Martin M. Anderson
Lawrence S. Neinstein
Alcohol is the most widely used drug in the United States. It is readily available and inexpensive. Alcohol has been used by 76.8% of adolescents by the time they reach 18 years of age. In 2006, 45.3% of high school seniors have used alcohol in the last month and 66.5% used in the last year (Johnston et al., 2007). In 2006, 3.0% of high school seniors used alcohol daily (Johnston et al., 2007). Approximately 25.4% percent of high school seniors reported that they had consumed more than five drinks in a row during the previous 2 weeks; 56.4% of high school seniors have been drunk (Johnston et al., 2007). Table 69.1 depicts trends in prevalence of any use of alcohol among 8th, 10th, and 12th graders between 1991 and 2005 (Johnston et al., 2006).
Morbidity and Mortality
An estimated 4.6 million adolescents aged 14 to 17 years have alcohol-related problems.
Motor Vehicle Injuries
Motor vehicle accidents caused by driving under the influence of alcohol are the leading cause of death in the 15- to 24-year-old age-group. Annually, approximately 5,000 youth below 21 years of age die from alcohol-related injuries. Alcohol-related motor vehicle accidents account for 1,900 deaths. Alcohol is a factor in 1,500 homicides and 300 suicides (Hingston, 2004). Almost 30% of students (28.5%) nationwide have ridden with a driver who had been drinking, and 9.9% (8.1% female, 11.7% male) have driven a car after drinking (Centers for Disease Control and Prevention, 2006). Forty percent to 50% of young males who drown were drinking when they died. The rate is similar to that for diving accidents (Office of the Inspector General, Report to the Surgeon General, 1992; Chaloupka et al., 2002). A 1985 study of coroner cases of unintentional injury deaths in adolescence showed that approximately 50% had a measurable blood alcohol level (Friedman, 1985). The National Highway Traffic Safety Administration estimates that a legal age of drinking at 21 saves 700 to 1,000 lives per year (NIAAA, 2004/05d). Since 1999 when New Zealand lowered its drinking age to 18, there has been a 12% increase in alcohol-related crashes amongst 18- to 19-year-olds and a 14% increase in 15- to 17-year-olds. For females, the increase was 51% for 18- to 19-year-olds and 24% for 14- to 17-year-olds (www.pire.org; Kypri, 2005).
Alcohol use is linked to acquisition of sexually transmitted diseases (STDs). Higher alcohol taxes and higher minimum legal drinking ages are associated with lower incidence of STDs among adolescents and young adults (Centers for Disease Control and Prevention, 2000). A 1999 Office of Juvenile Justice and Delinquency Prevention (OJJDP) study estimated that the cost of underage drinking in the United States totals more than $58 billion annually. Alcohol use in adolescents has been associated with several long- and short-term consequences—academic problems, social problems, physical problems, and unwanted, unintended, and unprotected sexual activity. It has been a factor in physical and sexual assaults, suicide, homicide, and alcohol-related unintentional injuries. There is evidence of its role in memory problems and in alterations in brain development (NIAAA, 2004/05b, c).
Alcohol use is not limited to healthy teens. Adolescents with chronic illnesses such as sickle-cell disease or cystic fibrosis engage in risk-taking behaviors such as smoking, sexual activity, and drug and alcohol use. They may use at lower rates than their peers, but should still be screened for health-risk behaviors. Health care providers should not underestimate the effects of alcohol use on adolescents or its consequences.
Risk Factors for Adolescent Alcohol Use
There are many factors that contribute to adolescent alcohol initiation, use, and alcohol-related problem behaviors.
and is influenced by peers more than family. Alcohol use in general is minimally influenced by genetics and is mainly influenced by environment (Rhee et al., 2003).
Factors not predictive of initiation of drinking:
Alcohol and Its Effects
Physiology and Metabolism
Alcohol is a nonionized lipid soluble compound that is completely miscible in water. It is rapidly absorbed from the gastrointestinal (GI) tract and is distributed throughout the total body water. It easily penetrates the central nervous system (CNS) because of its lipid solubility. It is a CNS depressant that also has the ability to increase brain activity in areas that produce endorphins and in those that activate the dopaminergic reward system. The principal ingredient of all alcoholic beverages is ethanol. Most beers and wines contain between 3% and 20% alcohol. A shot of whiskey, a can of beer, and a glass of wine have the same alcohol content. Women, because of their higher percentage of body fat and lower total body water per unit of weight develop higher blood alcohol levels than men with the same alcohol intake.
