J. Pediatr. (Rio J.) vol.93 número5

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www.jped.com.br

REVIEW

ARTICLE

Factors

to

the

association

of

social

anxiety

disorder

and

alcohol

use

among

adolescents:

a

systematic

review

夽

Elisabeth

Lima

Dias

da

Cruz

a,∗

,

Priscila

Diniz

de

Carvalho

Martins

b

,

Paula

Rejane

Beserra

Diniz

a

a_Universidade_Federal_de_Pernambuco_(UFPE),_{Pós-graduac¸ão}_em_{Neuropsiquiatria}_e_Ciência_do_{Comportamento,}_Recife,_PE,

Brazil

b_Universidade_Federal_de_Pernambuco_(UFPE),_{Pós-graduac¸ão}_em_Saúde_da_Crianc¸a_e_do_Adolescente,_Recife,_PE,_Brazil

Received20October2016;accepted9January2017 Availableonline1June2017

KEYWORDS

Phobicdisorders; Adolescent; Behavior; Ethanol; Riskfactors

Abstract

Objective: Toidentifytheriskfactorsrelatedtotheassociationbetweensocialanxietydisorder

andalcoholuseinadolescents.

Sourceofdata: ThePICOresearchstrategywasusedtoperformasystematicreviewinMedline,

LILACS,Pubmed,IBECSandCochraneLibrarydatabases.DeCS/MeSH:PhobicDisorders,

Adoles-cent,Behavior,Ethanol,RiskFactors,andtheBooleanoperator‘‘AND’’wereused.Inclusion

criteriawere:cross-sectional,prospective/retrospectivecohort,andcase-controlstudies,

car-riedoutinadolescents(10---19years),originalarticlesonsocialanxietydisorderandalcohol

usepublishedbetween2010and2015.Studiesthatdidnotreporttheterms‘‘anxietydisorder’’

and‘‘alcoholuse’’inthetitleandabstractwereexcluded.

Synthesisofdata: 409articleswereretrieved;aftertheexclusionof277repeatedarticles,the

followingwereeligible:94inMEDLINE,68inPubmed,12inIBCS,andthreeinLILACS.Titles

andabstractswereindependentlyreadbytwoexaminers,whichresultedintheselectionof

eightarticlesfortheanalysis.Riskfactorsassociatedtothetwodisorderswerefemalegender,

age,peer approvaland affectiveproblems for alcohol use,confrontationsituations and/or

compliancereasons,frequencyofalcoholuse,andsecondarycomorbidities,suchasdepression

andgeneralizedanxiety.

Conclusions: Itisnecessarytoassesstheperiodofsocialanxietydisordersfirstsymptomonset,

aswell astherisks for alcoholuse inordertoestablish corrective interventionguidelines,

especiallyforsociallyanxiousstudents.

anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

夽 _Please_cite_this_article_as:_Cruz_EL,_Martins_PD,_Diniz_PR._Factors_related_to_the_association_of_social_anxiety_disorder_and_alcohol_use

amongadolescents:asystematicreview.JPediatr(RioJ).2017;93:442---51.

∗_{Corresponding}_author.

E-mail:[email protected](E.L.Cruz).

http://dx.doi.org/10.1016/j.jped.2017.05.001

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PALAVRAS-CHAVE

Transtornosfóbicos; Adolescente; Comportamento; Etanol;

Fatoresderisco

Fatoresrelacionadosàassociac¸ãodetranstornodeansiedadesocialeusodeálcool entreadolescentes:umarevisãosistemática

Resumo

Objetivo: Identificar os fatores de risco relacionados a associac¸ão entre o transtorno de

ansiedadesocialeusodeálcoolentreadolescentes.

Fontesdosdados: Utilizou-se a estratégia de pesquisa PICO para realizar a revisão

sis-temática nasbasesMedline,LILACS, Pubmed, IBECSeBiblioteca Cochrane.Foiutilizadoos

DeCS/MeSH:TranstornosFóbicos,Adolescente,Comportamento,Etanol,FatoresdeRiscoeo

operadorboleano‘‘AND’’.Oscritériosdeinclusãoforam:estudotransversal,coorte

prospec-tiva/retrospectivaecaso-controle,realizadosemadolescentes(10a19anos),artigosoriginais

sobretranstornodeansiedadesocialeusodeálcoolpublicadoentre2010a2015.Excluíram-se

osestudosquenãoreferiamtranstornodeansiedadeeusodeálcoolnotítuloenoresumo.

