Adolescent Health Care: A Practical Guide

Chapter 69


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 (; Kypri, 2005).

Other Morbidities

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.

  1. Reasons teens give for drinking (Rachal et al., 1975):
  2. Curiosity
  3. Peer conformity
  4. Enjoyment
  5. Escape
  6. Parental encouragement to take first drink to celebrate a special occasion
  7. Genetic: The initiation of and use of alcohol are the result of a complex interplay between genes and environment. Several genes have been identified as affecting the risk of alcoholism. A twin study of alcohol use (Rhee et al., 2003) found that alcohol initiation arises from genetic, shared, and nonshared environmental contributions. Problem use has a heritability component


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).

  1. Ethnicity: Asian-Americans and African-Americans are less likely to drink than European Americans (white) or Native Americans. In general, white American adolescents start drinking earlier than nonwhite Americans with the exception of Native Americans (Donovan, 2004). In the 2005 National Youth Risk Behavior Survey, Hispanic high school students and non-Hispanic white students had a higher percent of lifetime use (79.4% and 75.3%) than black students (69%) (Centers for Disease Control and Prevention, 2006). This was also true for current use of alcohol (46.8%, 46.4%, and 31.2% respectively).
  2. Family factors: Adolescents' perception of parental approval and parents' use of alcohol are predictive of teens' initiation of alcohol use. If the parents are perceived as being more permissive toward drinking, adolescents are at higher risk of early initiation (Donovan, 2004). Teens with close relationships to their parents are less likely to initiate. Children of alcoholics are 4 to 10 times more likely to become alcoholic as compared with children whose parents were not alcoholic (NIAAA, 2004/05c).
  3. Peer factors: Peer involvement in drugs or alcohol, delinquent behaviors, or the perception that there is a high prevalence of alcohol use among peers increases the risk of a teen drinking alcohol.
  4. Behavioral risk factors: If teens have tolerant attitudes toward delinquent behavior or approve of alcohol use, they are at higher risk for drinking. Mood disorders, attention-deficit hyperactivity disorder (ADHD), conduct disorder, low school motivation, and low value placed on academic achievement are additional risk factors associated with initiation of alcohol use in adolescence.
  5. Risk factor of early initiation: Early onset of alcohol use (before age 14) is often associated with escalated drinking during adolescence and development of alcohol-related problems in adolescents and adults. Approximately one third of adolescents start drinking before 13 years and 10% of 9-year-olds have already started drinking. Youth who start drinking before 13 are 9 times more likely to binge drink than high school students who begin later (NIAAA, 2004/05a).

Factors not predictive of initiation of drinking:

  1. Gender: Gender is not predictive of drinking initiation (Donovan, 2004).
  2. Social economic status: SES (when family structure is accounted for) does not predict alcohol initiation (Donovan, 2004).

TABLE 69.1
Trends in Prevalence of Any Use of Alcohol for 8th, 10th, and 12th Graders


















2006–2006 Change

Adapted from Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the future national survey results on drug use, Overview of key findings. NIH Publications No. 07-6202, Bethesda, MD: National Institute on Drug Abuse, 2007.























































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.

Hormonal Changes

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:

  1. Adolescents are relatively resistant to the sedative effects of alcohol. They show less ataxia, social impairment, and fewer acute withdrawal effects than adults.
  2. Imaging studies of teens with significant alcohol use show a reduced volume of the hippocampus and abnormalities of the corpus callosum.
  3. Studies show a disruption in learning and memory.
  4. Functional magnetic resonance imaging (MRI) shows decreased functional activity of the frontal and parietal areas of the right hemisphere, areas responsible for spatial memory.
  5. Neurocognitive testing of long-term users shows decreased visuospatial motor speed, and decreased reading recognition, total reading, and spelling subtests on IQ testing.
  6. Increased consumption is associated with decreased memory, abstract thought, and language.
  7. Teens with more than 100 drinking episodes showed decreased verbal and nonverbal retention when compared to nondrinking controls.
  8. Withdrawal from alcohol also has neurocognitive effects. An increased number of withdrawal episodes is associated with greater decrease in visuospatial function with poor retrieval of verbal and nonverbal information.