Moderate doses of alcohol in the nontolerant individual induce sedation, euphoria, decreased inhibitions, and impaired coordination. As the dose and corresponding blood alcohol level increase, ataxia, decreased mentation, poor judgment, labile mood, and slurred speech occur. At higher doses, alcohol can induce unconsciousness, anesthesia, respiratory failure, coma, and death (Table 69.2).
Although alcohol can adversely affect many organ systems of the body, adolescent alcohol abusers are usually spared the complications of prolonged alcohol use such as cirrhosis, alcoholic hepatitis, and pancreatitis. Acute withdrawal symptoms such as delirium tremens (DTs) or seizures are also unusual in adolescents. However, Strauss et al. (2000) in a study of obese children and adolescents with elevated liver function test (LFT) values secondary to fatty liver showed a significant increase in LFTs with the addition of the alcohol. Acute alcohol intoxication can result in blackouts which are caused by acute dysfunction of the hippocampus. Hangovers are a form of subacute short-term withdrawal, which are different from acute withdrawals that are mainly found in adults.
Human studies as well as studies on animals have identified a variety of potential physiological effects of alcohol in adolescents. Drinking can lower estrogen levels in girls, and testosterone levels in males. In both genders, acute alcohol intake reduces growth hormone levels. Alcohol use in increased amounts can lower bone density in males but not females.
Alcohol is a neurotoxin. Its full effects on the developing adolescent brain are not yet known. The adolescent brain is continuing to develop. It is a time when the brain's efficiency is enhanced. There is increased myelination and synaptic pruning and development of the hippocampus and prefrontal cortex. The subcortical gray matter and limbal system increase in volume while the prefrontal cortex decreases in volume due to synaptic pruning. These areas of the brain are responsible for planning, integrating information, abstract reasoning, problem solving, and judgment. This is a dynamic developing system that is potentially susceptible to damage due to alcohol.
Research to date demonstrates the following effects:
These neurocognitive findings could potentially affect the developmental transition from childhood through adolescence to adulthood. Alcohol use is also known to disrupt the sleep–wake cycle resulting in increased sleep latency and increased day-time sleepiness.
Fetal Alcohol Syndrome
Fetal alcohol syndrome is the most common cause of teratogenic mental retardation, and it is also the most preventable. There is no known safe level of alcohol use during pregnancy. Alcohol readily crosses the placenta and can result in the fetal alcohol syndrome, which is characterized by the following:
Problem Drinking Among Adolescents
Problem drinking has been defined as having been drunk six or more times in the last year or acknowledging problems in three of the following areas because of drinking:
Nationally in the year 2006, 10.9% of 8th graders, 21.9% of 10th graders, and 25.4% of 12th graders were classified as heavy drinkers (five or more drinks in a row during the previous 2 weeks) (Johnston et al., 2007). In addition, 19.5% of 8th graders, 41.4% of 10th graders, and 56.4% of 12th graders said they have been drunk in their life. Daily alcohol use rates are 0.5% in the 8th grade, 1.4% in the 10th grade, and 3.0% in the 12th grade. The percentage of high school students who have a history of being drunk daily in 2006 is 0.2% in 8th grade, 0.5% in 10th grade, and 1.6% in 12th grade.
Adolescents may have little insight into the significance of their excessive alcohol intake. A study of 3,395 Arkansas middle school students showed that 13% (455) were heavy drinkers, but only 16% (65) of these youth acknowledged having an alcohol use problem. These statistics did not include school dropouts, and there is evidence that dropouts use alcohol more heavily than their counterparts who have stayed in school. Problem drinking can seriously interfere with successful completion of the developmental tasks of adolescence, resulting in a maturational arrest.