Síntesedosdados: 409artigosforamidentificadoseapósexclusãorepetidos277estudosforam

elegíveis:94noMEDLINE,68emPubmed,12IBCSe3LILACS.Foirealizadaaleituradostítulos

eresumosdeformaindependentepordoisexaminadores,queresultounaselec¸ãode8artigos

paraanálise.Fatoresderiscosassociadosaosdoistranstornos:predominânciadogênero

fem-inino,idade,aprovac¸õespelospareseproblemasafetivosparaousodeálcool,situac¸õesde

enfrentamentose/oumotivosdeconformidades,frequênciadeusodoálcoolecomorbidades

secundáriascomodepressãoeansiedadegeneralizada.

Conclusões: Énecessárioavaliaroperíododesurgimentodosprimeirossintomasdetranstorno

de ansiedade social e dos riscos para o uso de álcool e instituir normas corretivas de

intervenc¸ões,principalmenteparaosalunossocialmenteansiosos.

´

eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

Introduction

Social anxiety disorder (SAD) is a condition that starts in childhood/adolescence and is characterized by exces-sive fear or intense anxiety when the individual is faced with social exposure situations in public or meeting new people. It is estimated that between 5% and 13% of the population have this problem. It is considered as a chronic pathology, capable of incapacitating the indi-vidual and promoting the development of high rates of psychiatriccomorbidities, suchasdepression, generalized anxietydisorder,andagoraphobia,beingthemostcommon anxiety disorder and the third most frequent psychiatric disorder.1---4

Theseindividualshavedifficultiesininterpersonal rela-tionships(familyandsocialinteractions),lowself-esteem, low school performance, school dropout, and impairment inmemory, perception,andthinkingprocesses.Itis note-worthy that SAD usually precedes abuse and dependence of alcohol and other illicit substances, which aggravates symptoms.5

Consideredapublichealthproblem,alcohol experimen-tationtypicallybeginsinadolescence,betweentheagesof 12 and 15 years, regardless of social context; individuals withearlyonsetof SADareatrisk for developing depres-sionoralcoholism.2,6,7_This_diagnosis _occurs_shortly_before orconcurrentlywiththeonsetofsubstanceuse,which sug-gestsanassociationbetweenthesetwohealthproblemsand that,eveninthefaceofthisevidence,thistypeofdisorder inadolescencehasshownaconflictingassociationwiththe useofalcohol.

Thepresentsystematicreviewaimedtoidentifytherisk factorsrelatedtotheassociationbetweenSADandalcohol useamongadolescents.

Method

Asystematicreviewoftheliteraturewascarriedoutbased onasearchintheMedicalLiteratureAnalysesandRetrieval Online(Medline),LatinAmericanandCaribbeanLiterature in Health Sciences (LILACS), PubMed, Indice Bibliográfico Espa˜noldeCienciasdelaSalud(IBECS),andtheCochrane Librarydatabases.

Foreachresearchportal,aspecificstrategywas devel-opedfor crossing Descriptors in HealthSciences (DeCS, a Braziliandatabaseofmedicalkeywords)orMedicalSubject Headings(MeSH).Thekeywordsusedforthestudyselection were:PhobicDisorders,Adolescents,Behavior,Ethanol,Risk Factors, and the corresponding terms in Portuguese. The Booleanoperator‘‘AND’’wasusedtocombinekeywordsand termsforsearches.Theselectionwaslimitedtostudies pub-lishedinPortuguese,English,orSpanishbetween2010and 2015.

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andcase---controlstudies,carriedoutinhumansaged10---19 years10_;_original_studies;_with_alcoholism_as_a_risk_factor_for phobicdisorders.Studies that didnotmentionalcoholism andphobicdisordersinthearticletitlewereexcluded,as wellasthosewithapopulationofyoungadultsaged20---24 years.

