Reducing Underage and Young Adult Drinking

How to Address Critical Drinking Problems During This Developmental Period

Michael Windle, Ph.D., and Robert A. Zucker, Ph.D.

Forty years ago, when the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was founded, alcoholism was considered an adult disease driven principally by physiological determinants. As NIAAA expanded its research portfolio, new data and insights were obtained that led to an increased focus on underage and young adult drinking. Fostered by interdisciplinary research, etiologic models were developed that recognized the multiplicity of relevant genetic and environmental influences. This shift in conceptualizing alcohol use disorders also was based on findings from large-scale, national studies indicating that late adolescence and early young adulthood were peak periods for the development of alcohol dependence and that early initiation of alcohol use (i.e., before age 15) was associated with a fourfold increase in the probability of subsequently developing alcohol dependence. In recent years, developmental studies and models of the initiation, escalation, and adverse consequences of underage and early young adult drinking have helped us to understand how alcohol use may influence, and be influenced by, developmental transitions or turning points. Major risk and protective factors are being identified and integrated into screening, prevention, and treatment programs to optimize interventions designed to reduce drinking problems among adolescents and young adults. In addition, regulatory policies, such as the minimum drinking age and zero-tolerance laws, are being implemented and evaluated for their impact on public health. KEY WORDS: Underage drinking; drinking in young adulthood; psychosocial development; development of alcohol disorders; risk factors; protective factors; alcohol effects on brain development; screening among youth; preventive interventions; college drinking; treatment for adolescents and young adults

n 1970, the National Institutes Simultaneously, but unrelated to tion. At that time, NIAAA’s Division of Health (NIH) established the the research on the adult psychopathol- of Epidemiology and Prevention INational Institute on Alcohol Abuse ogy, a separate scientific community increasingly began to support research and Alcoholism (NIAAA). At that time, was sensitized to the public concern addressing these issues, and an impor­ both the general public and the scientific about an illegal activity—underage tant body of theory and research community predominantly regarded drinking—that potentially could began to articulate the developmental alcoholism as a disorder of adulthood, result in great personal and societal nature of drinking behavior and to and the major focus of NIH-funded cost in the form of accidents and loss scientific work was on understanding of life. By the late 1970s, a significant MICHAEL WINDLE, PH.D., is a professor its etiology and finding new treatments body of research was addressing the in, and chair of, the Department of for it. Most of the etiological research critical issue of why most youth only Behavioral Sciences and Health Education, focused on physiological and clinical begin drinking in mid- to late adoles- Emory University, Atlanta, Georgia. analyses in adults, and the drinking cence and consume alcohol in small behavior of adolescents only appeared amounts at infrequent intervals and ROBERT A. ZUCKER, PH.D., is a professor in discussions of the epidemiology and without problems, whereas others in the Departments of Psychiatry and sociology of drinking patterns (e.g., begin much earlier, and in some cases Psychology and director of the Addiction Kissin and Begleiter 1972, 1976; progress to consuming near-alcoholic Research Center, University of Michigan, Popham 1970). levels within a short time after initia- Ann Arbor, Michigan.

Vol. 33, Nos. 1 and 2, 2010 29 identify individual and social contex­ developmentally because they origi­ College Drinking (NIAAA 2002; tual factors that regulate it (Blane and nate before adulthood; moreover, the also see the article by Hingson, pp. Chafetz 1979; Jessor and Jessor 1977; highest prevalence of alcohol depen­ 45–54), which was charged with Kandel 1978). This research also start­ dence occurs in youth ages 18–20 reviewing the existing research on col­ ed to investigate how the initiation of (Grant et al. 2004). Since then, research lege drinking as a basis for implement­ drinking could be delayed and how the on underage drinking has increasingly ing and evaluating alcohol prevention occurrence of problems could be reduced crossed disciplines and now involves programs. The other is the Underage once drinking had begun (Kandel integrative work on the genetics and Drinking Research Initiative (National 1989; Robins and Przybeck 1985). neurophysiology of risk that is being Academy of Sciences 2004; also see As the developmental window from tied to behavioral and social environ­ sidebar), which was formed in 2004 childhood to early adulthood has mental science (Clark et al. 2008; to intensify research, evaluation, and been studied over the years, research Kendler and Prescott 2006; McGue outreach efforts on the underage drink­ on early drinking origins to adoles­ et al. 2001). ing problem. This initiative is ongoing cent problems on the one hand and Two initiatives in the past decade and has led to the development of on the origins of alcoholism on the underscore NIAAA’s recognition of the committee on Assessment and other hand has begun to converge. the importance of underage and early Screening for Underage Drinking Risk. An NIAAA news release in 2004 (Li adult drinking as a problem area of This article provides a brief snapshot 2004) articulates this integration, national significance and also have of the current scientific knowledge stating that both alcohol-related led directly to the work summarized about these earliest drinking years. It problems and alcohol use disorders in this article. One initiative, kicked summarizes the epidemiologic evidence (AUDs) needed to be understood off in 1998, was the Task Force on that documents the importance of the

NIAAA’s Underage Drinking Research Initiative

he National Institute tee. The mission of the steering multimedia resources; and other on Alcohol Abuse and committee is to stimulate research NIAAA-sponsored sites relevant to TAlcoholism’s (NIAAA’s) on underage drinking by drawing underage drinking. Other NIAAA- upon multiple disciplines (e.g., ado­ Underage Drinking Research Initiative sponsored sites include The Cool was undertaken in response to the lescent development, genetics, neu­ Spot (http://www.thecoolspot.gov), convergence of recent scientific roscience, prevention, and social advances and the increased public policy) to advise NIAAA on future an interactive site designed for concern about the seriousness of research to improve the prevention young people that features FAQs, underage drinking and its personal and treatment of underage drinking. statistics, and other information and societal costs. These concerns Thus far, goals identified by the about underage drinking, and The were expressed cogently both in the steering committee have yielded Leadership to Keep Children Alcohol 2007 Surgeon General’s Call to Action numerous products, including two Free (http://www.alcoholfree To Prevent and Reduce Underage special issues in scientific journals children.org), a unique coalition of Drinking (U.S. Department of (i.e., the April 2008 issue of Pediatrics Governors’ spouses, Federal agencies, Health and Human Services 2007) [Suppl. 4] and a 2009 issue of and public and private organizations and by the 2004 report Reducing Alcohol Research & Health [Vol. 32]) whose focus is on preventing the use Underage Drinking: A Collective that summarized existing research of alcohol by children. ■ Responsibility (Bonnie and O’Connell and identified important gaps. NIAAA also has established a Web 2004), which was sponsored by the References National Research Council and the site for the Underage Drinking Institute of Medicine. The focus of Initiative (http://www.niaaa.nih BONNIE, R.J., AND O’CONNELL, M.E., EDS. this NIAAA initiative is to intensify .gov/AboutNIAAA/NIAAASponsor Reducing Underage Drinking: A Collective edPrograms/underage.htm) that Responsibility. Washington, DC: National research, evaluation, and outreach Academies Press, 2004. efforts regarding underage drinking. contains updated statistics on To accomplish this, NIAAA formed underage drinking; updates from U.S. Department of Health and Human an interdisciplinary working group the Steering Committee; print pub­ Services. The Surgeon General’s Call to Action To Prevent and Reduce Underage Drinking. on underage drinking that consisted lications for parents, teachers, and Rockville, MD: U.S. Department of Health of NIAAA staff members and a young people, such as “Keep Kids and Human Services, Office of the Surgeon multidisciplinary steering commit­ Alcohol Free: Strategies for Action;” General, 2007.