Harrison and Luxenberg (1995) reported on alcohol and drug use among Minnesota adolescents. They found a continued trend in the proportion of students who reported at least three adverse consequences of alcohol and drug use, including 1% of 6th graders, 7% of 9th graders, and 16% of 12th graders. Alcohol was the primary substance of abuse among students. The most commonly reported consequences included tolerance, blackouts, violence, and school or job absenteeism. The problem users were 2 to 7 times more likely than comparable students with a lesser or no drug history to report parental alcohol or other drug problems, physical abuse, and sexual abuse. They were also 2 to 15 times more likely to have low self-esteem and emotional distress, to exhibit antisocial behavior, and to have made suicide attempts.
Binge drinking adolescents are at higher risk for the harmful effects of acute intoxication. They are also more likely to engage in risk-taking behaviors. They are more likely to carry a gun, use marijuana and cocaine, earn lower grades (D and F), be injured in fights, attempt suicide, and have sex with multiple partners (NIAAA, 2004/05a, d). Alcohol use in college students is discussed in Chapters 68 and 84.
The health care provider must be acutely aware of the differing patterns of use manifested in adolescence so as to be able to formulate accurate diagnostic impressions and thereby use therapeutic interventions with the greatest likelihood of improving outcome. Alcoholism and problem drinking during adolescence may have similar manifestations and consequences. Problem drinking can develop as an attempt to escape the psychic distress resulting from a distinct primary psychiatric disorder such as major depression. It may result in acting out in response to unique psychodynamic circumstances or an evolving personality disorder. In these circumstances, the use will generally subside if the primary disorder is properly identified and treated. If, however, the adolescent does, in fact, have alcoholism, attempts to treat the secondary psychiatric manifestations will do little or nothing to prevent the evolution of this progressive disorder. Because the manifestations of alcoholism in adolescence may be only very subtly distinguished from problem drinking, it is exceedingly important to have a clear understanding of the defining features of the diagnosis of alcoholism.
Characteristics of Alcoholism
Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.
the physician often does not recognize the alcohol dependence. The serious medical illnesses and somatic complaints associated with long-term adult drug or alcohol use are generally not available as clues when one is assessing the adolescent. Therefore, the physician is largely dependent on the history in recognizing and diagnosing adolescent alcohol abuse.
Fiellin et al. (2000) reviewed performance characteristics of screening methods for alcohol problems through 38 studies conducted between 1966 and 1998. Overall, the AUDIT was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%–97%; specificity, 78%–96%), although the CAGE questions proved better for discovering alcohol abuse and dependence (sensitivity, 43%–94%; specificity, 70%–97%). The authors concluded that these two screening instruments consistently performed better than other methods. However, these tests were not specifically examined in adolescents. CRAFFT has higher sensitivity (76%) and specificity (94%) for two positive responses and has been tested in primary care settings specifically for adolescents (Knight et al., 2002) (see Chapter 73).
The American Medical Association Guidelines for Adolescent Preventive Services (GAPS), Bright Futures, and the American Academy of Pediatrics Policy Statement on Substance Abuse all recommend that every adolescent be screened during history taking for alcohol, tobacco, and other drug abuse (ATODA) as part of routine care. If the screen is positive for alcohol, then the clinician must decide what to do next. Research shows that brief interventions in
physicians' offices can be effective in assisting patients in changing their behavior.
FIGURE 69.1 CAGE questionnaire for alcoholism. (From Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1985;252:14.)
FIGURE 69.2 Michigan Alcoholism Screening Test (MAST) questionnaire on drinking habits. (Adapted from Selzer ML. The michigan alcoholism screening test: the quest for a new diagnostic instrument. Am J Psychol 1971;127:89.)
Components of Successful Treatment of Adolescent Alcohol Abuse and Dependence
See Chapters 72 and 73 for further discussion on alcohol and drug abuse treatment interventions.
Al-Anon/Alateen Family Group Headquarters, Inc., P.O. Box 862 Midtown Station, New York, NY 10018-0862, telephone 1-212-302-7240 or 1-800-344-2666 (U.S.) or 1-800-443-4525 (Canada).
Boys and Girls Clubs of America, National Headquarters. 1275 Peachtree St., NE, Atlanta, GA 30309-3506. Telephone (404) 487–5700.
