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3
Health Consequences of Adolescent Alcohol Involvement

Sandra A. Brown and Susan F. Tapert

As underage drinking rates have increased and research technology has improved in recent decades, we have become more aware of the problems caused by alcohol use during the rapid transitions and growth of adolescence. Some adverse effects occur acutely while young people are under the influence of alcohol, whereas other negative effects may become apparent after months or years of heavy use. In this chapter, we discuss how alcohol affects adolescent physical health, brain development, and mental health, as well as the common behavioral consequences of underage drinking.

ACUTE EFFECTS

Accidents

The acute effects of alcohol consumption for adolescents depend on the blood alcohol concentration (BAC) attained. BAC is determined by the amount of alcohol consumed, time elapsed, body weight, and gender. Even at low BACs, impairments in motor control and judgment become apparent. Because rational thinking is increasingly weakened as BACs rise, intoxicated youth are susceptible to riding with drunk drivers (Monti et al., 1999). The leading cause of death for teenagers is unintentional injury, primarily related to motor vehicle accidents (National Center for Health Statistics, 1999), and 20 percent of all traffic crashes of 16- to 20-year-olds involve alcohol (Yi, Williams, and Dufour, 2001). Alcohol intoxication is



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Reducing Underage Drinking: A Collective Responsibility 3 Health Consequences of Adolescent Alcohol Involvement Sandra A. Brown and Susan F. Tapert As underage drinking rates have increased and research technology has improved in recent decades, we have become more aware of the problems caused by alcohol use during the rapid transitions and growth of adolescence. Some adverse effects occur acutely while young people are under the influence of alcohol, whereas other negative effects may become apparent after months or years of heavy use. In this chapter, we discuss how alcohol affects adolescent physical health, brain development, and mental health, as well as the common behavioral consequences of underage drinking. ACUTE EFFECTS Accidents The acute effects of alcohol consumption for adolescents depend on the blood alcohol concentration (BAC) attained. BAC is determined by the amount of alcohol consumed, time elapsed, body weight, and gender. Even at low BACs, impairments in motor control and judgment become apparent. Because rational thinking is increasingly weakened as BACs rise, intoxicated youth are susceptible to riding with drunk drivers (Monti et al., 1999). The leading cause of death for teenagers is unintentional injury, primarily related to motor vehicle accidents (National Center for Health Statistics, 1999), and 20 percent of all traffic crashes of 16- to 20-year-olds involve alcohol (Yi, Williams, and Dufour, 2001). Alcohol intoxication is

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Reducing Underage Drinking: A Collective Responsibility associated with even greater risks of traffic accidents for youth as compared to adults, and adolescent drivers are more likely than adults to get into accidents at lower BACs (Yi et al., 2001), likely because they have fewer years of driving experience (Hingson, Heeren, and Winter, 1994; Yi et al., 2001). Other Mortality Factors Alcohol is far from the “safe drug” parents often think. As BACs rise, alcohol overdose can occur, resulting in respiration failure, suffocation, coma, and, in some cases, death. Alcohol intoxication produces diminished inhibition, increased violent behavior, and poor judgment that can result in being in the wrong place at the wrong time, and these factors all contribute to young deaths and injuries due to alcohol-related aggressive behavior. Homicide is the second leading cause of death for those ages 10 to 20 (National Center for Health Statistics, 1999). Suicide is the third leading cause of death for youth (National Center for Health Statistics, 1999), and approximately 28 percent of suicides of those 9 to 15 years old can be directly attributed to or are related to alcohol use (Preuss et al., 2002; Reifman and Windle, 1995). Other Drug Use Young people under the influence of alcohol are at an increased likelihood of deciding to use other drugs (Brown, Tapert, Tate, and Abrantes, 2000b). Alcohol is often considered a gateway to the use of illegal substances. Youth who drink are significantly more likely to use other illicit drugs, compared to young nondrinkers (Kandel and Davies, 1996). A young person may decide to use an illicit substance after drinking because judgment is impaired, exposure to other substances is more likely, and susceptibility to peer influences is amplified. Once alcohol use has been initiated, the use of other intoxicants may no longer appear as risky to the teen. Withdrawal and Hangover Subacute effects of drinking may be experienced in the day or two following an episode of heavy drinking. For adolescents, these effects can include feeling dizzy when first standing up, nausea or vomiting, feeling depressed or irritable, tremor or shakes, racing heart, sweating, rapid breathing, insomnia, headaches, and muscle aches or weaknesses (Stewart and Brown, 1995; Tapert and Brown, 1999). Although relatively rare, youth who have developed a physical addiction to alcohol can experience withdrawal seizures in the first few days of abstinence.