Articleselectionwascarriedoutinthreesteps, follow-ing the Transparent Reporting of Systematic Reviews and Meta-Analyses(PRISMA)method.11_In_the_first_step,_two inde-pendentresearchersreadthe titles withoutknowledge of the authors and the journal where they were published. After the exclusion of the repeated articles, the second stepbegan,inwhich theabstractsoftheselectedstudies werereadand,likewise,thosethatdidnotmeetthe inclu-sioncriteriawereexcluded.Disagreementswereresolvedby consensus.Inthethirdstep,allstudiesnotexcludedinthe previousstepswerereadinfulltoselectthosethatwould beincludedinthisreview(Fig.1).

Results

Afterexclusionofthe repeatedarticles,277 studieswere eligible:94inMEDLINE,68inPubmed,12inIBCS,andthree inLILACS.Thetitlesandabstractswereindependentlyread bytwoexaminers,totalingeightarticlesforanalysisinthis review.

Table1showsthecharacteristicsoftheeightstudiesand the type of protocols used; one study was carried out in FinlandandsevenintheUnitedStates.Atotalof4579 ado-lescents,aged10---19years,whohadsymptomsofSADand whoconsumed alcohol wereinvestigated. In62.5% of the studies, the female gender predominated, accountingfor 54%ofthetotalsample.

The association between social anxiety symptoms and alcohol use was confirmed in six studies, two of which werecarriedoutinagroupof adolescentswithmeanage between10and11years,whereastheothersevaluated ado-lescentsolderthan15years.Theriskfactorsattributedby the studies for this association werefemale gender, peer acceptance,andaffectiveproblemsforalcoholuse,aswell asthepresenceofsecondarycomorbidities,suchas depres-sion,generalizedanxiety,agoraphobia,separationanxiety, and obsessive---compulsive disorder. Other factors such as cultural aspects,frequency ofalcohol use, andfrequency ofintoxicationinvestigatedbythestudiesdidnotappearto berelatedtothisassociation(Table2).

Discussion

The findings show that the evaluated association is still unclear,duetothesmallnumberofstudiesretrieved; how-ever,75%ofthestudiesshowedpositiveevidencebetween theassociationofSADandalcoholuse.

409 articles identified through database search

Screenin

g

Include

d

Eligibilit

y

Identification

132 duplicate articles subsequently removed

277 selected articles 258 excluded articles

19 full-text articles evaluated for readability

Full text articles excluded

Six did not have alcohol in title or abstract

Two included adults in the sample

Three included late adolescents in the sample Studies included for

quantitative synthesis (n = 8)

Figure1 Flowchartrepresentingtheselectionstepsofarticlesaboutsocialanxietydisorderandalcoholabuseinadolescents.

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Table1 Characteristicsofthestudiesandtypesofprotocolsused.

Authors,year,and

impactfactor(IF)

Country Studydurationand

sample

Genderandage Typeofstudy Researchtool

Fröjdetal.(2011)

IF:1.09

Finland 48months

Sample:2070

Boys:903

Girls:1167

Meanage:17.6

(SD=0.41)

Longitudinal study

SocialPhobiaInventory

(SPIN)

Terleckietal.

(2012)

IF:1.36

USA Sample:52 Boys:35

Girls:17

Meanage:20.38

(SD=1.46)

Longitudinal study

AlcoholUse

DisorderIdentification

Test(AUDIT)

BriefAlcoholScreening

andInterventionfor

College

Students(BASICS)

Quantity/Frequency/Peak

Index(QFI)

DrinkingNormsRating

Form(DNRF)

SocialPhobiaScale(SPS)

andtheSocial

InteractionAnxietyScale

(SIAS)

SpielbergerTraitAnxiety

Inventory

Dahneetal.

(2014)

IF:1.41

USA 48months

Sample:277

Boys:156

Girls:121

Meanagede11

(SD=0.81)

Longitudinal study

Generalizedestimating

equations(GEE)

TheRevisedChild

AnxietyandDepression

Scale(RCADS)

YouthRiskBehavior

SurveillanceSystem

Zeheetal.(2013)

IF:1.4

USA 12months

Sample:387

Boys:174

Girls:213

Meanage:12.1

Longitudinal study

SocialAnxietyScaleFor

Children---Revised

(SASC-R)

YouthSelf-ReportSurvey

(YSR)

Terleckiand

Buckner(2015)

IF:1.4

Girls:161

Meanage:19.32

(SD=1.34)

Cross-sectional study

SocialPhobiaScale(SPS)

SocialInteraction

AnxietyScale(SIAS)

DrinkingMotives

QuestionnaireRevised

(DMQR)

DrinkingContext

Scale-Revised(DCS-R)

Blumenthaletal.

