Published online February 1, 2008
PEDIATRICS Vol. 121 No. 2 February 2008, pp. 297-305 (doi:10.1542/peds.2006-2348)
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ARTICLE

Age of Alcohol Use Initiation, Suicidal Behavior, and Peer and Dating Violence Victimization and Perpetration Among High-Risk, Seventh-Grade Adolescents

Monica H. Swahn, PhDa, Robert M. Bossarte, PhDa and Ernest E. Sullivent, III, MDb

a Divisions of Violence Prevention
b Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. We examined the cross-sectional associations between reports of an early age of alcohol use initiation and suicidal ideation, suicide attempts, and peer and dating violence victimization and perpetration among high-risk adolescents.

METHOD. Data were obtained from the Youth Violence Survey conducted in 2004 and administered to all public school students enrolled in grades 7, 9, and 11/12 (N = 4131) in a high-risk school district in the United States. Our analyses were limited to seventh-grade students who either began drinking before the age of 13 or were nondrinkers, with complete information on all covariates (n = 856). Cross-sectional logistic and multinomial logistic regression analyses were conducted to determine the associations between early alcohol use and each of the 6 outcome behaviors (dating violence victimization and perpetration, peer violence victimization and perpetration, suicidal ideation, and suicide attempts) while controlling for demographic characteristics and other potential confounders (ie, heavy episodic drinking, substance use, peer drinking, depression, impulsivity, peer delinquency, and parental monitoring).

RESULTS. In our study, 35% of students reported alcohol use initiation before 13 years of age (preteen alcohol use initiators). Students who reported preteen alcohol use initiation reported involvement in significantly more types of violent behaviors (mean: 2.8 behaviors), compared with nondrinkers (mean: 1.8 behaviors). Preteen alcohol use initiation was associated significantly with suicide attempts, relative to nondrinkers, controlling for demographic characteristics and all other potential confounders.

CONCLUSIONS. Early alcohol use is an important risk factor for involvement in violent behaviors and suicide attempts among youths. Increased efforts to delay and to reduce early alcohol use among youths are needed and may reduce both violence and suicide attempts.

Key Words: alcohol initiation • suicidal ideation • suicide attempt • dating violence • peer violence • perpetration • victimization

Alcohol is the most commonly used drug among youths1 and is linked to numerous adverse health outcomes and deaths.2 In 2001, for example, moderate/heavy alcohol consumption contributed to 1200 homicides, 2067 motor vehicle crash deaths, and 479 suicides among youths <21 years of age.2 Underage drinkers consumed 20% of the alcohol that was consumed in the U.S. in 1999 and also accounted for 19% of the alcohol consumer expenditures for beer, distilled spirits and wine that year.3 It is estimated that underage drinking and its consequences cost society $61.9 billion in 2001, primarily due to alcohol-attributable violence and traffic crashes, when accounting for medical costs ($5.4 billion), work loss and other resource costs ($14.9 billion) and lost quality of life ($41.6 billion).4

The link between alcohol use and involvement in violent behaviors is well documented, and numerous studies of adolescents report that alcohol use is linked both to violent behavior5–15 and to violence-related injuries.16–18 However, much less is known about how early initiation of alcohol use influences involvement in a range of violent behaviors. Previous research showed that early alcohol use (before grade 7) is linked to many public health problems, including other substance use and criminal activity.19 Alcohol use before 19 years of age is also predictive of sustaining unintentional injuries among college students,20,21 involvement in unplanned and unprotected sex among college students,22 and involvement in physical fights after drinking.23 However, the extent to which an early age of alcohol use initiation is associated with both victimization and perpetration of violent behaviors and with violent behaviors across contexts (dating versus peer) has not been examined concurrently. Recent research indicated that early alcohol use initiation was associated with suicidal ideation and suicide attempts in a nationally representative sample of high school students24 and that early alcohol use was associated with suicide attempts in a sample of urban high school students.25