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.

TABLE 69.2
Effects of Alcohol Consumption in the Nontolerant Individual

Blood Alcohol Level (g/100 mL)


From Morrison SF, Rogers PD, Thomas MH. Alcohol and adolescents. Pediatr Clin North Am 1995;42:371–387.


Reached after approximately one drink; light or moderate drinkers feel some effect—warmth and relaxation


Most people feel relaxed, talkative, and happy; skin may become flushed


First sizable changes begin to occur; lightheadedness, giddiness, lowered inhibitions, and less control of thoughts may be experienced; both restraint and judgment are lowered; coordination may be slightly altered


Judgment is somewhat impaired; ability to make rational decisions about personal capabilities is affected (such as being able to drive)


Definite impairment of muscle coordination and slower reaction time occurs; driving ability becomes suspect; sensory feelings of numbness of the cheeks and lips occur; hands, arms, and legs may tingle and then feel numb (this constitutes legal impairment in Canada and in some U.S. states, e.g., California)


Clumsiness; speech may become fuzzy; clear deterioration of reaction time and muscle control (this level previously constituted drunkenness in most U.S. states)


Definite impairment of balance and movement


Motor and emotional control centers are measurably affected; slurred speech, staggering, loss of balance, and double vision can all be present


Lack of understanding of what is seen or heard occurs; individuals are confused or stuporous and may lose consciousness


Usually unconscious; the skin becomes clammy


Respiration slows and may stop altogether


Death occurs

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:

  1. Abnormal facies: Microcephaly; short, upturned nose; thin upper lip; short palpebral fissures; and hypoplastic maxilla
  2. Cardiac abnormalities: Especially atrial and ventricular septal defects
  3. Renal abnormalities: Deformed kidneys
  4. Genital abnormalities: Hypospadias and labial hypoplasia



  1. Skeletal abnormalities: Contractures of the extremities; pectus excavatum
  2. Hirsutism
  3. CNS abnormalities: Electroencephalographic changes, mental retardation
  4. Abnormal size: Small for gestational age
  5. Behavior: Irritability in infancy; hyperactivity in childhood

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:

  1. Trouble with a teacher or principal
  2. Difficulties with friends
  3. Driving after drinking
  4. Criticism by dates
  5. Trouble with the police

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.

  1. The disease is often progressive and may be fatal.
  2. The individual has impaired control over drinking, progressive preoccupation with alcohol use despite significant adverse consequences, and distortions in thinking, most notably denial.
  3. Adverse consequences include impairments in work or school functioning, negative influences on interpersonal relationships, and legal or health-status ramifications.
  4. A family history of alcoholism is present in most cases.
  5. Research suggests that genetics is a major determinant in the risk of alcoholism. Further recent information shows that the biological features of these genetic determinants create an environment in the dopaminergic mesolimbic reward systems that may predispose a person to progressive use of alcohol and, in addition, may facilitate potent biological reinforcement by substances other than alcohol that also stimulate this region of the brain. Cocaine and amphetamines are two such compounds with a great potential for dependency. Similarly, there appear to be unique elements of the endorphin system in the alcoholic brain that may result in a predisposition to opiate dependency. Although alcoholism is not the only route to dependency on these substances, experimentation with these drugs by an adolescent with suspected alcoholism suggests a more treacherous clinical circumstance and a need for immediate intervention by the health care provider.
  6. The biopsychosocial consequences of drug use during adolescence are often the same, whether or not addictions are present. The natural history of the clinical situation and the effectiveness of specific treatments, however, are clearly a function of the specificity of the diagnostic circumstances.
  7. Further confounding the diagnostic accuracy is the fact that adolescents who use large amounts of alcohol generally deceive the physicians with whom they come in contact. Because of the teen's (and family's) denial,


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.

TABLE 69.3
Developing Signs of Alcoholism in Teenagers

Social/Psychological Signs

Classroom Behavior

Physical Signs

Adapted from the National Council on Alcoholism of San Fernando Valley, California.