(2010)

IF:1.36

Girls:26

Meanage16.35

(SD=1.10)

AdolescentAlcoholand

DrugInvolvementScale

(AADIS)

YouthSelfReport(YSR)

DrinkingMotives

QuestionnaireRevised

(DMQ-R)

RevisedChildAnxiety

andDepressionScale

---Socialphobiasubscale

(RCADSSP)

Wuetal.(2010)

IF:1.47

Girls:369

Meanage:15

DiagnosticInterview

ScheduleforChildren

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Table1(Continued)

Authors,year,and

impactfactor(IF)

Country Studydurationand

sample

Genderandage Typeofstudy Researchtool

Clerkin.Barnett

(2012)

IF:1.4

USA 12months

Sample:730

Boys:295

Girls:435

Meanage18.35

(SD=0.47)

SocialAvoidanceand

DistressScale(SADS)

DrinkingMotives

Questionnaire---Revised

TheGraduated

FrequencyforAlcohol

Questionnaire

YoungAdultAlcohol

ProblemsScreeningTest

Contextualization

of

study

location

Thisreviewidentifiedapredominanceofstudiescarriedout indevelopedcountries,primarilyintheUnitedStates,which maybe relatedtogreater epidemiological surveillance in mentalhealthforchildrenandadolescents.

Itis importanttoremember thatapproximatelyonein fiveadolescentsinthatcountrysufferfromamental disor-dersevere enoughtohaveanimpactontheiractivitiesof dailyliving,andthesearerelevantdatafortheincreasein theinvestigations.12

InBrazil,population-basedstudieshaveshownthatthe onsetofanxietydisordersoccursatthemeanageof13years andtheuseofalcoholbetween12and15years,while sub-stanceabusebeginslater,attheageof24years.Thismay beanindicationthattheresourcesavailableforthe treat-mentofmentaldisordersinchildrenandadolescentsmight bedeficient,consequentlyincreasingtheratesof comorbid-ityinearly adultlife.13,14 _This_review_did_not_retrieve_any Brazilianpublicationthatcouldclarifythenationalreality abouttheassociationbetweenSADandalcoholuse.

These data are important to emphasize the need to diagnose and follow-up adolescents who are predisposed to developing mental disorders and to initially establish preventiveactionsinschoolsandhealthcareservices,thus reducingthelong-termassociatedburdenontheindividual, family,andcommunity.

SAD

and

alcohol

use

GiventhatSADisoneofthemostprevalentpsychiatric con-ditionsintheworld’spopulation,secondonlytodepression,6 andthatitsdevelopmentprecedestheonsetofalcoholuse disorders,itis importanttocarryoutalcoholintervention activities,15 _as _young _individuals _with _SAD _are _five _times morelikelytodevelopalcoholdependencethanthose with-outthedisorder.14,16---20

Studies that failed to show a significant association betweenSADandalcoholuseinadolescents,15,21_still indi-cated the possibility of reaching different results when culturaldifferenceswereobserved,suchasfreeaccessto alcoholbyadolescents.Anotherobservedriskwasthe devel-opmentofthisassociationwithdepression,whichmayoccur inlateadolescenceortakemorethantwoyearstodevelop.

Itisworthemphasizingtheimportanceofrecognizingand treating anxiety disorders in childhood,especially among girls,aimingtohelpthempreventthedevelopmentof sub-stanceusedisordersandsecondarycomorbidities.22

According to the Differential Diagnostic Guidelines for SocialAnxietyDisorder,theageofSADonsettendstooccur earlier and the distribution between the genders is more homogeneous.3_When _analyzing _gender_in _association_with alcohol consumption among Brazilian adolescents in the NationalSchoolHealthSurvey(PeNSE2012),ahigher preva-lenceofthefemalegender(51.7%;95%CI:50.8---52.6)was observed.23 _When_assessing_the_influence_of_gender_on_the association between illicit substance use and social anxi-ety,itwasobservedthatwomenwithhigherlevelsofsocial anxietyhadahighernumberoffriendswhousedrugsand alcohol.24

