Alcohol Use Disorders in Adolescents

Abstract

Alcohol is the drug of choice among youth, with 12% of 8th-graders, 22% of 10th-graders, and 29% of 12th-graders reporting heavy episodic drinking. Although prevalence rates are at historic lows, alcohol use continues to be widespread among adolescents, and pediatricians must screen for underage and family alcohol use in health assessment visits.After completing this article, readers should be able to:National surveys make it clear that the use of alcohol among adolescents is both widespread and harmful. By the 12th grade, close to three-quarters of adolescents in high school report ever having an alcoholic drink, and more than one-quarter report having their first drink before age 13 years. Data from Monitoring the Future, an annual survey of youth in the United States, show that 71% of high school seniors reported some experience with alcohol in the past; 41% reported use in the last 30 days and, of great concern, 3% reported daily use. More than one-half (58%) of 10th-graders and more than one-third (36%) of 8th-graders report having consumed alcohol at some point in their lives, and more than one-third of 10th-graders (37%) and one of six 8th-graders (16%) report having been drunk in the past. (1) The good news is that the use of alcohol by teens, as well as the use of many of the illicit drugs, has declined over the past decade. The bad news is that, although these declines are encouraging, alcohol remains the drug of choice among youth.The pattern of alcohol use that is exhibited by many adolescents is one of drinking too much and at too early an age, thereby creating problems for themselves, for people around them, and for society as a whole. Underage drinking is a leading public health problem in this country. Underage drinkers consume, on average, four to five drinks per occasion approximately six times per month. By comparison, older adult drinkers, ages 26 and older, consume, on average, two to three drinks per occasion approximately nine times per month. A particularly worrisome trend is the high prevalence of heavy episodic or binge drinking in adolescents, which is defined often as five or more drinks in a row in a single episode. Monitoring the Future data show that 12% of 8th-graders, 22% of 10th-graders, and 29% of 12th-graders report engaging in heavy episodic drinking.Studies find that drinking alcohol often starts at very young ages. Moreover, studies indicate that the younger children and adolescents are when they begin to drink, the more likely they are to engage in behaviors that can harm themselves and others. Those who start to drink before age 13 years, for example, are nine times more likely to binge drink frequently as high school students than those who begin drinking later. Data from recent surveys show that approximately 10% of 9- to 10-year-olds have already started drinking; nearly one third of youth begin drinking before age 13, and more than one in four 14-year-olds report drinking within the past year. (2)(3)A number of studies show that the early onset of alcohol use, as well as the escalation of drinking in adolescence, are risk factors for the development of alcohol-related problems in adulthood. Initiating alcohol use earlier in adolescence or in childhood is a marker for later problems, including heavier use of alcohol and other drugs. Individuals who report initiation of alcohol use before age 15 years were four times more likely to meet criteria for alcohol dependence and two times more likely to meet criteria for alcohol abuse as those individuals who began drinking after age 21 years. (4)The consequences of underage drinking include a range of physical, academic, and social problems. Perhaps most frightening is the fact that alcohol is the leading contributor to morbidity and mortality in youth. Alcohol use is the leading contributor to death due to injuries, the primary cause of death in individuals younger than 21 years of age. Annually, 5,000 youth die of alcohol-related injuries that involve underage drinking. This includes injuries sustained in motor vehicle crashes (∼1,900), homicides (∼1,600), and suicides (∼300), as well as unintentional injuries not related to motor vehicle crashes. Among studies of adolescent trauma victims, alcohol is reported in 32% to 45% of hospital admissions. The association between alcohol use and violent behavior is well documented. Numerous studies of adolescents report that alcohol use is linked to both violent behavior and to violence-related injuries. (5)(6)Other harmful behaviors and negative consequences frequently related to excessive drinking among adolescents are high-risk sexual behaviors (unplanned and unprotected intercourse); sexual misconduct, including rape; and assaults. Having multiple sexual partners, failing to use condoms, and performing other high-risk sexual behaviors have been associated with alcohol use in adolescents. Furthermore, alcohol use by the offender, victim, or both has been linked to sexual assault, including date rape.As youth move from adolescence to young adulthood, they encounter dramatic physical, emotional, and lifestyle changes. Developmental transitions, such as puberty and increasing independence, have been associated with alcohol use. Because drinking is so widespread among adolescents, simply being an adolescent may be a key risk factor for initiation of alcohol use, as well as for drinking dangerously.Data from imaging studies show that the brain continues developing well into the twenties, during which time it continues to establish important communication connections and further refines its function. Many believe that this lengthy developmental period may help to explain some of the behaviors characteristic of adolescence, such as the propensity to seek out new and potentially dangerous situations. For some adolescents, thrill-seeking includes experimenting with alcohol use. Developmental changes also may offer a possible