National Institute on Alcohol Abuse and Alcoholism 37 1997
Youth Drinking: Risk Factors and Consequences
Despite a minimum legal drinking age of 21, many young people in the
United States consume alcohol. Some abuse alcohol by drinking frequently or by
binge drinking--often defined as having five or more drinks* in a row. A
minority of youth may meet the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) criteria for alcohol dependence (1,2).
The progression of drinking from use to abuse to dependence is associated with
biological and psychosocial factors. This Alcohol Alert examines some of
these factors that put youth at risk for drinking and for alcohol-related
problems and considers some of the consequences of their drinking.
Prevalence of Youth Drinking
Thirteen- to fifteen-year-olds are at high risk to begin drinking (3).
According to results of an annual survey of students in 8th, 10th, and 12th
grades, 26 percent of 8th graders, 40 percent of 10th graders, and 51 percent of
12th graders reported drinking alcohol within the past month (4). Binge drinking
at least once during the 2 weeks before the survey was reported by 16 percent of
8th graders, 25 percent of 10th graders, and 30 percent of 12th graders.
Males report higher rates of daily drinking and binge drinking than females,
but these differences are diminishing (3). White students report the highest
levels of drinking, blacks report the lowest, and Hispanics fall between the two (3).
A survey focusing on the alcohol-related problems experienced by 4,390 high
school seniors and dropouts found that within the preceding year, approximately
80 percent reported either getting "drunk," binge drinking, or drinking and
driving. More than half said that drinking had caused them to feel sick, miss
school or work, get arrested, or have a car crash (5).
Some adolescents who drink later abuse alcohol and may develop alcoholism.
Although these conditions are defined for adults in the DSM, research suggests
that separate diagnostic criteria may be needed for youth (6).
Drinking and Adolescent Development
While drinking may be a singular problem behavior for some, research suggests
that for others it may be an expression of general adolescent turmoil that
includes other problem behaviors and that these behaviors are linked to
unconventionality, impulsiveness, and sensation seeking (7-11).
Binge drinking, often beginning around age 13, tends to increase during
adolescence, peak in young adulthood (ages 18-22), then gradually decrease. In a
1994 national survey, binge drinking was reported by 28 percent of high school
seniors, 41 percent of 21- to 22-year-olds, but only 25 percent of 31- to
32-year-olds (3,12). Individuals who increase their binge drinking from age 18
to 24 and those who consistently binge drink at least once a week during this
period may have problems attaining the goals typical of the transition from
adolescence to young adulthood (e.g., marriage, educational attainment,
employment, and financial independence) (13).
Risk Factors for Adolescent Alcohol Use, Abuse, and Dependence
Genetic Risk Factors. Animal studies (14) and studies of twins
and adoptees demonstrate that genetic factors influence an individual's
vulnerability to alcoholism (15,16). Children of alcoholics are significantly
more likely than children of nonalcoholics to initiate drinking during
adolescence (17) and to develop alcoholism (18), but the relative influences of
environment and genetics have not been determined and vary among people.
Biological Markers. Brain waves elicited in response to
specific stimuli (e.g., a light or sound) provide measures of brain activity
that predict risk for alcoholism. P300, a wave that occurs about 300
milliseconds after a stimulus, is most frequently used in this research. A low
P300 amplitude has been demonstrated in individuals with increased risk for
alcoholism, especially sons of alcoholic fathers (19,20). P300 measures among 36
preadolescent boys were able to predict alcohol and other drug (AOD) use 4 years
later, at an average age of 16 (21).
Childhood Behavior. Children classified as "undercontrolled"
(i.e., impulsive, restless, and distractible) at age 3 were twice as likely as
those who were "inhibited" or "well-adjusted" to be diagnosed with alcohol
dependence at age 21 (22). Aggressiveness in children as young as ages 5-10 has
been found to predict AOD use in adolescence (23,24). Childhood antisocial
behavior is associated with alcohol-related problems in adolescence (24-27) and
alcohol abuse or dependence in adulthood (28,29).
Psychiatric Disorders. Among 12- to 16-year-olds, regular
alcohol use has been significantly associated with conduct disorder; in one
study, adolescents who reported higher levels of drinking were more likely to
have conduct disorder (30,31).
Six-year-old to seventeen-year-old boys with attention deficit hyperactivity
disorder (ADHD) who were also found to have weak social relationships had
significantly higher rates of alcohol abuse and dependence 4 years later,
compared with ADHD boys without social deficiencies and boys without ADHD (32).
Whether anxiety and depression lead to or are consequences of alcohol abuse
is unresolved. In a study of college freshmen, a DSM-III (33) diagnosis of
alcohol abuse or dependence was twice as likely among those with anxiety
disorder as those without this disorder (34). In another study, college students
diagnosed with alcohol abuse were almost four times as likely as students
without alcohol abuse to have a major depressive disorder (35). In most of these
cases, depression preceded alcohol abuse. In a study of adolescents in
residential treatment for AOD dependence, 25 percent met the DSM-III-R criteria
for depression, three times the rate reported for controls. In 43 percent of
these cases, the onset of AOD dependence preceded the depression; in 35 percent,
the depression occurred first; and in 22 percent, the disorders occurred
simultaneously (36).
Suicidal Behavior. Alcohol use among adolescents has been
associated with considering, planning, attempting, and completing suicide
(37-39). In one study, 37 percent of eighth-grade females who drank heavily
reported attempting suicide, compared with 11 percent who did not drink (40).