However, there are differences between the patterns observed in adolescents and the results of studies with adults,i.e.,theassociationbetweenanxietydisordersand substanceusecanchangefromadolescencetoadulthood.22 What isinitially usedasananxiety coping tool, attenuat-inginhibition and makingthem feelsafewhile alleviating the fear in social situations throughout life, can lead to embarrassingsituationsanddependence,aswellasthe per-sistenceofphobicsymptoms.25

In the study carried out at schools, libraries, and adolescent clubs in the Washington, DC, United States metropolitanarea,theratesofalcoholusewererelatively low; however,theresults indicated thatyoung individuals weremorelikelytohaveproblemswithalcoholconsumption overtime.26

In the study that investigated social anxiety, general-izedanxiety,andsubstanceuse(cigarettesandalcohol)in theearly adolescencephase,itwasobservedthatfor the female gender, social anxiety is a risk factor when alco-holuse approval use bypeers is high (highlevels ofpeer approvalandhigh levelsofsocialanxiety wereassociated withahighlikelihoodofsubstanceuse),whereasfor gener-alizedanxiety,itisconsideredariskfactorwhentheuseby peersislow.27

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anxiety

and

alcohol

use

among

adolescents

447

Table2 Summaryofstudiesandriskfactorsassociatedwithsocialanxietydisorderandalcoholuseinadolescents.

Authors,yearand

impactfactor(IF)

Objective Analyzedriskfactors Results Conclusions

Fröjdetal.(2011)

IF:1.09

Toinvestigatewhetherthe

associationbetweenanxietyand

alcoholandothersubstancesare

alreadyevidentinthemiddle

adolescence,andwhetherthe

generalanxietyorsocialphobia

symptomsaffectsthecontinuityof

frequentuseofalcohol,frequent

drunkenness,andmarijuanause.

Generalizedanxiety

Socialphobia

Substanceuse

Frequencyofuse

Drunkennessfrequency

Useofmarijuana

Anxietyprecededtheuseofthe

substance,whilenoreciprocal

associationswereobserved.

Depression-mediatedassociations

betweenanxietyandsubstanceuse.

Symptomsofsocialphobiadidnot

increasetheincidenceofsubstance

use,butoverallanxiety.

Generalanxietyincreasedthe

persistenceoffrequentalcoholuse,

whileco-morbidsocialphobia

decreaseditspersistence.

Generalanxietyinadolescenceputs

adolescentsatriskforsubstanceuse.The

riskmay,however,beassociatedwith

depression.Socialphobiainmiddle

adolescencemayprotectagainstsubstance

use.

Adolescentswithsymptomsof

internalizationmayneedguidancein

copingwithsymptoms,eventhoughthe

symptomsdidnotmeetthecriteriaof

moodoranxietydisorder.

Terleckietal.

(2012)

IF:1.36

Toevaluatewhethersociallyanxious

studentsshowedlesschangein

alcoholusebehavioramongcollege

students.

Socialanxiety

Typicaldrinks

Rulesfordrinking

Amongstudentswithminorchanges

inrules,beingamemberofagroup

withsocialanxietywasassociated

withheavierdrinkingoftypical

drinks.

Amongstudentswithmajorchanges

inrules,beingamemberofasocial

anxietygroupwasnotsignificant.

Generalizedanxietyinmiddleadolescence

putsadolescentsatriskforconcomitant

substanceuseandsubsequentlyinlate

adolescence.

Theriskmay,however,beassociatedwith

depression.

Socialanxietyanduseofalcoholor

substancewasnotobservedinmiddleand

lateadolescence.

Dahneetal.

(2014)

IF:1.41

Toassesswhethersocialphobia

symptomspredictedincreased

likelihoodofalcoholuseovertime.

Demographicdata

Psychopathology

Alcoholuse

Therewerecorrelationsbetweenthe

baselinepredictors(child’sage,

child’sgender,baselinealcoholuse,

socialphobiasymptoms)andwaves

1---5alcoholuse

Ingeneral,theconcurrent

associationswerelowtomoderate.

Ithighlightstheimportanceofsocialphobia

symptomsinpredictingalcoholuseover

timeamongyoungadolescents.

Severalfuturedirectionswithinthislineof

researchwouldbevaluable,including

expandingtheassessedagerangeto

youngerchildrenandadolescents/older

youngadults.