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Reducing Underage Drinking: A Collective Responsibility Overall, the acute effects of alcohol use in adolescents are similar to those experienced by adults, except that youth experience less of the sedating effects (Silveri and Spear, 2002) and more memory impairment effects than adults (White, Ghia, Levin, and Swartzwelder, 2000), as revealed by animal studies. Thus, adolescents appear to be at even greater risk for continuing risky behaviors (such as driving drunk, riding with drunk drivers, engaging in sexual behavior, or participating in other physical activities that result in physical injury) during an episode of drinking (Bonomo et al., 2001) and incurring a blackout and forgetting the events of an alcohol-filled evening (Arria, Dohey, Mezzich, Bukstein, and Van Thiel, 1995). CHRONIC EFFECTS Some chronic health problems that are commonly observed in adults with alcohol dependence are seldom seen in adolescents, including gastritis, pancreatitis, hepatitis, liver cirrhosis, hypertension, anemia, and malnutrition (Aarons et al., 1999; Clark, Lynch, Donovan, and Block, 2001). However, adolescents who drink heavily are at risk for identifiable health problems, with young females at a somewhat greater risk of incurring more severe physical consequences (Aarons et al., 1999). In one of the few studies of youth using both physical exams and biological measures, Clark and colleagues (2001) found adolescents with alcohol use disorders (AUD) had more problems identified on their physical exams. Oral and sleep problems in particular were linked to alcohol involvement. AUD also reported more health problems and negative affect. Furthermore, extent of alcohol use in adolescence has been linked to dysphasia and poorer physical health during adolescence and young adulthood (Hansell, White, and Vali, 1999; Aarons et al., 1999). Whether youth drink beer, wine, or distilled spirits, poorer health outcomes are expected. As early as adolescence, chronic heavy alcohol use has been shown to affect bones and the liver, and, as we detail in the following section, the brain. Bone Density and Growth Animal studies show that chronic alcohol consumption near the time of puberty in male rats leads to decreased bone volume in the limbs and the skull because of its effects on bone-forming cells, and normal bone metabolism does not generally resume after cessation of alcohol use (Wezeman et al., 1999). Late adolescent male rats given alcohol and physical exercise showed reduced bone formation rates, suggesting an increased chance of exercise-related bone injuries in young drinkers (Reed, McCarty, Evans, Turner, and Westerlind, 2002). In female adolescent rats, bone density was reduced during a period of alcohol consumption, and after cessation, bone