Personality change when drinking


A change in tolerance to alcohol, either an increase or a decrease

Blackouts or temporary amnesia during and after drinking episodes

  Misses Monday mornings


  Late after lunch


Loss of control of drinking

  Leaves school early on Fridays


Drinks more than peers and more often

  Frequent absences

Marked weight gain or loss

Morning drinking to overcome hangover effects


Repeated minor injuries


  Works below expected potential level

Sexual activity beyond standard of peer group

Drinking-related arrests


Defensiveness about alcohol usage

  Inconsistency in aggressiveness and passivity in classroom participation

Characteristics of final phases—obvious and tragic:

Obsession with consumption of next drink


  Extended binges

Mixing of alcohol with drugs for a better high

  Drinks at school, hides alcohol in locker

  Physical tremors



Need to drink before going to a party

  Boasts about drinking


Feeling of remorse about drinking

  Alcohol on breath


Occurrence of fights when drinking

  Change in peer group affiliation


Development of elaborate system of lies, alibis, and excuses to cover up drinking

  Sleeps during classes


  General troubles in school



  1. Behavioral changes: Certain behavioral changes can arouse the suspicion of alcohol or other drug abuse (but none of them is an absolute indicator of excessive drinking). These include behaviors such as changes in activity; loss of interest in school, play, home, or work; changes in sleeping patterns; changes in eating patterns; and changes in personality. May be reflected in mood changes, fighting with friends and family members, or truancy, manifestations of depression, trouble with the law enforcement system, multiple or frequent accident-related injuries, school failure, and blackouts. Table 69.3 outlines developing signs of alcoholism in teens.
  2. Screening instruments: Determining the extent of alcohol abuse and diagnosing alcoholism in the adolescent is crucial. The HEADSS psychosocial profile, as outlined in Chapter 3, is a helpful interview technique for eliciting a history of substance abuse. Several screening devices are also available to help make this diagnosis (see Chapter 73 for details) and include the following:
  3. CAGE (Fig. 69.1)
  4. MAST: The Michigan Alcoholism Screening Test (Fig. 69.2)
  5. CRAFFT: See page 948, Chapter 73.
  6. AUDIT: Alcohol Use Disorders Identification Test

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).

  1. Family history: A family history of alcoholism or addiction also places the adolescent at high risk for abuse of an addictive substance and subsequent addiction, for the reasons described earlier.


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.

  1. Accurate diagnosis and assessment: Treatment of any primary psychiatric disturbances that may be identified. If the patient meets criteria for a diagnosis of alcoholism or addiction, then proceed with interventions listed later. If the diagnosis is uncertain, always proceed with these suggestions. Reassessment of psychiatric symptoms should be undertaken after a minimum of 30 days. Very often, prominent psychiatric symptoms remit spontaneously with abstinence.
  2. Disease concept of recovery: Viewing alcoholism as a primary progressive disease implies a long-term, ongoing recovery process that requires abstinence and learning to live without alcohol and drugs. The recovery process also helps expose and deal with accumulated feelings of guilt and shame, while rebuilding coping skills and self-esteem.
  3. Positive alternatives: Treatment requires that the adolescent learn substitute activities that provide pleasure and reward to replace the “highs” of drug use. These activities should be realistic and attainable.
  4. Support systems: Sober peer-support systems are essential for recovery. Alcoholics Anonymous, Cocaine Anonymous, and Narcotics Anonymous provide 12-step programs that are useful for the recovering adolescents.
  5. Family involvement: Alcoholism is a family illness. The substance abuse of one member of the family system affects the other members. Dysfunctional coping trends are established. Recovery and treatment should help establish a new, healthier equilibrium. Family members should be encouraged to attend Al-Anon or Alateen, which are 12-step self-help groups for family members.
  6. Referrals: The clinician should also be able to provide appropriate referrals for substance abuse services in the community.



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:

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 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 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 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 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)

Web Sites

For Teenagers and Parents The Nemours Foundation, TeensHealth site has information about alcohol. About Alcohol: Ten Tips for Teens. Al-Anon home page.

For Clinicians and Teens SAMHSA website. National Institute on Drug Abuse (NIDA). 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 (, as well as to journal articles. NIAAA.

