohol availability, peer modeling, and drinking games). Recent findings have indicated that DRSE can also become associated with internal cues, namely negative affective states (62). Students at the greatest risk for problem drinking may believe that they are less able to resist alcohol in the presence of specific external (e.g. alcohol availability) and internal (e.g. negative affect) cues. Coupled with the current emotion regulation findings, alcohol use in the presence of emotion-related cues could be perceived as adaptive given that college students (with and without a history of trauma) report drinking for regulatory purposes. Clinical implications highlight the importance of considering perceptions of DRSE in brief alcohol interventions. Selfefficacy has been emphasized as a mechanism of behavior change, meaning that if perceptions of efficacy can be modified, future drinking behavior can be modified (53). Recent findings reported that drinking refusal self-efficacy can be enhanced in college alcohol interventions and mediated reductions in drinking across time (54). While decreased DRSE can place students at increased risk for problem drinking, DRSE effectively incorporated into brief alcohol interventions can reduce problem drinking and related consequences. Brief interventions may also work to integrate educational information regarding emotion regulation, methods of effectively managing emotions, and risk factors associated with using alcohol to regulate affect (e.g. heavier drinking and alcohol use disorders) (96). Potentially, including such information would benefit non-traumatized students where drinking is associated with increased regulation difficulties, as well as traumatized students by improving insight into their regulatory abilities and drinking behaviors. The current study identified factors that substantiate the relationship between emotion regulation difficulties and


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problem drinking in college; however, results are cautioned by study limitations. Data used for the current study were cross-sectional, which precludes causal and temporal interpretations. It is recommended that results be replicated using a more rigorous longitudinal design to better gauge temporal associations among variables. Further, data on the specific characteristics of participants’ abuse and possible (re)victimization after 18 years old were not collected during this study. Future research may take such factors into account given that they may influence regulatory abilities and alcohol consumption (97). The current study did not address how emotion regulation difficulties following early trauma may differ from emotion regulation difficulties not related to trauma exposure. Future research is needed to examine alternative factors that may drive emotion dysregulation and determine if differences in type of emotion dysregulation exist depending on precipitating factor. Last, the current findings are specific to a college sample and may not generalize to non-college young adults, or alternative community or clinical populations. In conclusion, for students without a history of child/ adolescent trauma exposure, decreased DRSE and increased emotion regulation difficulties are risk factors for increased problem drinking. However, as trauma exposure increased, decreased DRSE coupled with decreased (rather than increased) emotion regulation difficulties related to higher rates of problem drinking. Findings emphasize the importance of strengthening students’ beliefs in their ability to refuse alcohol. Results also emphasize the need to better understand how an alcohol laden college environment may bias subjective appraisals of regulatory abilities for students with a history of abuse, who may perceive alcohol use as an adaptive regulatory strategy.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.

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Drinking behavior and drinking refusal self-efficacy in Korean college students.

Developing a screening questionnaire for problem drinking in college students.

Problem drinking among college freshmen.

Drinking patterns and drinking problems of college students.

A Latent Profile Analysis of drinking motives among heavy drinking college students.

Emotion dysregulation and coping drinking motives in college women.

Measuring drinking patterns among college students.

Heavy drinking and alcohol-related injuries in college students.

Heterogeneous dose-response and college student drinking: examining problem risks related to low drinking levels.

Drinking consequences and subsequent drinking in college students over 4 years.

Social anxiety symptoms and drinking behaviors among college students: the mediating effects of drinking motives.

The road to drink is paved with high intentions: Expectancies, refusal self-efficacy, and intentions among heavy drinking college students.

Who's driving? college students' choices of transportation home after drinking.

College students' expectations of the results of drinking.

Response of colleges to risky drinking college students.

Association of acculturation with drinking games among Hispanic college students.

Problem drinking in women.

Do drinking motives distinguish extreme drinking college students from their peers?

College students' daily-level reasons for not drinking.

College students' drinking problems: a national study, 1982-1991.

Drinking to toxicity: college students referred for emergency medical evaluation.

College students' drinking motives and social-contextual factors: Comparing associations across levels of analysis.

Perceptions and practices of student binge drinking: an observational study of residential college students.

Difficulties in emotion regulation and problem drinking in young women: the mediating effect of metacognitions about alcohol use.