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Reducing Underage Drinking: A Collective Responsibility growth resumed, but did not compensate for growth that had been lost during the alcohol ingestion period (Sampson and Spears, 1999). Large quantities of alcohol consumed by young rats resulted in weaker bones (Sampson, Perks, Champney, and DeFee, 1996). These findings from animal models are supported by studies in humans showing that alcohol drinkers tend to have less bone mineral density, especially adolescent males (Neville et al., 2002). High doses of alcohol have also been found to delay puberty in female rodents and primates (Dees, Dissen, Hiney, Lara, and Ojeda, 2000; Dees and Skelley, 1990; Dees, Srivastava, and Hiney, 2001) and male rats (Cicero et al., 1990). However, detailed studies in humans will be needed to understand how alcohol affects pubertal development in young people. Liver Function Although liver functioning is commonly compromised in adults who drink heavily, community studies show a negligible incidence of cirrhosis or alcoholic liver disease among adolescents (Bellentani et al., 1997). However, alcohol use-disordered teens show elevated liver enzyme assays and a greater likelihood of abnormalities detected by a physical exam (Clark et al., 2001). The liver absorbs most of the alcohol from the small intestine, and when the liver can no longer process fats, alcohol becomes the preferred fuel. This can set the stage for the development of alcoholic hepatitis or even permanent scarring of the liver, a condition known as cirrhosis, which develops in approximately 15 percent of alcohol-dependent adults. Other problems related to the digestive system include inflammation of the pancreas, gastric irritation, and an increased risk for ulcers (Schuckit, 2000), which can occur in youth but are rare. Future Problems Persistent adolescent drinking is associated with an increased risk of multiple future problems. Youth who begin drinking before age 15 are four times more likely to develop alcohol dependence than those who begin drinking at or after age 21 (Grant and Dawson, 1997). Among adults who developed alcoholism, the average age of first drink was 13, first intoxication was 15, and first alcohol-related problem was 20 (Schuckit, Anthenelli, Bucholz, Hesselbrock, and Tipp, 1995). Rodents given alcohol as adolescents show greater intake rates of alcohol as adults, suggesting alterations in sensitivity or tolerance as a result of drinking during adolescence (Yoshimoto et al., 2002). Furthermore, youth who use alcohol are at an increased risk for other drug involvement, failure to develop emotionally and cognitively, and criminal involvement (Newcomb and Bentler, 1988), as detailed

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Reducing Underage Drinking: A Collective Responsibility further in this chapter. Youth who increase heavy drinking from ages 18 to 24 and consistently drink heavily at least weekly during this period may have problems successfully managing the transition from adolescence to young adulthood, and may fail to complete goals regarding marriage, education, employment, and financial independence (Schulenberg, O’Malley, Bachman, Wadsworth, and Johnston, 1996). EFFECTS OF ALCOHOL USE AND ABUSE ON ADOLESCENT BRAIN DEVELOPMENT Importantly, chronic drinking during adolescence has been associated with brain functioning (Brown, Tapert, Granholm, and Delis, 2000a; Tapert et al., 2001a; Tapert and Brown, 1999; Tapert, Granholm, Leedy, and Brown, 2002). To understand how alcohol use affects adolescent brain development, it is helpful to briefly review the maturational processes that occur during these years. Healthy Adolescent Brain Development Myelination Well before adolescence, the brain achieves its full size and grossly contains the number of brain cells it will have in adulthood. The developments of the brain during adolescence primarily involve refinement into a more efficient organ that requires less fuel (oxygen, blood, and sugar) to operate. Starting before birth and until approximately age 30, the axons of brain cells are insulated with a fatty substance, called myelin, that helps speed the transfer of electric impulses across the cell to facilitate communication with neighboring brain cells (Benes, Turtle, Khan, and Farol, 1994; Sowell, Thompson, Tessner, and Toga, 2001). In adolescence, this process of myelination occurs predominantly in the front half of the brain (frontal and prefrontal lobes), which is responsible for important functions such as planning, organization, and halting an impulse. Thus, by age 30, a person can relay information throughout the frontal lobes and to other regions of the brain and perform planning and organizational tasks much more efficiently than was possible at age 12. Synaptic Refinement At birth, each brain cell has connections to up to 10,000 other neurons. These connections, or synapses, are small gaps between brain cells across which specific brain chemicals travel. However, not all these connections are necessary and, in fact, unneeded connections slow brain activity.