30 Alcohol Research & Health Reducing Underage and Young Adult Drinking adolescent and young adult periods in new insights into the prevalence of tant because an earlier age at onset determining level of alcohol con­ alcohol consumption, binge drinking, has been associated with a more sumption. The article then examines and AUDs, which have altered the man­ severe course of alcoholism, poorer the developmental nature of problem ner in which alcohol use and AUDs are treatment response, and higher relapse use, explores why the developmental viewed by professionals and lay people rates (Windle and Scheidt 2004). changes of this age period are of par­ alike. For example, data from the NESARC determined the age at onset ticular importance from a public NIAAA-funded National Epidemiologic of alcohol dependence for a national health standpoint, describes the critical Survey on Alcohol and Related sample of over 43,000 adults (see fig­ nature of timing in the onset of drink­ Conditions (NESARC) (Grant et al. ure 2). The findings indicated that ing behavior, and explains the man­ 2004) have indicated that the preva­ onset of first-time alcohol dependence ner in which the changes in drinking lence of past-year alcohol dependence is occurred most commonly in late ado­ that occur between age 10 and the highest in late adolescence (ages 18–20) lescence to early young adulthood, early 20s map onto other develop­ and early young adulthood (ages 21–24), subsequently declining with age. mental challenges of this period of life. with rates declining thereafter (see Yet another variable relevant to the Finally, the article briefly reviews figure 1). Similar findings have been association between age, alcohol use, current knowledge about the risk and reported in other national surveys, such and alcohol dependence is the age of protective factors that exist during as the National Survey of Drug Use first use of alcohol and its relation­ adolescence and young adulthood and and Health (NSDUH), which found ship to an important risk factor (i.e., summarizes the screening, prevention, that the highest prevalence of lifetime family history of alcoholism). Grant and intervention programs focused AUDs was reported in late adolescence and Dawson (1997) reported that on this age-group. Note that although and early young adulthood (Substance among people who developed alcohol the specific age ranges referenced in Abuse and Mental Health Services dependence, having a family history different places in this article may vary Administration [SAMHSA] 2003, 2004, of alcoholism (i.e., an alcoholic par­ to some extent contingent on the cited 2006). For instance, according to the ent) was significantly associated with studies, there is consistent agreement NSDUH, for a variety of population sub­ an earlier age of first use of alcohol regarding the problematic nature of groups (i.e., both male and female as well (also see figure 3). For example, among underage and young adult drinking. as for White, Black, and Hispanic sub­ people with alcohol dependence who jects) the highest rate of AUDs was found were family-history positive, almost in people ages 18–25 years. 60 percent initiated drinking at age Epidemiology of Underage Another way to examine the associ­ 13. By contrast, among people who and Young Adult Drinking ation between age and AUDs is to developed alcohol dependence and evaluate the age at onset of alcohol were family-history negative, only National, large-scale surveys conducted dependence. This variable is impor- over the past 20 years have provided about 28 percent initiated drinking at age 13. This finding demonstrates that a family history of alcoholism is associated with an earlier age of first use of alcohol, which for many peo­ ple ultimately evolves into alcohol dependence in later adolescence or young adulthood. The prevalence of AUDs is a valuable indicator of serious alcohol problems during late adolescence and early young adulthood. Another important parameter is the frequency of alcohol consumption and binge drinking among underage drinkers and young adults. In the United States, alcohol consumption occurs in the majority of adolescents (i.e., is statistically normative). According to the 2008 Monitoring the Future Survey (MFS) Figure 1 Prevalence of past-year DSM–IV alcohol dependence in the United States. (Johnston et al. 2009), almost 72 percent of high-school seniors report­ SOURCE: 18+ years: 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions, ed consuming alcohol during their 12–17 years: National Survey on Drug Use and Health 2003. lifetime. Moreover, 43 percent had consumed alcohol in the past 30

Vol. 33, Nos. 1 and 2, 2010 31 1 SAMHSA 2003, 2004,2006). (CDC 2005;Johnston etal.2009; Surveillance Survey andtheNSDUH (CDC)-funded Youth RiskB Disease Control andPrevention including theCentersfor surveys, sistent withthosefoundinother ences obtainedintheMFSare con­ gender, andrace/ethnicgroup differ­ terns ofalcoholuseintermsage, thesepat­ rates maydiffersomewhat, been bingedrinking thepast30days,and25percent had in days, 28percent reported beingdrunk • • dle- andhigh-schoolstudents. patterns ofalcoholuseamongmid­ allow several conclusionsregarding findings (see thetable).Thesurvey • 32 Binge drinkingwasdefined ashavingfiveormoredrinksinarow. epidemiologic studies. among seniorsintheseschool-based and therefore are not included be more likelyto drop outofschool teens whodrinkathigherratesmay Whites andBlacks. That is,Hispanic among Hispanics compared with par ter findingmaybeattributable,in tionship hadbeenr teens, butby 12thgrade,thisr likely tousealcoholthanWhite Hispanic teenswere slightlymore and Hispanic teens.At younger ages, heavy alcoholusethandidWhite in heavieramountsthanw current drinkersandtousealcohol w of alcohol,oldermaleadolescents adolescents were similarintheiruse Whereas younger maleandfemale to middleandlateradolescence. stantially asteensmoved from early weeks), prevalence increased sub­ and bingedrinkinginthepast2 inthepast30days, being drunk (i.e., drinkinginthepast30days, For thethree alcohol useindicators adolescents inthesamegrades. r A epor Although absolutepr cross grades,Black adolescents er t, tohigherschooldropout rates e somewhat moree somewhat likelytobe ted lo w er levels ofcurrent and 1 in thepast2weeks ev ersed. Thislat evalence er ehavior e female ela­ ­ SOURCE: NIAAANationalEpidemiologicSurveyonAlcoholandRelatedConditions2003. Figure 2 SOURCE: 2001–2002National EpidemiologicSurveyonAlcoholandRelated Conditions. Figure 3 Percentage In Each Age Group Who Develop First-time Alcohol Dependence Age atonsetofDSM–IValcoholdependence.Datawerederivedfromthe2003National Association betweenageatinitiationofalcohol useandlifetimedependence(i.e.,meeting Epidemiologic SurveyonAlcoholandRelatedConditions(NESARC). and theblackcurverepresentsrespondents withoutafamilyhistoryofalcoholism respondents, theredcurverepresentsrespondents withafamilyhistoryofalcoholism, the DSM–IVcriteriafordependenceatsome pointinlife).Thebluecurverepresentsall Age Alcohol Research &Health . Reducing Underage and Young Adult Drinking