Friday Night Live, California Friday Night Live Partnership, 2637 W. Burrel, P.O. Box 5091, Visalia, CA 93278-5091, telephone 1-559-733-6496, fax 1-559-737-4231, E-mail: firstname.lastname@example.org.
National Association for Children of Alcoholics, 11426 Rockville Pike, Suite 100, Rockville, MD 20852, telephone 1-301-468-2600 or 1-800-729-6686.
National Association of Teen Institutes, c/o CADA, 3520 General de Gaulle Dr., Suite 5010, New Orleans, LA 70114. Telephone 1-504-362-4272 or 834–4370.
National Clearinghouse for Alcohol and Drug Information, P.O. Box 2345, Rockville, MD 20852, telephone 1-301-468-2600 or 1-800-729-6686.
National Collaboration for Youth (NCY), The National Assembly of Health and Human Service Organizations, 1319 F Street, NW, Suite 402, Washington, DC 20004, telephone 1-877-693-4248.
National Council on Alcoholism and Drug Dependence, 22 Cortlandt St., Suite 801, New York NY 10007-3128, telephone 1-800-622-2255 or 1-800-475-4673.
National Families in Action, 2957 Clairmont Rd., Suite 150, Atlanta, GA 30329, telephone 1-404-248-9676.
Safe and Drug Free Schools, U.S. Department of Education, 400 Maryland Avenue SW, Washington, DC 20202, telephone 1-202-260-3954.
Publications and Other Resource Materials
Resources for Teens
Contact Substance Abuse and Mental Health Services Administration's (SAMHSA) National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686 or http://www.ncadi.samhsa.gov for the publications and videotapes listed here.
Alcohol Alert No. 37: Youth Drinking—Risk Factors and Consequences
Alcohol Impairment Chart (for both men and women)
Alcohol, Tobacco, and Other Drugs and the College Experience (ML003)
Alcoholism Tends to Run in Families (PH318)
Children of Alcoholics: Important Facts (NACoA)
Drugs of Abuse: Alcohol
A Guide for Teens: Does Your Friend Have an Alcohol or Other Drug Problem? (PHD688)
How to Cut Down on Your Drinking
Straight Facts about Alcohol
Sex Under the Influence of Alcohol and Other Drugs (ML005)
Resources for Families
Contact SAMHSA's National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686, P.O. Box 2345, Rockville, MD 20847-2345, or http://www.ncadi.samhsa.gov for the publications and videotapes listed here.
Growing Up Drug Free: A Parent's Guide to Prevention (PHD533)
If Someone Close Has a Problem with Alcohol or Other Drugs (PH317)
TAP 6: Empowering Families, Helping Adolescents: Family-Centered Treatment of Adolescents with Alcohol, Drug Abuse, and Mental Health Problems (BKD81)
Parents, Guardians and Caregivers (MS503)
Alcohol Alert No. 37. Youth Drinking–Risk Factors and Consequences (PH376)
Alcoholism Tends to Run in Families (PH318)
Children of Alcoholics: Important Facts
Poor Jennifer, She's Always Losing Her Hat (VHS65). Designed to educate adults about the issues faced by children of alcoholics.
Resources for Professionals
Contact SAMHSA's National Clearinghouse for Alcohol and Drug Information at 800-729-6686 or http://www.ncadi.samhsa.gov for the publications and videotapes listed here.
TIP 3: Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents (BKD108)
TIP 4: Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents (BKD109)
TIP 21: Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the Justice System (BKD169)
TIP 28: Naltraxone and Alcoholism Treatment (BKD268)
TIP 31: Screening and Assessing Adolescents for Substance Abuse Disorders (BKD306)
TAP 1: Approaches in the Treatment of Adolescents with Emotional and Substance Abuse Problems (PHD580)
The Physician's Guide to Helping Patients with Alcohol Problems. NIAAA, 1995 (PHD360)
Changing Lives: Programs that Make a Difference for Youth at High Risk. Center for Substance Abuse Prevention (CSAP), 1995 (PHD714)
The Young and Restless: Generation X and Alcohol Policy (RPO933)
Children at Risk Because of Parental Substance Abuse. AOS Working Paper. (RPO965)
Prevention Pipeline: Focus on Youth Prevention—Science and Practice in Action (July/August, 1997). Prevention Pipeline is an award winning bimonthly magazine developed by the Center for Substance Abuse Prevention.