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Reducing Underage Drinking: A Collective Responsibility Throughout childhood and into mid-adolescence until roughly age 16, these unneeded connections are eliminated, leaving the brain a more refined system (Huttenlocher, 1979) with which to interpret sensory information, conduct thinking, and coordinate motor responses. A related developmental process that continues into adolescence is the functioning of brain chemicals or neurotransmitters (Silveri and Spear, 2002). Adolescent brain developments are prominent in the prefrontal cortex, an area critical for considering the consequences of actions, and other frontal areas that are important for stress responses and managing drives (Spear, 2002). Some scientists speculate that adolescent brain developments carry an evolutionary advantage by encouraging independence and new experiences that reduce the chances of inbreeding (Spear, 2002). How Alcohol Affects Adolescent Brain Development Animal Studies We are just beginning to understand how alcohol use affects brain functioning during this critical period of brain development, both during adolescence and in the long term. Animal studies have suggested that alcohol affects adolescent brain development processes in several ways. A recent study gave adolescent and adult rats multiple episodes of large quantities of alcohol, mimicking the pattern characteristic of many U.S. teens. Once all rats became adults, those who had been given alcohol during adolescence showed more impairments on a memory task than those who had been given alcohol only as adults (White et al., 2000). Furthermore, studies of adolescent and adult rats reveal that chronic alcohol use during adolescence alters sensitivity to alcohol-induced motor dyscoordination (White et al., 2002). Another study examined the effects of a 4-day alcohol binge on adolescent and adult rats. While significant brain damage was found in both groups during the autopsy, several frontal brain regions were damaged only in the adolescent rats, suggesting that different brain regions vary in vulnerability to alcohol effects across development (Crews, Braun, Hoplight, Switzer, and Knapp, 2000). In summary, adolescents appear to be more sensitive than adults to the learning and memory impairments of alcohol, but less sensitive to the sedation and temperature regulation effects (Spear, 2002). Brain Imaging Studies A growing number of studies on human adolescents have supported the findings from animal studies: Drinking alcohol during adolescence appears to affect brain functioning and development. Brain size was compared

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Reducing Underage Drinking: A Collective Responsibility between youth with adolescent-onset alcohol use disorders and healthy matched comparison youth using magnetic resonance imaging (MRI). Youth with alcohol use disorders had significantly smaller left and right hippocampi, central brain regions critical for the formation of new memories. These results suggested that, during adolescence, the hippocampus may be particularly vulnerable to the adverse effects of alcohol (De Bellis et al., 2000). The implications of these brain structure studies have been highlighted by functional MRI (fMRI) studies. This technique essentially takes a movie instead of just one picture of the brain as the subject performs a task. Using this approach, alcohol-dependent youth were compared to healthy matched comparison youth as they performed a memory task. Participants with alcohol dependence showed significantly less brain response than controls as they performed the challenging memory task, especially in frontal and parietal (upper back of brain) areas (Tapert et al., 2001a). Neuropsychological Studies The importance of the animal studies and human brain imaging studies is apparent in the reports of thinking and memory tests with heavy-drinking adolescents. Although some studies have found that teens with alcohol use disorders perform reasonably well on tests of language, intellect, and reasoning (Moss, Kirisci, Gordon, and Tarter, 1994), other studies have found that young heavy drinkers perform more poorly on tests of planning and executive functioning (Giancola and Mezzich, 2000), memory (Brown et al., 2000a), spatial operations (Tapert and Brown, 1999; Tapert et al., 2002), and attention (Tapert et al., 2001a; Tapert and Brown, 1999) tasks. In one study, alcohol-use disordered adolescents who were detoxified in a long-term treatment program demonstrated a 10 percent deficit in their ability to recall both verbal and nonverbal information that had been previously presented to them (Brown et al., 2000a). Having had withdrawal or hangover experiences in the days following a bout of heavy drinking was a particular risk factor for performing more poorly on most cognitive tests (Tapert and Brown, 1999; Tapert et al., 2002), especially those involving spatial functioning (e.g., copying a complex picture or solving a puzzle). Understandably, the problems in the brain affect thinking and memory abilities, which in turn influence how well young drinkers do in school. A large college survey reported that youth with grade point averages at the D or F level drink three times as much as those who earn A grades (Presley, Meilman, and Lyerla, 1994). For youth being treated for alcohol problems, those who continue to drink and those who experience any alcohol withdrawal appear most likely to exhibit continued deterioration in cognitive functioning (Tapert and Brown, 1999; Tapert et al., 2002).