Zeheetal.(2013)

IF:1.4

Toassesstheassociationbetween

socialandgeneralizedanxiety

symptomsandalcoholandcigarette

useinearlyadolescenceandasa

precautionarymeasure(perceived

peeruseapproval)and(perceived

usepoint)descriptiverulesmay

moderatetheassociation.

Peernorms

Genderdifferences

Peernormsweremoderatedforthe

associationbetweensocialanxiety

symptoms,generalizedanxiety,and

thelikelihoodofalcoholand

cigaretteusebygirls,butnotfor

boys.

Girlswithhighlevelsofsocialanxiety

symptomswereatriskforusewhen

perceivedpeerapprovalofusewashigh,

andprotectedfromusewhenperceived

peerapprovalofusewaslow.

Profilesofanxietysymptomsandperceived

peerapprovalofusemayhelpidentifygirls

whoarepotentialtargetsforintervention,

butthenatureoftheseinterventionsisstill

unclear,sincethisstudydidnotassessthe

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Cruz

EL

et

al.

Table2(Continued)

Authors,yearand

impactfactor(IF)

Terleckiand

Buckner(2015)

IF:1.4

Identifycognitive/motivational

factorsrelatedtodrinkingin

high-risksituations.

Demographicdata

SocialanxietyandReasonstodrink

Highsocialanxietywasassociated

withgreatercopingandcompliance

reasons.

Bothcopingandcompliancemotives

weremediated,theassociation

betweensocialanxietytoheavy

alcoholconsumptiontonegative

emotionalandpersonal/intimate

contexts.

Multiplemediationanalysishas

indicatedthattomediateanxiety

situationsuniversitystudentsdrink

socially,suchthatheavydrinking

amongcollegestudentswith

clinicallyelevatedsocialanxietycan

beattributedjointlytothedesireto

dealwithnegativeaffectandto

avoidsocialscrutiny.

Blumenthaletal.

(2010)

IF:1.36

Toassessthereasonsforalcoholuse

amongyoungindividualsasafunction

ofsocialanxiety,associatedvariables

(age,gender,frequencyofalcohol

use,affectiveproblems)

Age

Frequencyofalcoholuse

Affectiveproblems

Highsocialanxietywassignificantly

associatedwithahighlevelof

affectiveproblems,aswellaswith

copingreasons.

Socialanxietywassignificantly

associatedwithcopingmotives,so

thatyoungindividualswhohadhigh

socialanxietyreportedgreater

motivationtodrinkfor

coping-relatedpurposes.

Sociallyanxiousyoungindividuals

endorsehigherconsumptionmotives,

relatedtocopingissues,a

characteristicthatmayputthemat

riskfordevelopingalcoholism

problems.

Prospectivestudiesfocusedon

clarifyingassociationsbetween

adolescentsocialanxiety,dealing

withreasonsfordrinkingand

problematicuseofalcohol,withthe

ultimategoalofdesigningprevention

programstargetingyoungindividuals

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anxiety

and

alcohol

use

among

adolescents

449

Table2(Continued)

Authors,yearand

impactfactor(IF)

Wuetal.(2010)

IF:1.47

Toassesstheuseofthreesubstance

categoriesbyadolescents(frequent

smoking,frequentdrinking/heavy

use,anduseofillicitdrugs)in

relationtoeachofthesixanxiety

disorders(socialphobia,

agoraphobia,highanxiety

disorder/generalizedanxiety

disorder,separationanxiety,and

obsessive-compulsivedisorder).

Substanceuse

Anxietydisorder

Demographicsandfamilyfactors

Depression

Socialphobiawasassociatedwith

smokingonlyamongboys.Forgirls,

socialphobiaappearedtobe

negativelyassociatedwithdruguse.

Fortheotheranxietydisorders,

associationswithsubstanceusetend

tobestrongeramonggirls.

Therewasanassociationbetween

socialanxietysymptomsandalcohol

useonlyingirls.Frequentorheavy

drinkingwasmorecommonamong

boysthangirls,butthisdifference

wasonlymarginallysignificant.

Thedifferencesbetweenthe

patternsobservedinthestudy

sampleofadolescentsandtheresults

ofstudieswithadultsregardingsocial

phobiatosomeextentindicatethat

theassociationbetweenanxiety

disordersandsubstanceusemay

changefromadolescenceto

adulthood.

