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Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity
Open accessAbstract
A large body of research has examined the development of internalizing and externalizing symptoms in childhood and early adolescence. Notably, there is significant concomitant impairment associated with early adolescent symptomatology, as well as association of these symptoms with future development of psychopathology, poor physical health, self-destructive thoughts and behaviors, criminal behavior, and HIV risk behaviors. Drawing on negative reinforcement theory, the current study sought to examine the potential role of distress tolerance, defined as the ability to persist in goal-directed activity while experiencing emotional distress, as a potential mechanism that may underlie both internalizing and externalizing symptoms among 231 Caucasian and African American youth (M age=10.9 years; 45.5% female; 54.5% Caucasian ethnicity). A series of regressions resulted in significant moderated relationships, such that low distress tolerance conferred increased risk for alcohol use among Caucasians, delinquent behavior among African Americans, and internalizing symptoms among females. Clinical implications, including the potential role of negative reinforcement models in early intervention with young adolescents, are discussed.
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“findings that SIDI targets distress tolerance directly (and effectively) suggest the potential portability and generalizability of this treatment, highlighting its potential utility for a variety of psychological difficulties and maladaptive behaviors thought to stem from distress intolerance”
From Initial RCT of a distress tolerance treatment for individuals with substance use disorders (2012) · cites this paper as Daughters et al., 2009
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Lower distress tolerance levels were found to be associated with more severe internalizing symptoms”
From The Factorial Structure, Psychometric Properties and Sensitivity to Change of the Distress Tolerance Scale for Children with Emotional Disorders. (2024) · cites this paper as [29]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“and that is associated with higher levels of externalizing problems (such as alcohol use and delinquent behaviors) among nonclinical samples of both Western and Chinese adolescents”
From The Factorial Structure, Psychometric Properties and Sensitivity to Change of the Distress Tolerance Scale for Children with Emotional Disorders. (2024) · cites this paper as [29]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
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“a variety of psychological difficulties and maladaptive behaviors thought to stem from distress intolerance (e.g., Bornovalova et al., 2008; Daughters et al., 2008; Daughters et al., 2009).”
From Initial RCT of a distress tolerance treatment for individuals with substance use disorders (2012) · cites this paper as Daughters et al., 2009
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“The toleration of distress may be exhibited as the ability to move in a goal-directed activity while experiencing emotional distress and the ability to withstand experiential discomfort (e.g., Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Daughters et al., 2009).”
From Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD (2014) · cites this paper as Daughters et al., 2009
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“Globally, these results are in line with our hypotheses and with those postulated in previous studies (e.g., [25,28,29]).”
From The Factorial Structure, Psychometric Properties and Sensitivity to Change of the Distress Tolerance Scale for Children with Emotional Disorders. (2024) · cites this paper as [29]
Experimental — accuracy not yet measuredIn the citing paper
“The PASAT-C (Lejuez et al., 2003) is a widely employed behavioral measure of distress tolerance (Daughters, Lejuez, Kahler, Strong, & Brown, 2005; Daughters et al., 2009; Lejuez et al., 2003).”
From Investigating the association between parental reflective functioning and distress tolerance in motherhood. (2015) · cites this paper as Daughters et al., 2009
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“Available work suggests that lower levels of perceived DT for emotional distress and aversive physical states, as well as a lesser ability to withstand acute episodes of emotional stress, are significantly related to increased intensity of hyperarousal anxiety symptoms and panic attacks (Boelen and Reijntjes 2009; Bon…”
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“Details of the larger longitudinal study are reported elsewhere (Daughters et al., 2009; MacPherson, Magidson, Reynolds, Kahler, & Lejuez, 2010).”
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“Daughters et al. (2009) emphasized that inadequate or poor coping strategies, particularly during adolescence, may result in psycho-pathological symptoms in adulthood [53].”
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“Procedure Informed consent was obtained from parents and children provided assent prior to completing a series of self-report questionnaires as part of a larger battery of assessments (see Daughters et al., 2009) in a private room.”