Available from SAMHSA, National Clearinghouse for Alcohol and Drug Information
Adolescent Treatment Issues (VHS40). Stresses the importance of understanding the specific treatment needs of adolescents.
Resources for Educators
Contact SAMHSA's National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686 or http://www.ncadi.samhsa.gov/for the resources listed here.
Alcohol Practices, Policies, and Potentials of American Colleges and Universities: A White Paper (CS01). Exhaustively researched, this resource on alcohol and drinking problems at American colleges and among college students outlines a full range of policy, regulatory, and program responses that some colleges are using to reduce campus drinking problems.
Success Stories from Drug-Free Schools (PHD588). This book salutes the 107 schools honored by the U.S. Department of Education's Drug-Free School Recognition Program. School leaders talk about their achievements, the obstacles they faced, how they overcame them, and what remains to be done.
Getting a Head Start: Teacher's Guide (PHD647). Although these materials were originally designed for Head Start, they are appropriate for early childhood and primary grades to increase awareness of alcohol and drug use.
Strategies for Preventing Alcohol and Other Drug Problems on College Campuses: Faculty Members Handbook (CS04). Faculty members can become involved in efforts to address drinking problems at colleges and universities. This handbook provides resources and tables on recent alcohol and drug use by college students.
Learning to Live Drug Free Curriculum Guides
Schools play a vital role in educating youth about the harmful effects of drugs. This curriculum model provides a framework for prevention education from kindergarten through 12th grade. National Clearinghouse for Alcohol and Drug Information (NCADI) has copied the curricula and grouped them by specific grades: Grades K–3 (RPO894), Grades 4–6 (RPO895), Grades 7–8 (RPO896), and Grades 9–12 (RPO897).
Studies and Reports
Driving After Drug or Alcohol Use: Findings of the 1996 National Household Survey on Drug Abuse
Drinking Under Age 21: Problems and Solutions (RPO961)
The National Household Survey Summary of Findings, 1998
The National Household Survey Population Estimates, 1998
Combating Drunk Driving and Underage Drinking
Monitoring the Future Study, 1975–2004. National Survey Results on Drug Use 1975–2004. Volume I: Secondary Students (NIH Publication #05-5727)
Monitoring the Future Study, 1975–2004. V Survey Results on Drug Use 1975–2004. Volume II: College Students and Adults aged 19–45. (NIH Publication #05-5728)
Prevalence of Youth Substance Abuse: The Impact of Methodological Differences Between Two National Surveys (RPO941)
For Teenagers and Parents
http://kidshealth.org/teen/. The Nemours Foundation, TeensHealth site has information about alcohol.
http://www.aap.org/. About Alcohol: Ten Tips for Teens.
http://www.al-anon.org. Al-Anon home page.
For Clinicians and Teens
http://ncadi.samhsa.gov/. SAMHSA website.
http://www.nida.nih.gov. National Institute on Drug Abuse (NIDA).
http://www.nofas.org/about/programs.aspx. The National Organization on Fetal Alcohol Syndrome lists several programs to educate the community, youth, and health professionals about the effects of the syndrome and to provide assistance to women in treatment centers. The site includes links to a number of related sites (http://www.nofax.org/resource/links/aspx), as well as to journal articles.
For Health Professionals
http://www.cdc.gov/ncbddd/fas/. Web site dedicated to providing information about Fetal Alcohol Syndrome, sponsored by the Centers for Disease Control (CDC). Includes links to CDC activities, publications, fast facts, and current research on the subject. Can also contact by mail at NCBDD, CDC, Mail Stop E-86, 1600 Clifton Rd., Atlanta, GA 30333. Phone 1-800-CDC-INFO (232–4636), FAX 404-498-3040, e-mail email@example.com.
http://www.healthfinder.gov/orgs/HR0027.htm. SAMHSA's National Clearinghouse for Alcohol and Drug Information—NCADI.
http://www.nida.nih.gov/TB/Clinical/Clinicaltoolbox.html. The NIDA Clinical Toolbox: Science-based materials for drug abuse treatment providers).
http://monitoringthefuture.org/. Monitoring the Future Site with statistics.
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