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Reducing Underage Drinking: A Collective Responsibility Mental Health Problems Unfortunately, adolescent alcohol involvement is associated with a wide variety of mental health concerns, ranging from low self-esteem and deviant behaviors to depression and suicide. Mental health problems and disorders occur significantly more frequently among youth with alcohol use disorders than in the general population and substantially more often than can be accounted for by the base rates of these individual disorders (Lilienfeld, Waldman, and Isreal, 1994). Such comorbidity can occur simultaneously or sequentially, and the timing of the onset of each disorder has important implications for the etiology of the problems, severity of symptoms, typical course of disorders, and outcomes from treatment (Costello, Erkanli, Federman, and Angold, 1999). Early Alcohol Use The earlier alcohol use is initiated during childhood or adolescence, the greater the risk for a variety of adverse consequences. It is now well known that when youth begin drinking alcohol before age 14, they have a 41 percent chance of developing alcohol dependence during their lifetime compared to individuals who wait to the legal drinking age of 21 when the risk is reduced to 10 percent (Grant and Dawson, 1997). Not only is age of initial use universally associated with lifetime risk for alcohol dependence, but early use also elevates risk for a multitude of mental health and social problems (McGee, Williams, Poulton, and Moffitt, 2000). Rates of conduct disorder, antisocial personality disorder, nicotine dependence, and illicit drug abuse and dependence are significantly higher among youth who drink early (McGue, Iacona, Legrand, Malone, and Elkins, 2001). Cross-culturally, studies indicate that heavy adolescent alcohol use is associated with psychological distress, anxiety, and depression (Mazaira Castro, Dominguez Santos, and Rodriguez Lopez, 1993) at a time when social anxiety normally increases dramatically. Youth with early problems such as school difficulties, personal difficulties (e.g., hyperactivity, impulsivity, and inattentiveness), or family problems are at risk of beginning to drink early (McGue et al., 2001). The psychophysiological marker of alcoholism risk P3 amplitude is also apparent by mid-adolescence. Although alcohol use is a prevalent problem among adolescents, those most disadvantaged, such as the homeless, abused or neglected, show high rates of AUDs as well as behavioral and psychological symptoms (McCaskill, Toro, and Wolfe, 1998). Youth with certain mental health disorders evident in early adolescence are more likely to use alcohol early and accelerate their use throughout adolescence (White, Xie, Thompson, Loeber, and Stouthamer-Loeber,

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Reducing Underage Drinking: A Collective Responsibility 2001). Disruptive disorders with conduct problems and aggressive or oppositional behaviors have been associated with the early onset of use and abuse (Rose, 1998; Costello et al., 1999). In girls early anxiety disorders may also accelerate alcohol involvement (Rose, 1998). Although drinking patterns fluctuate throughout adolescence, the pattern of youth alcohol consumption is also predictive of later heavy drinking problems. For example, 15- to 19-year-old males who drink or smoke cigarettes to relieve stress are more likely to be heavy or problematic drinkers 5 years later (Poikolainen, Tuulio-Henrikkson, Aalto-Setaelae, Marttunen, and Loennqvist, 2001). The mental health of minority populations is also significantly disadvantaged by adolescent drinking. For example, heavy drinking in Mexican-American adolescents is associated with alcohol and drug abuse as well as depression in adulthood. Suicide attempts in adulthood are predicted by heavy youth drinking in cross-cultural studies (Hintikka et al., 2000), and suicide is twice as likely for Mexican Americans when alcohol is used heavily during adolescence (Vega, Alderete, Kolody, and Aguilar-Gaxiola, 2000). When alcohol involvement reaches the level of a disorder (abuse or dependence), the likelihood of the disorder resolving by the mid-20s is low, and young adult health and mental health consequences continue to mount (Rohde, Lewinsohn, Kahler, Seeley, and Brown, 2001; Aarons et al., 1999). Gender differences are evident in several mental health problems associated with adolescent drinking. For example, problematic drinking is associated with posttraumatic stress symptoms for girls, but not boys (Lipschitz, Grilo, Fehon, McGlashan, and Southwick, 2000). Conduct disorder is more prevalent among heavy-drinking boys than girls (Brown, Gleghorn, Schuckit, Myers, and Mott, 1996). The prevalence rate of sexual abuse is also significantly higher for girls than boys with alcohol or other substance use disorder. Unfortunately, adolescent drinking is associated with a variety of other risky behaviors (e.g., Donovan and Jessor, 1985; Flisher, et al., 2000), which also influence the health, mental health, and social functioning of teens. Youth drinking is associated with nicotine and marijuana use, fighting, early intercourse, school dropout, and suicidal ideation/attempts. Suicide is the third leading cause of death for youth (National Center for Health Statistics, 1999) and is consistently related to alcohol use across studies (e.g., Preuss et al., 2002). Adolescent Alcohol Use Disorders It is becoming increasingly evident that the comorbidity of AUD and other mental health disorders is one of the most prevalent and important challenges facing professionals treating youth with alcohol problems to-