MethodSelf-citationCarson, N. J., Cook, B. L., Chen, C.-N., & Alegría, M. (2012) · Journal of Children and Media · doi:10.1080/17482798.2012.724592 · Cited by 8
“Some authors have proposed that some youth use avoidant coping styles to tolerate the negative affect that accompanies externalizing behaviors (Daughters et al., 2009).”
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“Furthermore, inasmuch as addicts and posttraumatic stress disorder patients often exhibit an inability to tolerate distress (Daughters et al. 2009; Howell et al. 2010; Marinkovic et al. 2009), studies have shown that they can reduce their alcohol intake by learning strategies to cope with stress (Armeli et al.”
BackgroundTonarely, N. A., Hirlemann, A., Shaw, A. M., LoCurto, J., Souer, H. R., Ginsburg, G. S., Jensen‐Doss, A., & Ehrenreich, J. T. (2020) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-020-09830-7 · Cited by 10
“%) than reported in previous studies of nonclinical youth (50–60%; Cummings et al. 2013; Daughters et al. 2009).”
BackgroundMethodResultInfluentialDistress Tolerance as Risk and Maintenance Factor for PTSD: Empirical and Clinical Implications
Vujanovic, A. A., Litz, B. T., & Farris, S. G. (2015) · Springer eBooks · doi:10.1007/978-3-319-08359-9_66 · Cited by 17
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“they develop is also considered to be distinct (Achenbach & Edelbrock, 1984; Daughters et al., 2009).”
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“Globally, these results are in line with our hypotheses and with those postulated in previous studies (e.g., [25,28,29]).”
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“The BIRD has been validated as a behavioral measure of distress tolerance in samples of adolescents (Amstadter et al., 2012; Daughters et al., 2009; MacPherson et al., 2010), and those studies found that around 50% of adolescents quit the task early.”
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“It should be noted that the BIRD task has been typically used with adolescent participants (Daughters et al., 2009; Danielson et al., 2010; Amstadter et al., 2012), whereas its predecessor task, the PASAT, has typically been used in adults.”
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“Participants commonly “max out” on tasks of psychological DT (i.e., Abrantes et al., 2008; Daughters et al., 2009; Kiselica et al., 2015; McHugh et al., 2011; Sirota et al., 2013), resulting in clear ceiling effects.”
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Self-citationDefining distress tolerance in a structural model of Big Five personality domains
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“…as risk-taking (Game of Dice Task (Brand et al., 2002)), peer influence over risk evaluations (Social Influence Task (Chawla et al., 2009)), and cognitive persistence under conditions of frustration tolerance (Behavioral Indicator of Resiliency to Distress (BIRD) Task (Daughters et al., 2009)).”
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“a proxy for engagement in negative reinforcement behavior (Daughters et al., 2009).”
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“Therefore, we summed the raw scores of the depression and PTSD scales at each time point, and used the resulting composite scores as an index of internalizing problems, in keeping with previous studies (Daughters et al., 2009; Murray et al., 2021; Wang et al., 2021).”
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“Further, internalizing behaviors often may lead to externalizing behaviors, which habitually violate social norms or standards such as lashing out, physical assault, defiance and substance abuse (Eisenberg et al., 2001) (Daughters et al., 2009; Lau et al., 2021; Martel, 2013; Mas-chi et al., 2008).”
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“…(e.g., low distress tolerance or higher levels of rumination) were found to be linked to internalization problems among girls, but not boys [27], who report more externalization problems than girls [28]. as well as their internalizing (i.e., anxiety and depression), and externalizing…”
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“In addition, the lack of a significant moderating effect of gender is also consistent with prior research (Yoon et al., 2018), though it is inconsistent with the results of an empirical study (Daughters et al., 2009).”
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“Past research has examined the relationship between depressive symptoms, negative affect, and DT [20-24], as well as PTSD and DT [14,18].”
