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Underage Drinking - The National Institute on Alcohol
Abuse and Alcoholism
(From "Alcohol Alert," The
National Institute on Alcohol Abuse and Alcoholism No. 37
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
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
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
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
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
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
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
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
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
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
*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
Full text of this publication is available on NIAAA's
World Wide Web site at
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