Research does not indicate whether drinking causes suicidal behavior, only that
the two behaviors are correlated.
Psychosocial Risk Factors
Parenting, Family Environment, and Peers. Parents' drinking
behavior and favorable attitudes about drinking have been positively associated
with adolescents' initiating and continuing drinking (41,42). Early initiation
of drinking has been identified as an important risk factor for later
alcohol-related problems (43). Children who were warned about alcohol by their
parents and children who reported being closer to their parents were less likely
to start drinking (42,44,45).
Lack of parental support, monitoring, and communication have been
significantly related to frequency of drinking (46), heavy drinking, and
drunkenness among adolescents (47). Harsh, inconsistent discipline and hostility
or rejection toward children have also been found to significantly predict
adolescent drinking and alcohol-related problems (46).
Peer drinking and peer acceptance of drinking have been associated with
adolescent drinking (48,49). While both peer influences and parental influences
are important, their relative impact on adolescent drinking is unclear.
Expectancies. Positive alcohol-related expectancies have been
identified as risk factors for adolescent drinking. Positive expectancies about
alcohol have been found to increase with age (50) and to predict the onset of
drinking and problem drinking among adolescents (51-53).
Trauma. Child abuse and other traumas have been proposed as
risk factors for subsequent alcohol problems. Adolescents in treatment for
alcohol abuse or dependence reported higher rates of physical abuse, sexual
abuse, violent victimization, witnessing violence, and other traumas compared
with controls (54). The adolescents in treatment were at least 6 times more
likely than controls to have ever been abused physically and at least 18 times
more likely to have ever been abused sexually. In most cases, the physical or
sexual abuse preceded the alcohol use. Thirteen percent of the alcohol dependent
adolescents had experienced posttraumatic stress disorder, compared with 10
percent of those who abused alcohol and 1 percent of controls.
Advertising. Research on the effects of alcohol advertising on
adolescent alcohol-related beliefs and behaviors has been limited (55). While
earlier studies measured the effects of exposure to advertising (56), more
recent research has assessed the effects of alcohol advertising awareness on
intentions to drink. In a study of fifth- and sixth-grade students' awareness,
measured by the ability to identify products in commercials with the product
name blocked out, awareness had a small but statistically significant
relationship to positive expectancies about alcohol and to intention to drink as
adults (57). This suggests that alcohol advertising may influence adolescents to
be more favorably predisposed to drinking (57).
Consequences of Adolescent Alcohol Use
Drinking and Driving. Of the nearly 8,000 drivers ages 15-20
involved in fatal crashes in 1995, 20 percent had blood alcohol concentrations
above zero (58). For more information about young drivers' increased crash risk
and the factors that contribute to this risk, see Alcohol Alert No. 31:
Drinking and Driving (59).
Sexual Behavior. Surveys of adolescents suggest that alcohol
use is associated with risky sexual behavior and increased vulnerability to
coercive sexual activity. Among adolescents surveyed in New Zealand, alcohol
misuse was significantly associated with unprotected intercourse and sexual
activity before age 16 (60). Forty-four percent of sexually active Massachusetts
teenagers said they were more likely to have sexual intercourse if they had been
drinking, and 17 percent said they were less likely to use condoms after
drinking (61).
Risky Behavior and Victimization. Survey results from a
nationally representative sample of 8th and 10th graders indicated that alcohol
use was significantly associated with both risky behavior and victimization and
that this relationship was strongest among the 8th-grade males, compared with
other students (62).
Puberty and Bone Growth. High doses of alcohol have been found
to delay puberty in female (63) and male rats (64), and large quantities of
alcohol consumed by young rats can slow bone growth and result in weaker bones
(65). However, the implications of these findings for young people are not
clear.
Prevention of Adolescent Alcohol Use
Measures to prevent adolescent alcohol use include policy interventions and
community and educational programs. Alcohol Alert No. 34: Preventing Alcohol
Abuse and Related Problems (66) covers these topics in detail. See the
National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) World Wide Web
site at http://www.niaaa.nih.gov.
Youth Drinking: Risk Factors and Consequences--A Commentary by NIAAA
Director Enoch Gordis, M.D.
Alcohol, the most widely used and abused drug among youth, causes
serious and potentially life-threatening problems for this population. Although
alcohol is sometimes referred to as a "gateway drug" for youth because its use
often precedes the use of other illicit substances, this terminology is
counterproductive; youth drinking requires significant attention, not because of
what it leads to but because of the extensive human and economic impact of
alcohol use by this vulnerable population.
For some youth, alcohol use alone is the primary problem. For others,
drinking may be only one of a constellation of high-risk behaviors. For these
individuals, interventions designed to modify high-risk behavior likely would be
more successful in preventing alcohol problems than those designed solely to
prevent the initiation of drinking. Determining which influences are involved in
specific youth drinking patterns will permit the design of more potent
interventions. Finally, we need to develop a better understanding of the alcohol
treatment needs of youth. Future questions for scientific attention include,
what types of specialized diagnostic and assessment instruments are needed for
youth; whether treatment in segregated, "youth only" programs is more effective
than in general population programs; and, irrespective of the setting, what
types of specific modalities are needed by youth to increase the long-term
effectiveness of treatment.
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___________
*A standard drink is 12 grams of pure alcohol, which is equal to one 12-ounce
bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of
80-proof distilled spirits.
Full text of this publication is available on NIAAA's World Wide
Web site at http://www.niaaa.nih.gov
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Citation of the source is appreciated.
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Health Service * National Institutes of Health
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