Research studies based on national cence, steadily increases throughout age at first use. This latter finding is survey data from both adolescents the high school years, reaches a peak the source of intervention programs and adults have indicated that heavier in the mid-20s, and begins to decline targeted at delaying the age of initia­ alcohol use distinguishes late adolescents thereafter. The findings are consistent tion of alcohol use. and early young adults from adults. across different indicators of drinking The significance of earlier initiation For example, for male and female sub­ (e.g., alcohol use, drinking to intoxica­ as a risk factor for AUDs, in conjunc­ jects, binge drinking increased during tion, and binge drinking) and across tion with other data based on longi­ adolescence, peaked between ages 18 sex and racial/ethnic groups. These tudinal studies, has fostered the notion and 25 years, and declined thereafter age trends also are evident for AUDs, of the developmental nature of (see figure 4). Similarly, the MFS which peak in late adolescence and underage and young adult drinking, indicated that the prevalence of “having early young adulthood. which has been confirmed by other been drunk” in the past year increased findings. For example, Greenfield substantially from 8th grade (12.7 and Rogers (1999) reported that percent) to 12th grade (45.6 percent) The Developmental Nature adolescents to young adults ages and to young adulthood (66.0 percent). of Underage and Young 18–29 were disproportionately repre­ Another measure of drinking patterns Adult Drinking sented among the heaviest drinkers. during different portions of the life­ Thus, although this age-group repre­ span is the number of drinking days The prevalence data on alcohol use and sented only 27 percent of the U.S. per month and the usual number of AUDs clearly illustrate that adolescence population, they accounted for about drinks per drinking occasion (see figure and early young adulthood are critical 45 percent of overall adult drinking. 5). Survey data indicate an ordering for understanding the occurrence of In an analysis of the commercial value by age-group of these variables—that these conditions. In and of themselves, of underage drinking, Foster and is, underage drinkers had the fewest these findings do not necessarily indicate colleagues (2006) determined that number of drinking days per month that alcoholism is a developmental in 2001, the short-term cash value but drank the most on the days that disorder. However, data on age of initi­ to the alcohol industry from under­ they did drink; young adults followed ation of alcohol use and its relationship age drinkers was 22.5 billion dollars, the underage group with fewer drinking to the subsequent development of representing 17.5 percent of total days and more drinks per occasion alcohol dependence provides a strong consumer expenditures for alcohol than adults. Thus, compared with indication of the developmental nature beverages. adults, underage drinkers and young of AUDs. Grant and Dawson (1997) In a separate study using different adults drink on fewer occasions but reported that people who began drink­ data sources, Miller and colleagues consume more per occasion. This ing before age 15 were four times more (2006) estimated that in 2001, under­ drinking pattern may be more haz­ likely to subsequently become alcohol age drinkers accounted for 16.2 ardous to the drinker’s social function­ dependent than people who did not percent of all alcohol sales in the United ing and physical and mental health. drink alcohol before age 21. Furthermore, States. However, the economic costs In summary, extant epidemiologic the odds of subsequently developing attributable to alcohol-related youth data indicate that the prevalence of alcohol dependence were reduced by problems, such as drinking and driving, alcohol use begins in early adoles­ 14 percent with each increasing year of interpersonal violence, property

Table Prevalence (%) of Various Indicators of Alcohol Consumption by Race/Ethnicity, Gender, and School Grade, in 2008. Percentage of Students Reporting Having Had Five or Demographic Alcohol Use in the Having Been Drunk More Drinks in a Variables Past 30 Days in Past 30 Days Row in Past 2 Weeks

School grade 8th 10th 12th 8th 10th 12th 8th 10th 12th Race/ethnicity White 15.2 33.3 48.6 5.5 19.2 32.7 7.8 23.5 29.9 Black 12.9 20.6 28.6 3.8 8.0 14.8 5.7 11.0 10.9 Hispanic 21.5 33.7 38.9 6.7 14.0 22.2 12.3 26.0 21.5 Gender Total 15.9 28.8 43.1 5.4 14.4 27.6 8.1 16.0 24.6 Male 15.4 28.6 45.8 5.3 14.6 29.2 8.1 16.6 28.4 Female 16.4 29.0 40.9 5.4 14.3 26.2 8.0 15.4 21.3

SOURCE: National Institute on Drug Abuse and University of Michigan, Monitoring the Future Surveys (Johnston et al. 2009).