For Health Professionals

P.886 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 SAMHSA's National Clearinghouse for Alcohol and Drug Information—NCADI. The NIDA Clinical Toolbox: Science-based materials for drug abuse treatment providers). Monitoring the Future Site with statistics.

References and Additional Readings

Abel EL, Hannigan JH. Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences. Neurotoxicol Teratol 1995;17:445.

Bauman A, Phongsavan P. Epidemiology of substance use in adolescence: prevalence, trends, and policy implications. Drug Alcohol Depend 1999;55:187.

Bertrand J, Floyd RL, Weber MK. Guidelines for identifying and referring persons with fetal alcohol syndrome. MMWR 2005;54(RR-11):1.

Blanken AJ. Measuring use of alcohol and other drugs among adolescents. Public Health Rep 1993;108:25.

Bobo JK, Husten C. Sociocultural influences on smoking and drinking. Alcohol Res Health 2000;24(4):225.

Britto MT, Garrett JM, Dugliss MA, et al. Risky behavior in teens with cystic fibrosis or sickle cell disease: a multicenter study. Pediatrics 1998;101:250.

Brown SA, Tapert SF, Granholm E, et al. Neurocognitive functioning of adolescents: effects of protracted alcohol use. Alcohol Clin Exp Res 2000;24:164.

Carmichael-Olson H, Feldman JJ, Streissguth AP, et al. Neuropsychological deficits in adolescents with fetal alcohol syndrome: clinical findings. Alcohol Clin Exp Res 1998;22: 1998.

Centers for Disease Control and Prevention. Alcohol policy and sexually transmitted disease rates–United States, 1981–1995. MMWR Morb Mortal Wkly Rep 2000;49:346.

Centers for Disease Control and Prevention. Fetal alcohol syndrome: guidelines for referral and diagnosis. Washington, DC: Department of Health and Human Services; July 2004.

Centers for Disease Control and Prevention. Guidelines for identifying and referring persons with fetal alcohol syndrome. Continuing education activity sponsored by CDC. Expiration—October 28, 2007. MMWR 2005;54(RR-11):1.

Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2005. Morb Mortal Wkly Rep Surveill Summ 2006;55(SS05):1.

Chaloupka FJ, Grossman M, Saffer H. The effects of price on alcohol consumption and alcohol-related problems. Alcohol Res Health 2002;26(1):22.

Church MW. The effects of prenatal alcohol exposure on hearing and vestibular function. In: Abel EL, ed. Fetal alcohol syndrome: from mechanism to prevention. Boca Raton, FL: CRC Press; 1996:85.

Donovan JE. Adolescent alcohol initiation: a review of psychosocial risk factors. J Adolesc Health 2004;35:529–e7.

Donovan JE, Lessor R, Lessor L. Problem drinking in adolescence and young adulthood: a follow-up study. J Stud Alcohol 1983;44:109.

Durant RH, Smith JA, Kreiter SR, et al. The relationship between early age onset of initial substance use and engaging in multiple health risk behaviors among young adolescents.Arch Pediatr Adolesc Med 1999;153:286.

Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1985;252:14.

Farrow JA, Rees JM, Worthington-Roberts BS. Health, developmental, and nutritional status of adolescent alcohol and marijuana abusers. Pediatrics 1987;79:218.

Fiellin DA, Reid MC, O'Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med 2000;160:1977.

Flanagan P, Kokotailo P. Adolescent pregnancy and substance use. Clin Perinatol 1999;26:185.

Frances R, Miller SI. Clinical textbook of addiction disorders. New York: The Guildford Press; 1991.

Friedman IM. Alcohol and unnatural deaths in San Francisco youths. Pediatrics 1985;76(2):191.

Halpern-Feshler BL, Millstein SG, Ellen JM. Relationship of alcohol use and risky sexual behavior: a review and analysis of findings. J Adolesc Health 1996;19:331.

Harrison PA, Luxenberg MG. Comparisons of alcohol and other drug problems among Minnesota adolescents in 1989 and 1992. Arch Pediatr Adolesc Med 1995;149:137.

Harwood GA. Alcohol abuse screening in primary care. Nurse Pract 2005;30(2):56.