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Reducing Underage Drinking: A Collective Responsibility day. Consequently, study of these disorders has recently expanded. According to a recent review, in the 1990s more than 125 studies were published focusing on alcohol and drug use disorders and comorbid mental health problems. Specifically, comorbidity refers to the co-occurrence of two or more disorders (Perrin and Last, 1995), which can be present simultaneously or sequentially. The disorder occurring first (Schuckit, Irwin, and Brown, 1990) or the disorder with the most dominant symptoms (Klerman, 1990) is referred to as the primary disorder. The order of symptoms and disorder onset has important clinical implications for understanding both the causal pathways to the difficulties these youth face (e.g., Mueser, Drake, and Wallach, 1998) as well as the likely clinical course following treatment. AUDs and mental health disorders of youth may reflect common risk (e.g., genetic predisposition, environmental adversity), or be precipitated or exacerbated by each other (e.g., alcohol-induced mood disorder, conduct disorder-provoked alcohol use disorder). The prevalence of these etiological pathways varies across types of mental health disorders and specific drugs of addictions. Across a variety of service sectors (i.e., alcohol and drug, mental health, juvenile justice, child welfare), youth with alcohol abuse and dependence are most likely to present with other drug disorders, disruptive disorders, and anxiety disorders. In adolescent substance abuse treatment programs, approximately two-thirds of youth evidence a major mental health disorder as measured by DSM Axis I psychopathology in addition to their alcohol problem. According to a recent review of research in this area, 54 to 95 percent of youth in treatment for alcohol problems have conduct or oppositional defiant disorder. Mood disorders are evident in approximately half of treated AUD teens and 15 percent to 42 percent exhibit anxiety disorders (e.g., post-traumatic stress disorder, social phobia). In juvenile justice settings, conduct disorders are the most common comorbid disorder for these teens, whereas in inpatient mental health settings, depressive disorders are as prevalent as disruptive disorders. Recent studies of youth with an alcohol use disorder indicate poorer outcomes for those with comorbid mental health disorders. In particular, disruptive disorders, anxiety disorders, and severity of psychiatric symptoms have been associated with higher relapse rates and greater severity of posttreatment drug involvement (Brown, 1999). It is unclear whether the poorer outcomes reflect poorer retention in treatment, worse compliance with interventions, or more limited personal resources (e.g., poorer coping skills, fewer family and social supports). Clearly these comorbid youth are exposed to more risks in their home and community environments (e.g., stressors). Because we know so little about optimal behavioral or pharma-