Vol. 33, Nos. 1 and 2, 2010 33 crimes, and suicide, totaled $61.9 bil­ drinking represent a pervasive public the means of the total sample over the lion (in 2001 dollars). These costs health problem involving the entire interval does not reflect the pattern for included medical care costs, lost work population in this age-group. Therefore, any subset of individuals (see figure 6) and other monetary costs, and quality­ appropriate responses also should be but is a composite of five starkly differ­ of-life costs. Hence, underage and targeted at the entire adolescent and ent trajectory courses: young-adult populations clearly are young adult population rather than heavy consumers of alcoholic beverages be restricted only to those who meet • A chronic trajectory of continuously and result in economic costs that are clinical diagnostic criteria for an AUD. high frequency of binge drinking; nearly three times higher than the profits of the alcohol industry. • A trajectory with decreasing fre­ From a public health perspective, Developmental Framework quency of binge drinking over time; it also is important to highlight that the for Understanding three major causes of death among Underage and Young • A trajectory with increasing fre­ 12- to 20-year-olds in the United Adult Drinking quency of binge drinking over time; States—unintentional injuries (with motor vehicle crashes accounting for As the findings provided in the previous • A “fling” trajectory with a transient the majority of deaths), homicides, sections show, drinking behavior and increase in binge drinking frequency; and suicides (Subramanian 2006)— drinking problems change across ado­ and all are associated with alcohol use, lescence and young adulthood, with a especially heavy use. For example, in clear pattern of age-graded variation. To • A trajectory of continuously low 2003, motor vehicle crashes were the consider these changes as “maturation”— frequency of binge drinking. leading cause of death among 12- to that is, as a process of emergence and 20-year-olds. In that same year, a report linear growth of alcohol use and alcohol More recent trajectory studies of by the National Highway Traffic problems—is insufficient because this age-group continue to support Safety Administration (Pickrell 2006) drinking levels across this developmental the validity of these trajectory patterns, indicated that among drivers ages 20 period vary considerably among indi­ although class membership percent­ years or younger who were involved viduals. These differences in course have ages vary somewhat as a function of in fatal traffic crashes, approximately been demonstrated vividly by Schulenberg sample age, number of waves of data 20 percent had consumed alcohol at and colleagues (1996) in their trajectory available, and trajectory class analytic the time of the crash. In addition, the analysis of a nationally representative method (Brown et al. 2008; Windle median blood alcohol concentration sample they had followed through ages et al. 2005). It is important to note, (BAC) for this age-group ranged from 18–22 years. The analysis found that however, that this variability is occur­ 0.12 to 0.14 percent, well above the the pattern of binge drinking based on ring during a developmental period legal limit of intoxication (i.e., 0.08 percent) of intoxication. Finally, higher levels of alcohol use are associated not only with increased mortality but also with a broad range of other problem behaviors, including cigarette and other drug use, deviant behavior, earlier sexual activity and increased risk for sexually transmitted infections (including infection with the human immunodeficiency virus [HIV]), as well as truancy, academic difficulties, and school drop out. These consequences of heavy alcohol use among teenagers and young adults affect not only the drinker but also may adversely impact others via alcohol- related injuries and violence (e.g., victims of adolescent or young adult alcohol-related crashes, campus disrup­ Figure 4 Number of days in the past 30 days on which drinkers consumed five or more drinks, tions, or enhanced aggressive tendencies). by age and gender. Clearly, the morbidities, mortality, SOURCE: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health 2007. and collateral damage associated with underage and early young adult

34 Alcohol Research & Health Reducing Underage and Young Adult Drinking

when a great deal of life change is and change that also has served as a tations may be more differentiated or occurring. (This will be discussed powerful guide for investigation in even changed in structure or appearance further below.) fields as far removed as plant biology, (i.e., morphologically changed). For A maturational concept of the evolutionary biology, and early child­ example, there is compelling evidence development of drinking behaviors hood development. The model empha­ that a developmental connection exists does not account for these radically sizes the importance of studying earlier between behavioral undercontrol in different trajectories, nor is it capable behaviors and identifying the multilevel early life and problem drinking and of addressing a variety of major public processes involved in creating them AUD outcomes in late adolescence health concerns about drinking in and the contexts in which they emerge, and early adulthood. this and younger age-groups, such persist or change, increase or decline In adolescence and young adulthood, as the following: (Cicchetti 2006; Masten et al. 2008). one of the most robust correlates of Understanding the earlier system of problem alcohol use is behavioral • Why does drinking start when it does? relationships provides clues to conti­ undercontrol (Zucker et al., in press). nuity, even when no apparent link Measures of this construct are • Why do some youth cross that exists, and discontinuity, even when subsumed under a number of differ­ threshold earlier than others? there appears to be no organismic ent labels, such as disinhibition, explanation of it. externalizing behavior, aggressiveness, • How can we explain the fact that delinquency, conduct problems, and some youth begin drinking in mid- Examples of the Utility of the sensation seeking (Brown et al. 1996; to late adolescence in small amounts Developmental Framework Clark et al. 2005; Dubow et al. 2008; at infrequent intervals and without Guo et al. 2001; Jessor and Jessor problems, and others begin much The developmental framework described 1977). These measures are positively earlier, with some drinking at near- above can be used to probe the causes correlated with one another, tend to alcoholic levels within a short time of, and highlight the critical issues operate similarly in their relationships after they start? associated with, underage and young with other variables, and in factor adult drinking. This is illustrated here analyses load on the same factor (Bogg • Do factors unrelated to alcohol with three examples. and Finn, in press; Donovan and play any significant role in the Jessor 1985). Moreover, longitudinal development of drinking? Exploring the Salience of Earlier studies have found that behavioral Behavior for Later Outcomes. One of undercontrol in adolescence is a robust To address these questions, the major principles of development is predictor of alcohol problems, AUDs, researchers have turned to a develop­ that later behavior evolves out of earlier and other substance use disorders in mental conceptual model of stability behavior and that the pathway is iden­ early adulthood (Brown et al. 1996; tifiable, even though the later manifes- Clark et al. 2005; Dubow et al. 2008). However, the question is whether this relationship already exists at earlier developmental stages. The evidence for such a connection in fact is quite strong and has been replicated many times. A recent review (Zucker 2006) identified four longitudinal studies in the general population and two studies with high-risk subjects that found a positive relationship between measures of undercontrol and aggressiveness in early to middle childhood and problem alcohol use in mid-adolescence and severe alcohol problems and AUDs in young adulthood. In two of those studies, undercontrol/disinhibition Figure 5 Number of drinking days per month and usual number of drinks per occasion was identified as early as the preschool for youth (ages 12–20), young adults (ages 21–25), and adults (ages 26 years. Another series of four longitu­ and older). dinal studies (Schulenberg and Maggs 2008) reported similar relationships. SOURCE: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2007. Without the conceptual framework of developmental theory, it is doubt-