physiologic explanation for why teens act so impulsively, often not recognizing that their actions—such as drinking—have consequences.How adolescents view alcohol and its effects also influences their drinking behavior, including whether they begin to drink and how much. An adolescent who expects drinking to be a pleasurable experience is more likely to drink than one who does not. Beliefs about alcohol are established very early in life, even before entering elementary school. Before age 9 years, children generally view alcohol negatively and see drinking as bad and associated with adverse effects. By approximately age 13 years, however, their expectancies shift, becoming more positive. Accordingly, adolescents who drink the most also place the greatest emphasis on the positive and arousing effects of alcohol.Differences between the adult brain and the brain of the maturing adolescent may explain why many young drinkers are able to consume much larger amounts of alcohol than adults before experiencing the negative consequences of drinking, such as drowsiness, lack of coordination, and withdrawal or hangover effects. This unusual tolerance may help to explain the high rates of binge drinking among many adolescents and young adults. At the same time, adolescents appear to be particularly sensitive to the positive effects of drinking, such as feeling more at ease in social situations, and young people may drink more than adults because of these positive social experiences.Children who begin to drink at a very early age (before age 12 years) often share similar personality characteristics that may make them more likely to start drinking. Young people who are disruptive, hyperactive, and aggressive—often referred to as having conduct problems or being antisocial—as well as those who are depressed, withdrawn, or anxious, may be at greatest risk for alcohol problems. Other behavior problems associated with alcohol use include rebelliousness, difficulty avoiding harm or harmful situations, and a host of other traits seen in young people who act out without regard for rules or the feelings of others (ie, disinhibition).Some of the behavioral and physiologic factors that converge to increase or decrease a person’s risk for alcohol problems, including tolerance to alcohol’s effects, may be linked directly to genetic factors. For example, being a child of an alcoholic or having several alcoholic family members places a person at greater risk for alcohol problems. Children of alcoholics (COAs) are between 4 and 10 times more likely to become alcoholics themselves than are children who have no close relatives with alcoholism. (7) COAs also are more likely to begin drinking at a young age and to progress to drinking problems more quickly.Research shows that COAs may have subtle brain differences that could be markers for developing later alcohol problems. For example, by the use of newer brain-imaging techniques, scientists have found that COAs have a distinctive feature in one brainwave pattern (called a P300 response) that could be a marker for later alcoholism risk. (8) Some studies suggest that these brain differences may be particularly evident in people who also have certain behavioral traits, such as signs of conduct disorder, antisocial personality disorder, sensation-seeking, or poor impulse control. (9)Drinking and alcohol-related problem behavior reflect a complex interplay between inherited and social-environmental factors, the implications of which are only beginning to be explored in adolescents. And although even more is understood about the role and contribution of genetics, this knowledge still does not tell the entire story.Social and environmental factors, such as the influence of parents and peers, also play a role in alcohol use. For example, parents who drink more and who view drinking favorably may have children who drink more. Other influences, such as the impact of the media, have been examined and are felt to play an important role. Today, alcohol is widely available and aggressively promoted through television, radio, billboards, and the Internet.Although the severe health problems associated with harmful alcohol use are not as common in adolescents as they are in adults, studies show that adolescents who drink heavily may put themselves at risk for a range of health problems.Chronic heavy drinking during adolescence and into young adulthood appears to be associated with detrimental effects on brain development, brain functioning, and neuropsychological performance. Recent evidence suggests that heavy drinking during adolescence is associated with poorer neurocognitive functioning during the young adult years and is associated particularly with impairment of attention and visuospatial skills. (10)Brain imaging and studies of event-related potentials have demonstrated subtle but significant abnormalities in brain structure and function. In a recent study, researchers used magnetic resonance imaging to determine the effects of heavy drinking on the changing brain structure of teens and young adults with alcohol use disorders. Hippocampal volumes were smaller in youths with alcohol use disorders than in matched controls and correlated with the onset of alcohol use disorder and with the duration of alcohol use disorder. (11) The earlier an individual developed an alcohol use disorder and the longer the duration of the alcohol use disorder, the smaller was the volume of his or her hippocampus. (12) Other studies have looked at the effect of alcohol on the structure of white matter and have demonstrated that white matter integrity was reduced in the corpus callosum of youths with alcohol use disorders.Research studies indicate that a number of factors seem to influence how and to what extent alcohol affects the brain, including:Elevated liver enzymes, indicating some degree of liver damage, have been found in some adolescents who drink alcohol. 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