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Self-citationElevated integration within the reward network underlies vulnerability to distress
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“…sex differences may serve as a starting point for continued research in this area and mirror some previous work on DT in non-autistic adolescents (Daughters et al., 2009, 2013), and elevated emotion dysregulation and intolerance of uncertainty in autistic females (Cai et al., 2019; Wieckowski et…”
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“The presence of higher peak cortisol in response to induced stressors/cues in substance abuse dropouts found by Daughters et al. [96] and Fatseas et al. [31] indicated that a distorted HPA axis may exist in substance abusers.”
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“These results were consistent with the results of Moschak et al. (2017), Daughters et al. (2009), and Forouzanfar et al. (2017).”
BackgroundResultSmith, R. K. (2020) · Carolina Digital Repository (University of North Carolina at Chapel Hill) · doi:10.17615/rnvj-4k02 · Cited by 1
THE EASE PROGRAM: THE DEVELOPMENT OF A DISTRESS TOLERANCE INTERVENTION FOR MIDDLE SCHOOL ADOLESCENTS
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Sheedy, A. L. (2013) · Syracuse University Libraries (Syracuse University)
Thomas, A. L. (2015) · TopSCHOLAR (Western Kentucky University)
Evaluation of Behavioral Distress Tolerance Task Stability Across Settings
Overstreet, C. M. (2015) · VCU Scholars Compass (Virginia Commonwealth University) · doi:10.25772/qtgt-mf81
“…from negative reinforcement theory whereby actions of avoidance and escape are core motivations for behavior in the presence of negative stimuli (Daughters et al., 2009), individuals 7 exhibiting low levels of DT would theoretically perceive negative internal states as overwhelming and…”
BackgroundInfluentialInterpersonal Aggression Perpetration: Static and Emotion Regulation Risk Factors
Panuzio, J. (2011) · Lincoln (University of Nebraska)
Macintyre, J. (2013) · Murdoch University Research Portal
Acceptance and Commitment Therapy for Adolescent Difficulties with Emotion Regulation: An Open Trial
Duenas, J. A. (2016) · ScholarWorks - WMU (Western Michigan University)
Gender Differences in Terms of Life Stressors in Adolescence
Fortes, L. D. S., & Fernandes, M. (2018) · Indian Journal of Mental Health(IJMH) · doi:10.30877/ijmh.5.3.2018.317-323
“For instance, adolescent girls’ response to stress is characterized by negative self-evaluation, rumination, and withdrawal [16; 30-31], whereas adolescent boys’ response to stress most frequently takes the form of risk behaviour such as substance use, delinquency, and disagreeable, aggressive or…”
الباقی, أ. إ. م. ع. (2018) · دراسات نفسية · doi:10.21608/psj.2018.91953
Minority stress, emotion regulation, and substance misuse in sexual minoritiesPreprint
Rogers, A. H., van Dyk, I. S., Haines, N., Hahn, H. A., Aldao, A., & Ahn, W. (2017) · PsyArXiv (OSF Preprints) · doi:10.31234/osf.io/cxv5z
The action of maternal separation on glutamate receptors and neuroinflammation
Ganguly, P. (2018) · Digital Repository Service (Northeastern University) · doi:10.17760/d20316401
Association between cognition and personality factors among female harmful substance users
Sannamoth, R., & Halder, S. (2023) · Telangana Journal of Psychiatry · doi:10.4103/tjp.tjp_36_22
Zeng, Z. (2024) · Studies in Social Science Research · doi:10.22158/sssr.v5n3p183
Measuring Patriarchal Family Culture: Questionnaire Development and Its Psychosocial CorrelatesPreprint
Starowicz, A., Wnuk, A., Oleksy, T., Szczecińska, M., Szołtysek, M., & Gambin, M. (2025) · doi:10.31234/osf.io/mv6gx_v2
Development and Validation of the Family Patriarchy Questionnaire (FPQ) in Polish AdultsPreprint
Starowicz, A., Wnuk, A., Oleksy, T., Szczecińska, M., Szołtysek, M., & Gambin, M. (2023) · doi:10.31234/osf.io/mv6gx_v1
The role of distress tolerance and expectancies in women's alcohol consumption
Holzhauer, C. G. (2014) · Scholars Archive - University at Albany (University at Albany, State University of New York) · doi:10.54014/4h88-c4km
Secondary Youth-Level Mechanisms of Change in Parent Training for Anxious Youth
Anderberg, J. L., Barry, K. R., Upshaw, B. M., Mangen, K. H., Spencer, S. D., Guzick, A. G., Ayton, D. M., Palo, A. D., Candelari, A. E., & Storch, E. A. (2025) · Child & Youth Care Forum · doi:10.1007/s10566-025-09880-6
“…(DT), defined as the ability to endure negative emotional states when such endurance is adaptive (Simons & Gaher, 2005 ), is an important factor in the development and perpetuation of various forms of psychopathology across the lifespan (Daughters et al., 2009 ; Tonarely & Ehrenreich-May, 2020 ).”