Vol. 33, Nos. 1 and 2, 2010 35 ful that this long chain of relationships linked to all of these context changes. assistance or guidance can have would have been uncovered. Yet these Some of the changes typically involve major impact (see Blomberg 1992; relationships are highly significant increases in alcohol use, such as the Cunningham et al. 2009). For example, because they indicate that some central move away from home (Stice et al. the College Drinking Initiative has etiologic components that contribute 1998) and the transition to college been influenced by turning-point to alcohol problems and AUDs are (Timberlake et al. 2007). Conversely, transitions in guiding university inter­ nonspecific to alcohol. And whatever some changes, such as the onset of ventions (NIAAA Research Findings the underlying predisposition is, it is parenthood (Bachman et al. 1996), on Underage Drinking and Minimum sufficiently strong to emerge very early marriage (Gotham et al. 2003), or Legal Drinking Age 2008). in the developmental course. Moreover, the shift from being a college student the strength of the developmental to full-time employee (Bachman et al. Social Policy Regarding Minimum pathway suggests it should be, to a 1996), involve decreased alcohol use. Legal Drinking Age. One of the most substantial degree, under genetic control. Thus, these transition times pose a dramatic policy actions of the last significant challenge to the adolescent generation has been legislation that Contexts of Alcohol Use and Life or young adult not only with respect increased the minimum legal drinking Cycle Transitions. Home is the primary to the successful adaptation to new life age (MLDA) from 18 to 21 years. source of alcohol in childhood and tasks but also with respect to alcohol Recent advocacy efforts to return to an preadolescence (Donovan and Molina use. During transitions to contexts MLDA of 18 years minimum could 2008) and one of the primary sources typically associated with increasing suggest that the change had been inef­ in early adolescence (Centers for Substance alcohol use, the challenge is to resist fective. However, scientific evidence Abuse Research 2008). Similarly, asso­ this demand or at least to moderate it unequivocally demonstrates that drinking­ ciating with peers who already drink so alcohol use does not become exces­ and-driving crashes and the resulting is one of the most important proximal sive (Maggs 1997). During transitions loss of life among 18- to 20-year-olds causes of drinking onset and problem where the demand is for decreasing have declined as a result of the legisla­ use during adolescence (Wills and Cleary alcohol use, the challenge is to move tion, even though the size of the effect 1999). Differences in level of use in from a previously unrestrained pattern varies among States (Shults et al. 2001; differing contexts, which in turn make of use to one of greater restraint. At Wagenaar and Toomey 2002). More­ alcohol more or less available, are only the same time, these turning points over, the influence of this legislation part of the way that these drinking potentially are useful places for inter­ extends to young adults older than 21 environments exert their effects. The vention, where a small amount of years of age, providing an indication of presence of alcohol also is a cueing effect, a stimulus for thinking that one could have a drink. Similarly, the fact that someone else already is drinking also acts as a cue because it demonstrates the acceptability of the behavior (Bank et al. 1985). Lifecycle transitions, such as those occurring during adolescence and young adulthood, also are times of context change, although primarily in relationships and identity rather than in physical contexts. They are points in the life course where the develop­ mental demand is for changes in age- and gender-specified roles. Some of these changes—such as the onset of puberty and parallel onset of adoles­ cence or the onset of parenthood— primarily are driven by biological events, Figure 6 Different patterns (i.e., trajectories) of binge drinking over time among people ages although they typically also have a 18–24. For the studied population as a whole, the overall frequency of binge drinking strong socially prescribed component. remained relatively steady at less than one time per 2-week interval. More detailed Other context changes, such as moving analysis, however, identified five subgroups of drinkers that differed in how fre­ away to college or starting a full-time quency of binge drinking evolved over time. job, are dictated more by the role SOURCE: Schulenberg et al. 1996. demands of the culture. Changes in patterns of alcohol use have been

36 Alcohol Research & Health Reducing Underage and Young Adult Drinking the long-lasting impact of this change. are explored in some detail, using them unprotected sex, driving while Thus, lower drinking rates persisted as a vehicle around which to examine the intoxicated, drinking instead of in the subsequent 21- to 25-year age- operation or function of specific risks. studying). group (O’Malley and Wagenaar l991). Recent work also has shown lasting Family History. Male children of However, some genetic risk also differences in drinking outcomes between alcoholics (COAs) are four to nine is conveyed indirectly, through the those living in the era before the MLDA times more likely to develop alcoholism behavior of alcoholics as parents. of 21 years was in effect and those who in adulthood, and female COAs are Thus, COAs obviously are exposed were exposed to the legislation. Even two to three times more likely than to greater alcohol consumption in the when in their 40s and 50s, people not are children without such a family his­ home, with its attendant context risks exposed to the MLDA legislation had tory (Russell 1990; also see figure 3). of availability and modeling that were higher rates of both AUDs and other Approximately 50 percent of that risk described previously. It is not surprising, substance use disorders than did people is conveyed through genetic factors therefore, that COAs begin drinking who were affected by the legislation (Dick and Bierut 2006; McGue 1999). earlier than their non-COA peers, (Norberg et al. 2009). There are a number of pathways through with a small subset beginning even in Although the effects of changing which such genetic risk can be trans­ preadolescence (see figure 3). In fact, the MLDA have been studied the mitted from parent to child, all of the greatest differences in prevalence longest, analyses of the effects of the which are relevant in the developmen­ between COAs and non-COAs occur more recent policy changes (i.e., tal period discussed here (i.e., adoles­ very early, illustrating the effect of some reduction of legal blood alcohol limits cence to young adulthood). Some of of the family differences described and zero-tolerance laws) on adoles­ the risk is conveyed via direct genetic above. Similarly, COAs are more likely cents and young adults under age 21 effect on the offspring—that is, genes to have been drunk by early adoles­ years also show significant reductions responsible for relevant characteristics cence (Wong et al. 2004), and, as in drinking while driving (Wagenaar are passed on from parent to child. The described earlier, they are more likely to et al. 2001) and alcohol-related prob­ relevant characteristics may include develop an AUD as they become older. lems (e.g., DUI citations and alcohol- structural and functional differences Furthermore, alcoholic homes are involved fatal crashes) (Voas et al. in brain physiology (e.g., variation in more likely to be high in conflict 2003). All these findings demonstrate spatial memory; [Pulido et al. 2009]), (Loukas et al. 2001, 2003) and to that changes in MLDA, lower legal differences in peripheral physiological expose children to spousal violence blood alcohol limits, and zero-tolerance systems (e.g., intensity of response to and parental divorce (Leonard 2002; laws indeed have had an impact on alcohol [Schuckit et al. 2004]), and Roberts and Linney 2000) than homes underage drinking and related problems. temperament differences (e.g., behavioral without an alcoholic parent. This undercontrol) that appear very early difference may be a direct result of in life (e.g., Dick et al. 2006, 2009) parental intoxication or an indirect Risk and Protective and which play a major role in the result of parental conflict over spousal Factors of Underage and developmental pathway to problematic consumption. High levels of conflict, Young Adult Drinking alcohol and other drug (AOD) use in violence, and divorce also are risk fac­ adolescence and young adulthood. One tors for earlier use by offspring and As young people deal with the challenges such temperamental trait is behavioral more problematic use once drinking and opportunities of adolescence and undercontrol/disinhibition, which has begun. early adulthood, they are exposed to already has been discussed in the previous numerous influences that either increase section. It conveys risk through several Risk Cascades. Although the list of their risk of developing alcohol-related pathways: apparently consequential risk factors problems and AUDs or reduce that associated with COA status is long, this risk. This section highlights some of • By leading the youngster into does not mean that risk automatically these risk and protective factors. relationships with undercontrolled is conferred whenever there is a positive peers who are more likely to be early history. Although the relationships Risk Factors and heavier alcohol users; between family history and each of The inventory of risk factors that increase these risks are significant, not all alco­ the likelihood of problem alcohol use • By interfering with normal inhibitory holic families share all attributes. For in the underage and young adult popu­ mechanisms, thereby allowing those COAs who experience fewer of lation is considerable. A comprehensive alcohol use to continue even when these risk elements, the “weight” of the review of these factors is beyond the it reaches problem levels; and risk burden is lower, as is the probability scope of this article (for more intensive of a problem outcome. Furthermore, reviews see Brown et al. 2008; Windle • By potentially facilitating use even some people without a positive family et al. 2008); instead, the discussion will in circumstances that are likely to history also may experience early and focus on three critical risk issues that cause problems (e.g., engaging in heavy exposure to alcohol, family