Clerkinand

Barnett(2012)

IF:1.4

Totesttheseparateandinteractive

effectsofdrinkingmotivesandsocial

anxietysymptomsinpredicting

drinkinganddrinking-related

problems.

Socialanxietysymptoms

Reasonstodrink

Alcoholconsumption

Problemswithalcohol

Increasedsocialanxietysymptoms

weresignificantlyassociatedwith

lessalcoholconsumption,andthere

wassomeevidencethatgreater

socialanxietysymptomswerealso

associatedwithgreaterproblems

withalcohol.

Themaineffectsofsocialanxiety

symptomsandconsumptionmotives

weremoreinfluentialinpredicting

consumptionoutcomes.

Greatersocialanxietywasassociated

withgreaterendorsementofcoping

andcompliancemotives,andless

endorsementofreasonsfor

enhancement.

Symptomsofsocialanxietywere

associatedtoloweralcohol

consumption,andalsowithmore

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increasedmotivationto drinkassociatedwithcoping pur-poses.Thiswasalsodemonstratedinthethreemodelsused toassessthegroupsofpeoplewithsocialanxietywhoused alcohol in situations of confrontation and/or compliance reasons.29

Adolescentswithelevatedsocialanxietysymptoms con-sumelessalcohol,butshowahigherassociationwhenitis relatedwithcopingendorsementandcompliancemotives.30

Future

perspectives

Thelimitationsoftheanalyzedstudiesarebasedonsample size;onthe shortperiodof follow-upof the adolescents; on the fact that, as it was not possible to observe the students’behaviorduringthetransitionperiodfrom elemen-tarytohighschool,15,26,28_the_results_cannot_be_generalized for allphases of adolescenceor for allregions (ruraland urban areas), since each phase has different characteris-tics and behaviors regarding the decision-making for use of alcohol according to the place of residence27_; _and _on theuseofacombinationofvariablesregardingtheuseof alcohol,cigarettes,marijuana,andothersubstances,which hasimplicationsfortheirassociationwithanxiety,aseach substancehas uniquepropertiesanddistinct physiological effects.21,22,27

Regardingfutureinvestigations,itisnecessarytoassess theindividualsattheinitial,middle,andlateadolescence phases, as well as to expand racial and ethnic groups; to use both the descriptive analysis (perceptions of the drinkingbehavior)andtheanalysisofprecautionarynorms (approval/disapprovalof thedrinkingbehavior); to evalu-atethetreatmentanditseffectsontheadolescent;andto assessthecopingreasonsfordrinkingandproblematicuse ofalcohol,withtheultimategoalofdevelopingprevention programsaimedatyoungindividualsatrisk.

Limitations

The present systematic review study had as limitations: (a)non-use ofthe Webof ScienceandPschynfo scientific databases,withthelatterbeingthedatabasespecializedin behavioralandsocialscienceresearch;(b)scarcityof stud-iespublishedinPortuguese,English,orSpanish;and(c)the smallnumberofarticlesincludedintheanalysis.

Despitethelimitations,thisreviewbecomesrelevant,as itallowedtheidentificationandunderstandingofthemain riskfactorsassociatedwithSADandalcoholusein adoles-cents,inadditiontobroadening theknowledgeabout the subject.

Conclusions

TheassociationbetweenSADandalcoholuseinadolescents appears tobe unclear, due to the few identified studies, the methodological heterogeneity, and their regionaliza-tion.Nevertheless,thisreview raisedinterestingevidence ontheexistenceofthisassociationandidentifiedthemain riskfactorsrelatedtotheassociationbetweenSADand alco-hol use among adolescents, such as female gender, peer acceptance,andaffectiveproblemsregardingalcoholuse,

aswellasthepresenceofsecondarycomorbidities,suchas depression and anxiety disorders. Therefore,studies with representativesamples,withanincreaseintheracialand ethnicgroupsandthatcontemplatetheinitial,middle,and latephasesofadolescencearestillnecessary.

Some authors also suggest that prospective studies be carriedouttoobservestudents’ behaviorduringthe tran-sition period from elementary to high school, as well as evaluatetheonsetperiodofthefirstsymptomsofSADand therisksforalcoholuse;assessthereasonsforalcoholuse; evaluatetreatment anditseffectsonadolescents;andto implementcorrectiveinterventionguidelinesforalcoholuse amongsociallyanxiousstudents.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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