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Reducing Underage Drinking: A Collective Responsibility cological treatment for these youth, their adverse outcomes may also reflect poorer client-treatment match. Although intervention research on AUD adolescents with comorbid mental health problems lags behind such research on adults, integrated treatment of the co-occurring problems appears critical (Dembo, 1996). For example, integrated interventions with youth with comorbid conduct disorder and alcohol and drug problems have been shown to increase engagement and retention in treatment (Henngellar et al., 1996). Engagement and retention in treatment has been identified as critical to treatment success with youth (Hser et al., 2001). Similarly, integrated interventions involving family members facilitate engagement as well as retention of such youth (e.g., Liddle and Dakof, 1995) and have demonstrated improved outcomes. At present, the efficacies of specific medications and forms of intervention have not been well explicated for AUD youth with comorbid mental health disorders although joint treatment of the disorders appears advisable. BEHAVIORAL AND SOCIAL CONSEQUENCES Among the many concerns related to adolescent alcohol involvement is the risk for serious problems in areas critical to development. For youth to mature into successful adults, clearly they need not only to be physically and emotionally healthy, but also to become successful in domains essential for their roles as adults. To the extent that alcohol use during adolescence disrupts functioning in school or work, or produces interpersonal or psychological impairment, it alters the trajectory of development and reduces potential adult functioning. Unfortunately, substantial evidence shows that not only is alcohol abuse and dependence associated with problems in these domains, but even modest involvement during high school may create significant problems. For example, of twelfth graders in a well-designed national survey, Monitoring the Future, or MTF (O’Malley, Johnston, and Bachman, 1998), 53 percent had consumed alcohol on at least 10 occasions and two-thirds of these youth indicated they had one or more problems because of their drinking. In fact, one-third of the high school seniors with drinking experience (i.e., 10 or more occasions) reported 3 or more alcohol-related problems. Thus, approximately 15 percent of high school seniors reported multiple problems from alcohol. Similarly, the National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (1998) reports that 38 percent of youth ages 12 to 17 who drank alcohol in the prior year experienced at least one problem related to alcohol. The most commonly reported alcohol-related problems for high school

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Reducing Underage Drinking: A Collective Responsibility seniors in the MTF Study included behavior they later regretted (52 percent) and interference with the ability to think clearly (30 percent). One in five students reported damage to their relationship with their significant other (i.e., boyfriend, girlfriend, fiancé) and/or driving unsafely. One of every six students indicated they became involved with people who were a bad influence on them and damage to their relationship with their parents. Approximately 10 percent of high school seniors with alcohol experience said alcohol damaged friendships, hurt them emotionally, got them in trouble with police, and hurt their performance in school. Sexual Behavior The impaired judgment resulting from alcohol intoxication can result in risky, early, and unwanted sexual behaviors in youth, which may lead to unintended teen pregnancies and sexually transmitted diseases. For example, youth who drink heavily are three times less likely to use condoms than nondrinkers or infrequent drinkers (Tapert, Aarons, Sedlar, and Brown, 2001b), and heavy drinking is associated with unprotected intercourse and sexual activity before age 16 (Fergusson and Lynskey, 1996). Forty-four percent of sexually active teenagers report they are more likely to have intercourse if they have been drinking (Strunin and Hingson, 1992). Some of this sexual activity is unwelcome. Alcohol use is involved in one- to two-thirds of sexual assault and date rape cases among teens and college students (Office of Inspector General, 1992), and a survey of high schoolers reported that 39 percent of males and 18 percent of females perceive that it is acceptable for a boy to force sex on a girl if she is drunk or high (Office of Inspector General, 1992). A national survey of eighth and tenth graders linked alcohol use with risky behavior as well as sexual victimization, particularly for younger males (Windle, 1994). As a result of these risky behaviors, youth with alcohol use disorders are twice as likely to have a sexually transmitted disease (Tapert et al., 2001b), and girls with alcohol problems are three times more likely to have a pregnancy before age 18 (Tapert et al., 2001b). School Functioning As noted previously, school functioning is impacted by student drinking. Alcohol reduces students’ ability to think clearly (O’Malley et al., 1998), and use of alcohol on 100 occasions or more is associated with poorer recall of verbal information (Brown et al., 2000a), such as in English or social studies classes, as well as visual spatial information like that presented in math, science, or computer classes (Tapert and Brown, 2000).