Vol. 33, Nos. 1 and 2, 2010 37 conflict, instability, or life stress. however, is further exacerbated by the although perhaps obvious, individuals, Additionally, the genes that put a person fact that adolescence also is a time of circumstances, and contexts associated at elevated risk are present not only in major changes in brain structure and with no or only low levels of risk by alcoholic families, and not all risk factors function. Neural alterations are taking definition also are protective against a are familial in nature. For example, neigh­ place particularly in brain areas at the problematic outcome. For example, borhood social disorganization is a front of the brain that are part of exec­ youth with more effective behavioral non–alcohol-specific and nonfamilial utive and reward systems involved in control capability are less likely to exhibit factor that has been shown to affect impulse control and emotional regula­ problem use in adolescence (Wong et risk development in adolescence and in tion. For example, an area called the al. 2006). Similarly, at the contextual later adulthood (Buu et al. 2007, 2009). dorsolateral prefrontal cortex—which level, social policies (e.g., zero-tolerance In recent years, developmental psy­ is especially important to decision mak­ laws) can have a protective influence. chopathologists have suggested that ing and planning—is one of the last Even more important, however, are a cascade model of risk accumulation brain areas to mature, with structural those personal or contextual attributes may best characterize how this multi­ change continuing through adolescence that can provide active insulation plicity of risk factors develops (Masten into early adulthood (Gogtay et al. against risk. For instance, positive et al. 2005). The model proposes 2004). Developmental changes related parenting has been associated with a that not just simple addition of various to increasing the development of myelin later onset and lower levels of alcohol risk factors but their sequencing as sheaths around nerve fibers in the central use among adolescents (Kumpfer and well as the timing of when they enter nervous system (i.e., myelogenesis) Alvarado 2003). Similarly, involvement the individual’s life determine risk directly affect impulse and emotional with low- or nonusing peers, attend­ accretion or risk dilution. Thus, expo­ regulation, and there also are gains in ing a college with no or low levels of sure to a given risk factor at one time the ability to suppress or inhibit irrele­ alcohol consumption, or living in a period can create elevated risk, where­ vant information (Casey et al. 2002), dorm committed to nondrinking all as exposure to the same factor at which in turn are crucial skills in social have been related to lower levels of another time may have little impact. relationships and in decision-making. use and problem use (Wechsler and Furthermore, each step in the cascade Findings primarily obtained in animal Nelson 2008). Although selection of risk increases the predictive value studies, but to a limited degree also factors are one issue in determining of the preceding step, and moving out supported by human cross-sectional residence (i.e., adolescents who already of the cascade subsequently decreases studies, suggests that high alcohol (and oppose drinking are most likely to prior risk. A recent cascade analysis other drug) consumption during this choose a college or dorm committed by Dodge and colleagues (2009) developmental period may have lasting to abstinence), other research indi­ describes the interplay of seven differ­ effects on the maturation of these critical cates independent effects of context ent risk domains involving the child, brain areas, inhibiting the development (Cranford et al. 2009). Religious parents, and peers, in a transactional of crucial regulatory and decision-making involvement is another area where process over the course of childhood circuitry (Clark et al. 2008; Spear 2000). individual choice and context combine that culminates in substance use onset. Accordingly, the fact that late adoles­ to protect against problem alcohol The analysis indicated that not only cence/early adulthood often is the time use. Thus, many studies have reported risk accumulation at each new step of highest alcohol consumption poten­ low-order negative relationships of the cascade is important but tially makes the problem even more between religious involvement and opportunities for risk offset also are serious. Moreover, even within the ado­ alcohol use, with some of the effect critical because they suggest concrete, lescent period, the highest consumers being attributable to the cultivation phase-specific ways in which inter­ are likely to be early-onset drinkers, so of self-control and self-regulatory vention programs might interrupt that exposure to alcohol’s deleterious capacities (McCullough and what otherwise would be a sequence effects will be earlier, continue longer, Willoughby 2009). of risk potentiation or elevation. and be most severe within a group that A few studies have focused on already is most vulnerable. Therefore, another potentially highly important Alcohol Use and Adolescent Brain it is essential that researchers seek to area—that is, resilience. Resilience Development. A recurring theme of confirm the findings of animal studies is defined as the ability to avoid a this article is that adolescence is a time in humans, and indeed much of this pathological outcome, or achieve a of increasing alcohol consumption and work now is in progress. successful one, despite the experience that consumption typically peaks during of adversity (Rutter 1987). In theory, the late adolescent to early adult years. biological, psychological, and social This consumption pattern and the Protective Factors characteristics all can contribute to problems associated with excessive alcohol Like risk factors, protective factors can resilience. Despite the importance of use alone would mark this develop­ have functional influences at all levels this adaptation, very few studies have mental stage as a period of special risk of analysis from the biological to the investigated this area and followed for adverse consequences. This risk, broader contextual. Furthermore, participants into late adolescence to