Shelton, D., & Veilleux, J. C. (2025) · Journal of Research in Personality · doi:10.1016/j.jrp.2025.104677
Engle, J., Commerce, E., Mezhenska, M., & Neumann, C. S. (2025) · Mindfulness · doi:10.1007/s12671-025-02724-3
“Still, low DT, self-reported or assessed behaviorally, is associated with a range of INT psychopathology (Daughters et al., 2009; Keough et al., 2010; Li et al., 2023).”
Impulsivity and pain attentional bias in veterans receiving care for chronic non-malignant pain
Bjork, J. M., Norris, P. J., & Trost, Z. (2026) · Frontiers in Pain Research · doi:10.3389/fpain.2026.1652567
“This stands in contrast to previous findings wherein both decisions to quit (67) and time spent in the final challenge block (69) correlated with anxiety symptomatology.”
InfluentialLi, J., Dong, J., & Liu, H. (2026) · Mindfulness · doi:10.1007/s12671-026-02879-7
“…employ maladaptive responses aimed at escaping negative emotions, typically manifesting as dysregulated behaviors (Bresin, 2020) such as binge eating (Corstorphine et al., 2007), substance use and aggressive behaviors (Daughters et al., 2009), and non-suicidal self-injury (Slabbert et al., 2018).”
Jagasia, E., Nebel, M. B., Johnson, S., Campbell, J. C., & Perrin, N. (2026) · Brain and Cognition · doi:10.1016/j.bandc.2026.106456
Emotion reactivity and depression among music students: The mediating role of distress tolerance
Ou, J., Zhang, L., Sun, C., Sun, S., & 项天舒 (2026) · Acta Psychologica · doi:10.1016/j.actpsy.2026.107555
Metadata
- Authors
- Daughters, S. B., Reynolds, E. K., MacPherson, L., Kahler, C. W., Danielson, C. K., Zvolensky, M., & Lejuez, C. W.
- Affiliations
- University of Maryland, College Park (US)
- Brown University (US)
- Medical University of South Carolina (US)
- University of Vermont (US)
- Corresponding author
- Daughters, Stacey B.
- ORCID
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 47
- Issue
- 3
- Pages
- 198-205
- ISSN
- 0005-7967 (ISSN-L)
- PMC
- PMC2653593
- OpenAlex
- W2029992258
- Cited by
- 203
- References
- 74
- Citations by year
- 2026: 9 · 2025: 11 · 2024: 10 · 2023: 9 · 2022: 15 · 2021: 15 · 2020: 13 · 2019: 6 · 2018: 14 · 2017: 14 · 2016: 19 · 2015: 10 · 2014: 9 · 2013: 20 · 2012: 8
- FWCI
- 7.78
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Drug Abuse (R01DA18647, R01DA018647, R21DA022741)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- distress tolerance, early adolescence, externalizing problems, internalizing problems, gender differences, ethnicity, African American youth, alcohol consumption, delinquency, moderating effect
- MeSH terms
- Adaptation, Psychological, Adolescent, Adolescent Behavior, Alcohol Drinking, Black or African American, Child, Cross-Sectional Studies, Female, Humans, Internal-External Control, Juvenile Delinquency, Male, Socioeconomic Factors, Stress, Psychological
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