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Reducing Underage Drinking: A Collective Responsibility Additionally, alcohol use is associated with poor attendance, truancy, and school drop-out (O’Malley et al., 1998). Consequently, youth miss opportunities to learn because of their drinking and are less able to retain learned information when they try. In concert, such a pattern leads to increasing failure in the school setting. Family Functioning Family conflict is a common complaint for all families with adolescents experiencing problems. However, youth with heavy alcohol involvement also experience less expressiveness and cohesion in their families. Alcohol-abusing youth less often identify parents as important supports and develop support networks with more drinking peers (Tapert, Tate, and Brown, 1999). In fact, alcohol abuse is associated with elevated rates of running away from home overnight and homelessness. When adolescent alcohol problems are compounded by parental alcoholism, family communication patterns are marked by more negative affect and poorer problem-solving skills. As noted earlier, a variety of other problem and deviant behaviors cooccur with adolescent drinking (e.g., reckless driving, high-risk sexual behaviors). However, early alcohol involvement is also associated with socialization into deviant peer groups who decrease participation in healthy school, family, and community activity. Association with more deviant peers is linked to increases in illegal behavior, including other drug involvement, theft, and property damage. These results clearly indicate that even modest alcohol involvement by adolescents has adverse consequences on important domains of functioning despite the prevalence of such behavior. However, youth who meet criteria for alcohol abuse or dependence evidence even more severe social and behavioral consequences and obvious disadvantages (e.g., suspension, expulsion, or dropping out from school) which can have pronounced short term and long term impacts. Table 3-1 depicts common problems of youth with identified alcohol abuse or dependence as they enter treatment. These youth exhibit an average of more than five such major problems (Brown, 1993). Clearly, these problems span all domains of functioning identified as important in both adolescent and young adult functioning. AUDs developing during adolescence are not benign conditions, do not typically resolve over time, and are associated with a multitude of adverse health, psychological, and social consequences, which we are only now starting to understand.

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Reducing Underage Drinking: A Collective Responsibility TABLE 3-1 Common Behavioral Correlates of Adolescent Alcohol Abuse Domain of Functioning Behavioral Correlates School Attendance: truancy, suspension, expulsion, dropout Academic performance: decreased studying or grades, decreased comprehension Behavioral problems: conflict with authorities and peers Family Withdrawal: decreased contact and expressiveness Conflict: arguments, running away, lying Social Behavior: decreased communication, fights Peer group: change in friends or peer alcohol drug use Sexuality: earlier intercourse, high-risk behaviors, teen pregnancy Activities Work: absenteeism, firing, walking off job School activities: decreased participation Illegal behavior: property damage, theft Reckless behavior: speeding while driving, driving under influence Health Physical: accidents, injury, withdrawal symptoms Emotional: emotional lability, anxiety, depression or anger, suicidal ideation, psychotic thoughts, decreased motivation REFERENCES Aarons, G.A., Brown, S.A., Coe, M.T., Myers, M.G., Garland, A.F., Ezzet-Lofstram, R., Hazen, A.L., and Hough, R.L. (1999). Adolescent alcohol and drug abuse and health. Journal of Adolescent Health, 6, 412-421. Arria, A.M., Dohey, M.A., Mezzich, A.C., Bukstein, O.G., and Van Thiel, D.H. (1995). Self-reported health problems and physical symptomatology in adolescent alcohol abusers. Journal of Adolescent Health, 16(3), 226-231. Bellentani, S., Saccoccio, G., Costa, G., Tiribelli, C., Manenti, F., Sodde, M., Saveria Croce, L., Sasso, F., Pozzato, G., Cristianini, G., and Brandi, G. (1997). Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group. Gut, 41(6), 845-50. Benes, F.M., Turtle, M., Khan, Y., and Farol, P. (1994). Myelination of a key relay zone in the hippocampal formation occurs in the human brain during childhood, adolescence, and adulthood. Archives of General Psychiatry, 51(6), 477-484. Bonomo, Y., Coffey, C., Wolfe, R., Lynskey, M., Bowes, G., and Patton, G. (2001). Adverse outcomes of alcohol use in adolescents. Addiction, 96(10), 1485-96. Brown, S.A. (1993). Recovery patterns in adolescent substance abuse. In J.S. Baer, G.A. Marlatt, and R.J. McMahon (Eds.), Addictive behaviors across the lifespan: Prevention, treatment, and policy issues (pp. 161-183). Beverly Hills, CA: Sage. Brown, S.A. (1999). Treatment of adolescent alcohol problems: Research review and appraisal. NIAAA Extramural Scientific Advisory Board: Treatment. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Brown, S.A., Gleghorn, A.A., Schuckit, M.A., Myers, M.G., and Mott, M.A. (1996). Conduct disorder among adolescent alcohol and drug abusers. Journal of Studies on Alcohol, 57(3), 314-324.

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