38 Alcohol Research & Health Reducing Underage and Young Adult Drinking identify problem outcomes. We are use, delinquency) still is in the nascent platform for subsequent studies. The aware of only one study, albeit with stages of development, and several issues issue of screening, referral, and brief a small sample, that has investigated currently are being addressed. Thus, interventions is of sufficient promi­ biological factors contributing to investigators still need to determine the nence that NIAAA has formed a resilience using functional magnetic feasibility of screening for alcohol use committee on the Assessment and resonance imaging (fMRI) to assess in different research settings (e.g., pri­ Screening for Underage Drinking brain activity (Heitzeg et al. 2008). mary-care physician offices, schools, Risk as part of the larger Underage The study included COAs ages 16–20 juvenile justice settings), using different Drinking Initiative. years, who were divided into resilient modes of administration (e.g., using subjects who had not developed alcohol self-report surveys/questionnaires versus Prevention problems by this time and vulnerable computer-based approaches), using subjects who had developed such screening tools of different lengths and The development of successful preventive problems, as well as non-COA control comprehensiveness (e.g., a few items interventions for underage and early subjects. The investigators exposed specifically focusing on alcohol use versus young adult drinking is a challenging the participants to emotional stimuli a test battery assessing alcohol use, other task for a variety of reasons, including and then measured brain activity in drug use, and risk factors), and with the multiplicity of risk and protective various areas. These analyses detected different associated costs. For instance, factors that may vary in their influence clear differences between resilient and primary-care physicians probably would across different developmental periods vulnerable subjects in the activation not be receptive to asking a lengthy set (e.g., early adolescence, young adult­ of various brain areas.2 The activation of questions during adolescent check­ hood) and possibly for different sex pattern observed in the resilient COAs ups; likewise, if a screening survey were and/or racial/ethnic groups. Nevertheless, was consistent with an explanation administered via a computer, the costs a broad range of alcohol prevention that resilient youth have greater emo­ for the computer, software, training of programs have been developed that target tional monitoring capability, which participants completing the survey, and different units or levels of analysis (e.g., is protective against excessive analyses of the data collected would school, family, individual), with some responding. In contrast, the vulnerable have to be considered. interventions targeting more than one group displayed a pattern consistent Currently, several well-developed level of analysis. For example, some with active suppression of affective alcohol screening tests for adolescents intervention programs are school based responses, suggesting a possible deficit are available that have demonstrated and rely on social influences (e.g., peer in the ability to engage adaptively high reliability and validity, including refusal skills) or motivational enhance­ with emotional stimuli. Clearly, this the Alcohol Use Disorders Identification ment principles and youth preference work is only a beginning effort at Test (AUDIT), Problem-Oriented (Brown et al. 2005). Other programs understanding the dynamics of Screening Instrument for Teenagers focus on families and rely on strength­ resilient capability. (POSIT), and CRAFFT (Knight et ening parent–child ties to reduce alcohol al. 2003). These instruments vary in use (Spoth et al. 2006). Still, others are length and have been applied across a aimed at high-risk youth or focus on Screening, Prevention, variety of adolescent settings. However, social policy interventions (e.g., alcohol and Treatment Programs some of the feasibility issues discussed taxation, minimum legal drinking age, for Underage Drinking above still remain to be explored fur­ and zero-tolerance laws). Because of and Problem Use ther, along with other practical issues space constraints, the discussion here (e.g., parental consent to administer only describes some prominent univer­ a screening instrument) and the criti­ sal preventive intervention programs. Screening cal issue of how positive screens can Universal programs, which include Because of the high rates of alcohol be linked with appropriate referral all individuals in a particular popula­ use, binge drinking, and AUDs among resources. The health care, educational, tion (e.g., all students in a school), underage drinkers and young adults, and juvenile justice systems in the are the most widely used form of increasing emphasis has been placed on United States currently are not com­ preventive intervention for underage screening for these difficulties in recent prehensively equipped to address the youth. The most common programs years. The goals of such screening are range of adolescent and young adult include classroom curricula adminis­ both to identify current or potential alcohol use problems. Nevertheless, tered to students within school settings, alcohol use problems and to initiate some recent initial findings from which may be supplemented with appropriate referral to prevent and treat screening and brief intervention studies 2 Resilient subjects showed more activation of the orbital frontal these problems. Although the goals of in hospital emergency rooms (Monti gyrus (OFG) on both sides of the brain as well as in the left insula/ screening appear relatively straightfor­ et al. 2007) and college student putamen than did control and vulnerable subjects. In contrast, the ward, the screening of adolescents and health centers (Fleming et al. 2010; vulnerable group exhibited greater activation of dorsomedial pre­ frontal cortex and less activation of ventral striatum and extended young adults for alcohol and other Schaus et al. 2009) have demonstrated amygdala, bilaterally, than did either control or resilient groups; problem behaviors (e.g., other drug promising findings and may provide a moreover, these subjects exhibited more externalizing behavior.

Vol. 33, Nos. 1 and 2, 2010 39 components to change the school- (Perry et al. 2000), and the family- • There was evidence demonstrating wide climate regarding alcohol use, focused Iowa Strengthening Families the effectiveness of skills-based parent programs, mass media programs, Program (Spoth et al. 2006). Although interventions, such as monitoring and community-wide interventions. the specific alcohol outcome variables the amount of one’s drinking, setting Most universal interventions are based assessed by these programs have dif­ limits on the amount consumed, on the social-influence model, which fered to some extent (e.g., delayed and avoiding alcohol-related risky suggests that the primary influences drinking initiation or reductions in situations. Motivational interven­ affecting youths’ AOD use behaviors current alcohol use), each program tions with personalized feedback are social factors, such as peer, family, has reported successes in short- and also yielded positive findings with and media influences (Bauman and medium-term posttest evaluations regard to reductions in alcohol use Ennett 1996). Accordingly, these pro­ and in some instances in longer-term among college students. grams strive both to help adolescents evaluations. In addition, for some of acquire skills that will enable them to these programs there has been evidence • Although significant progress has effectively resist social pressures (espe­ of the generalizability of the interven­ been made in recent years with cially peer pressures) to use AODs tions to different ethnic groups. regard to individual-focused college and to promote social attitudes and However, these quite positive and drinking prevention programs, addi­ norms that oppose AOD use. Most encouraging findings must be tem­ tional studies are needed with stronger AOD prevention curricula for youth pered by a range of methodological research designs, appropriate control are administered during the late ele­ limitations and concerns that have groups, and retention of participants mentary and junior high-school years been raised about universal preventive across the course of studies. because AOD use often is initiated in interventions to reduce underage alco­ this age period. hol use. For example, in the review In addition to individual-focused In a meta-analysis of 207 universal, by Spoth and colleagues (2009), only college drinking programs, several school-based AOD prevention pro­ 127 of 400 studies examined provid­ policy-based prevention activities grams, Tobler and colleagues (2000) ed sufficient data to evaluate the pro­ have been implemented on campuses reported that interactive prevention grams, and of these 127 programs, to reduce alcohol use and associated programs (e.g., programs that encour­ only 41 indicated any evidence of a problems. These include such policies aged social interactions with peers significant effect. Thus, despite sig­ as establishing alcohol-free residences and focused on interpersonal skills, nificant advances in the development, and campuses, prohibiting beer kegs refusal skills, and changes in normative implementation, and evaluation of on campus, prohibiting the self-service beliefs) yielded stronger outcomes in multidomain preventive interventions of alcohol at campus events, and ban­ reducing alcohol use than those that as well as of policy, legal, and envi­ ning the marketing of alcohol on were noninteractive (e.g., teachers ronmentally focused interventions, campus. Findings regarding the impact providing knowledge to students about a number of issues remain to be of these policies are limited, although the effects of alcohol). Other charac­ addressed. These include additional some studies have demonstrated a teristics of effective programs were a evaluations of the generalizability of reduction in binge drinking in AOD- smaller number of participants (e.g., findings to nonwhite populations and free residences (Toomey and Wagenaar programs with 300 participants were of the relative contributions of specific 2002). Similar to the findings for more effective than those with a 1,000 components of multidomain interven­ individual-focused college prevention participants), higher intensity (i.e., more tions, enhancement of dissemination programs, considerably more research delivery hours), and greater compre­ plans, and quality assurance for the is needed on the impact of university hensiveness with regard to changes at implementation of such evidence- and community policies targeted at multiple levels (e.g., individual, par­ based programs. reducing alcohol use and alcohol ent, school, and community levels). A review of individual-focused col­ problems among college students. In a major review of extant preven­ lege-based prevention programs from (For more information on college tive interventions focused on underage 1999 to 2006 (Larimer and Cronce drinking and related problems, see drinking, Spoth and colleagues (2009) 2007) provided several important the article by Hingson, pp. 45–54.) identified 41 intervention studies that conclusions. demonstrated some evidence of sig­ Treatment nificant effects, or positive changes, • There was no evidence to support in targeted alcohol use behaviors. Some the usefulness of information- A large number of different inpatient of the most highly visible universal or knowledge-based prevention and outpatient therapies have been adolescent alcohol use preventive approaches; simply providing infor­ used with underage drinkers, including intervention programs were the com­ mation about the dangers of drink­ the 12-step model, behavioral interven­ munity-wide Midwestern Prevention ing was not sufficient to produce tions, family therapy, and educational Project (Pentz et al. 1989), the com­ any appreciable change in college and vocational assistance and rehabili­ munity-wide Project Northland students’ drinking behaviors. tation. Among the most widely used