Hingson R, Heeren T, Winter M. Lower legal blood alcohol limits for young drivers. Public Health Rep 1994;109:738.

Hingston R, Kenkel D. Social, health, and economic consequences of underage drinking. In: National Research Council and Institute of Medicine. Bonnie, R.J., and O'Connell, M.E., eds. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: National Academies Press, 2004;351.

Hingson R, Merrigan D, Heeren T. Effects of Massachusetts raising its legal drinking age from 18 to 20 on deaths from teenage homicide, suicide, and nontraffic accidents. Pediatr Clin North Am 1985;32:221.

Johnson MS, Moore M, Mitchell P, et al. Serious and fatal firearm injuries among children and adolescents in Alaska: 1991–1997. Alaska Med 2000;42:3.

Johnson VP, Swayze VW, Sato Y, et al. Fetal alcohol syndrome: craniofacial and central nervous system manifestations. Am J Med Genet 1996;61:329.

Johnston LD, O'Malley PM, Bachman JG, et al. Teen drug use down but progress halts among youngest teens. Ann Arbor, MI: University of Michigan News and Information Services; 2005. December 19, [On-line]. Available:; accessed 6/25/2006

Johnston LD, O'Malley PM, Bachman JG, et al. Monitoring the future national results on drug use, 1975–2005: volume I, secondary school students. NIH Publication No. 06–5883 Bethesda, MD: National Institute on Drug Abuse; 2006.

Johnston LD, O'Malley PM, Bachman JG et al. Monitoring the future national results in drug use, overview of key findings. NIH Publications No. 07-6202, Bethesda, MD: National Institute on Drug Abuse, 2007.

Kaemingik K, Paquette A. Effects of prenatal alcohol exposure on neuropsychological functioning. Dev Neuropsychol 1999;15:111.

Kandel DB. On processes of peer influences in adolescent drug use: a developmental perspective. Adv Alcohol Subst Abuse 1985;4:139.



Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patientsArch Pediatr Adolesc Med 2002;156:607.

Konovalov HV, Lovetsky NS, Bobryshev YV, et al. Disorders of brain development in the progeny of mothers who used alcohol during pregnancy. Early Hum Dev 1997;48:153.

Kypri K, Voas RB, Langley JD, et al. Traffic crash injuries among 15 to 19 year olds and minimum purchasing age for alcohol in New Zealand. Am J Public Health 2005 Nov 29; published ahead of print as (will be printed as Am J Public Health 2006; 96(1):1).

Lewis DD, Woods SE. Fetal alcohol syndrome. Am Fam Physician 1994;50:1035.

Lieber CS. Medical disorders of alcoholism. N Engl J Med 1995; 333:1058.

Maes HH, Woodard CE, Murrelle L, et al. Tobacco, alcohol, and drug use in eight- to sixteen-year-old twins: the Virginia twin study of adolescent behavioral development. J Stud Alcohol 1999;60:293.

Mattson SM, Riley EP, Gramling L, et al. Heavy prenatal alcohol exposure with or without physical features of fetal alcohol syndrome leads to IQ deficits. J Pediatr 1997;131:718.

McLennan JD, Shaw E, Shema SJ, et al. Adolescents' insight in heavy drinking. J Adolesc Health 1998;22:409.

Meyer R. Neuropharmacology of ethanol. Boston: Birkhauser; 1991.

Monforte R, Estruch R, Valls-Sole J, et al. Autonomic and peripheral neuropathies in patients with chronic alcoholism: a dose-related toxic effect of alcohol. Arch Neurol1995;52:45.

Morrison SF, Rogers PD, Thomas MH. Alcohol and adolescents. Pediatr Clin North Am 1995;42:371.

National Clearinghouse for Alcohol and Drug Information. Teens and alcohol don't mix: Alcohol Awareness Month, April 2000. SAMHSA. Available at

NIAAA (National Institute on Alcohol Abuse and Alcoholism), U.S. Department of Health and Human Services. Imaging and alcoholism: a window on the brain. Alcohol Alert2000;47:1. Available at

NIAAA (National Institute on Alcohol Abuse and Alcoholism), U.S. Department of Health and Human Services. Alcohol and development in youth–a multidisciplinary overview. The scope of the problem. Alcohol Res Health 2004/05a;28(3):111

NIAAA (National Institute on Alcohol Abuse and Alcoholism), U.S. Department of Health and Human Services. Alcohol and development in youth–a multidisciplinary overview. The effects of alcohol on physiological processes and biological development. Alcohol Res Health 2004/05b;28(3):125.