40 Alcohol Research & Health Reducing Underage and Young Adult Drinking inpatient approach is the 28-day, used to increase the magnitude of highlight NIAAA’s central role and the group-oriented Minnesota model that effects for the treatments, improve the need for continued involvement in uses the 12-step program of recovery relapse rates, and improve the dissemi­ reducing underage and young adult (Wheeler and Malmquist 1987). This nation of evidenced-based treatments. drinking. ■ program includes different compo­ nents, such as group meetings, educa­ tional presentations about alcoholism Summary and Conclusions Financial Disclosure and associated health and social prob­ lems, group counseling, family therapy, In the 40 years since NIAAA began, The authors declare that they have no and the completion of workbook the attention to the interval prior to competing financial interests. assignments to instill personal moni­ adulthood has steadily increased. Thus, this developmental period has become toring of progress in the program. The References multiple components of this approach recognized as an interval during which much of the risk for later alcohol prob­ are designed to increase personal BACHMAN, J.G.; JOHNSTON, L.D.; O’MALLEY, P. resources and resolve family problems lems and alcoholism begins to emerge, M.; AND SCHULENBERG, J. Transitions in drug use to increase the prospects of recovery. and when the developmental pattern­ during late adolescence and young adulthood. In: ing for later disorder begins to consoli­ Graber, J.A.; Brooks-Gunn, J.; and Petersen, A.C. Whereas the Minnesota model is Eds. Transitions Through Adolescence: Interpersonal based on an inpatient program, most date. At the same time, appreciation Domains and Context. Hillsdale, NJ, England: of the existing research on treatment has deepened about the significance of Lawrence Erlbaum Associates, 1996. pp. 111–140. adolescence and young adulthood as a for underage drinkers has been con­ BANK, B.J; BIDDLE, B.; ANDERSON, D.S.; ET AL. ducted on outpatient programs. Some major playing field in its own right, Comparative research on the social determinants of therapies and approaches, such as within which heavy consumption occurs adolescent drinking. Social Psychology Quarterly cognitive–behavior therapy, have been and where great immediate risk exists 48(2):164–177, 1985. used with some success to foster for damage to self and others. This BAUMAN, K.E., AND ENNETT, S.T. On the impor­ recovery among adolescents in treat­ article has provided a brief overview of tance of peer influence for adolescent drug use: ment (Deas and Clark 2009). research from both of these perspec­ Commonly neglected considerations. Addiction 91:185–198, 1996. PMID: 8835276 However, across these different treat­ tives, summarizing the epidemiologic ment modalities, effect sizes (i.e., the evidence, reviewing the importance of BLANE, H.T., AND CHAFETZ, M.E. Youth: Alcohol strength or magnitude of the inter­ social policy as a “shaper” of drinking and Social Policy. New York, NY: Plenum Press, 1979. vention effect) have been small and patterns, and providing a brief snapshot the relapse rates within 9 months as of the many ways that developmental BLOMBERG, R.D. Lower Legal BAC Limits for Youth: high as those of adults (Brown et al. markers both prior to drinking and in Evaluation of the Maryland 0.02 Law. Washington, the early drinking years can indicate DC: U.S. Department of Transportation, 1992 1994). Finally, although several medi­ (Report DOT HS–806–807). cations have been approved by the risk for drinking problems and even for U.S. Food and Drug Administration emerging AUDs. As described in this BOGG, T., AND FINN, P.R. A self-regulatory model overview, over the past 40 years sub­ of behavioral disinhibition in late adolescence: for the treatment of alcohol depen­ Integrating personality traits, externalizing psy­ dence in adults, there have been few stantial progress has been made in the chopathology, and cognitive capacity. Journal of applications of these medications to areas of etiology, screening, preventive Personality 78(2):441–470, 2010. PMID: 20433626 interventions, and treatment regarding adolescents. BROWN, S.A.; ANDERSON, K.G.; SCHULTE, M.T.; Thus, despite the very high rates underage and young adult drinking. ET AL. Facilitating youth self-change through of alcohol use, binge drinking, and The increasing maturity of the field is school-based intervention. Addictive Behaviors AUDs among underage drinkers, the evidenced by the current interdisci­ 30(9):1797–1810, 2005. PMID: 16111834 service delivery system has been lack­ plinary, multilevel research integrating BROWN, S.A.; GLEGHORN, A.; SCHUCKIT, M.A.; ing in addressing this serious public social, behavioral, and biological levels ET AL. Conduct disorder among adolescent alcohol health issue. Research in the areas of of analysis to understand mechanisms and drug abusers. Journal of Studies on Alcohol service delivery and treatment has of risk and protection. Furthermore, 57(3):314–324, 1996. PMID: 8709590 lagged and is compounded by diffi­ sophisticated methods of applied research BROWN, S.A.; MCGUE, M.; MAGGS, J.; ET AL. A culties in addressing the multiple are being used to develop new screening developmental perspective on alcohol and youths methods for early identification of risk 16 to 20 years of age. Pediatrics 121(Suppl. problems (e.g., AOD use, delinquency, 4):S290–S310, 2008. PMID: 18381495 academic difficulties) of this high-risk as well as more effective, multisystemic population. 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