NIAAA (National Institute on Alcohol Abuse and Alcoholism), U.S. Department of Health and Human Services. Alcohol and development in youth–a multidisciplinary overview. Genetics, pharmacokinetics, and neurobiology of adolescent alcohol use. Alcohol Res Health 2004/05c;28(3):133.

NIAAA (National Institute on Alcohol Abuse and Alcoholism), U.S. Department of Health and Human Services. Alcohol and development in youth–a multidisciplinary overview. Environmental and contextual considerations. Alcohol Res Health 2004/05d;28(3):155.

Office of the Inspector General, Report to the Surgeon General. Youth and alcohol: dangerous and deadly consequences. Washington, DC: U.S. Department of Education; 1992.

Project CHOICES Research Group. Alcohol-exposed pregnancy: characteristics associated with risk. Am J Prev Med 2002; 23:166.

Rachal JV, Williams JR, Brehm ML, et al. A national study of adolescent drinking behavior, attitudes, and correlates [conducted by Research Triangle Institute for the National Institute on Alcohol Abuse and Alcoholism]. Washington, DC: U.S. Department of Health, Education, and Welfare; 1975. [Available from National Technical Information Service, Springfield, VA.]

Rhee SH, Hewitt JK, Young SE, et al. Genetic and environmental influences on substance initiation, use, and problem use in adolescents. Arch Gen Psychiatry 2003;60:1256.

Robuck TM, Simmons RW, Richardson C, et al. Neuromuscular responses to disturbance of balance in children with prenatal exposure to alcohol. Alcohol Clin Exp Res1998;22:1992.

Selzer ML. The Michigan alcoholism screening test: the quest for a new diagnostic instrument. Am J Psychol 1971;127:89.

Smith BH, Molina BSG, Pelham WE. The clinically meaningful link between alcohol use and attention deficit hyperactivity disorder. Alcohol Res Health-Alcohol Comorbid Ment Health Disord 2002;26(2):122.

Sokol RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA 2003;290:2996.

Strauss RS, Barlow SE, Dietz WH. Prevalence of abnormal serum aminotransferase values in overweight and obese adolescents. J Pediatr 2000;136:727.

Streissguth AP. Fetal alcohol syndrome: a guide for families and communities. Baltimore, MD: Paul Brookes Publishing Co; 1997.

Streissguth AP, Barr HM, Kogan J, et al. Understanding the occurrence of secondary disabilities in clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE): final report. Seattle, WA: University of Washington Publication Services; 1996.

Sutocky JW, Shultz JM, Kizer KW. Alcohol-related mortality in California, 1980 to 1989. Am J Public Health 1993;83:817.

Thomas SE, Kelly SJ, Mattson SN, et al. Comparison of social abilities of children with fetal alcohol syndrome to those of children with similar IQ scores and normal controls.Alcohol Clin Exp Res 1998;22:528.

U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendations statement. Ann Intern Med2004;140:554.

U.S. Public Health Service. Alcohol and other drug abuse in adolescents. Am Fam Physician 1994;50:1737.

Werenko DD, Olson LM, Fullerton-Gleason L, et al. Child and adolescent suicide deaths in New Mexico, 1990–1994. Crisis 2000;21:36.

Wilson DM, Killen JD, Hayward C, et al. Timing and rate of sexual maturation and the onset of cigarette and alcohol use among teenage girls. Arch Pediatr Adolesc Med 1994;148: 789.

Windle M, Windle RC. Adolescent tobacco, alcohol, and drug use: current findings. Adolesc Med 1999;10:153.

Zeigler DW, Wang CC, Yoast RA, et al. The neurocognitive effects of alcohol on adolescents and college students. Prev Med 2005;40:23.