The purpose of the current study was to examine the associations between early alcohol use initiation and involvement in 3 different types of violence (dating violence, peer violence, and suicide attempts). The current study also determined whether an early age of alcohol use initiation was associated with perpetration or victimization of dating and peer violence. On the basis of previous research linking early alcohol use to a broad range of adverse outcomes, including violence perpetration, unintentional injuries, unprotected sex, and suicidal behaviors, we predicted that early alcohol use would be an important risk factor across all 6 outcomes assessed in the current study. Analyses were conducted to determine whether any of the associations remained statistically significant when controlling for demographic characteristics and other potential confounders. The potential confounders included in the analyses were selected on the basis of previous research examining the link between age of drinking onset and involvement in physical fights23 and unintentional injuries,20 as well as a review of the psychosocial risk factors for adolescent alcohol use initiation.26 Finally, the study also determined whether an early age of alcohol use initiation was associated with the number of violent behaviors adolescents reported. The findings from this investigation might have important implications for the design of prevention and intervention programs that seek to delay or to reduce alcohol use and violent behaviors among adolescents.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data Collection
The Youth Violence Survey was administered to all public school students enrolled in grades 7, 9, and 11/12 in a school district in a high-risk community. The high-risk community was chosen by ranking US cities with respect to several community indicators (ie, poverty, unemployment, single-parent households, and serious crimes) and determining the most-appropriate school districts within those cities on the basis of the number of students enrolled, the feasibility of conducting the study, and the school district's willingness to host the study. The selected city and school district were among the highest 25 nationally in poverty, the highest 15 in single-parent families, the highest 10 in rates of serious crimes, and the highest 35 in rates of unemployment. The selected school district was racially and ethnically diverse and located in a city with a population of <250000. This district operated 16 schools and served students at ≥1 of the targeted grades. All 16 schools were invited and all 16 schools agreed to participate in the study; these included elementary, middle, and high schools and alternative schools.

All eligible English-speaking students in the selected grades were invited to participate in the survey. The 3 grade levels were selected to assess potential age differences or developmental patterns during the transition from early to late adolescence among high-risk students. Students were identified through class lists of required core subjects (eg, English) in the selected grades or through their homerooms. Before data collection, active, signed, written, parental permission and student assent for participation in the study were required for all students <18 years of age. Students who were ≥18 years of age provided written consent before participating in the survey. Student permission forms were provided in English, Spanish, and other major languages as requested by the schools.

Data collection occurred in April 2004. The anonymous, self-administered questionnaire was administered by experienced field staff members during a 40-minute class period. Students were ineligible to participate if they could not complete the questionnaire independently (eg, were enrolled in a special education class, required the assistance of a translator, or had cognitive disabilities that would prevent adequate understanding of and response to the survey) (n = 151) or had dropped out of school, had been expelled, or were on long-term, out-of-school suspension (n = 202). Of the 5098 students who were eligible for participation, 4131 participated, yielding a participation rate of 81.0%. Participants were enrolled from 3 grade levels, that is, 1491 in seventh grade, 1117 in ninth grade, and 1523 in 11th and 12th grades.

Measures
Because of the decreased validity of self-reports of early alcohol use among older adolescents,27 analyses were restricted to seventh-grade participants who provided complete information about their age of alcohol use initiation and other covariates (n = 856). Participants responded to the following question: "How old were you when you had your first drink of alcohol other than a few sips?"1 Response options were "I have never had a drink of alcohol other than a few sips," "<9 years old," "9 or 10 years old," "11 or 12 years old," "13 or 14 years old," "15 or 16 years old," and "17 years old or older."1 Participants were then grouped into 2 categories, namely, preteen alcohol use initiators (had first drink of alcohol at age 12; n = 302) and nondrinkers (did not report alcohol use; n = 554). Comparisons between all participants (n = 4131) and the larger sample of seventh-grade students (n = 1484) showed that seventh-graders were more likely than students in other grades to have missing data (P = .05). Compared with the complete population of participating students (n = 4131), seventh-grade students were significantly more likely to be Hispanic, to report peer violence victimization, and to initiate alcohol use before 13 years of age (Table 1). Seventh-grade students were significantly less likely to report peer alcohol use or depression. Of the 1484 seventh-grade students included in the original sample, 628 were omitted from the analysis because of incomplete or missing data on ≥1 of the covariates included in the analyses. A significantly smaller proportion of seventh-grade students in the analytic sample reported perpetrating dating violence, compared with the larger sample of seventh-grade students (Table 1). There were no other significant differences between the complete sample of seventh-grade students and the students retained in the analytic sample.


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  		TABLE 1 Comparison of the Full Sample, Seventh-Grade Students, and the Analytic Sample

 
Six outcome measures were examined (dating violence victimization and perpetration, peer violence victimization and perpetration, suicidal ideation, and suicide attempts). The 4 scales used to assess dating and peer violence were adapted from a previous study on adolescent dating violence and abuse.28,29 In our study, each participant was asked 36 questions, that is, 9 questions for each of the 4 modules assessing dating violence victimization, dating violence perpetration, peer violence victimization, and peer violence perpetration in the past 12 months. The items involved specific forms of violent acts, including scratched; hit or slapped; threw something that could hurt; slammed or held against a wall; kicked; pushed, grabbed, or shoved; punched or hit with something that could hurt; threatened or injured with a knife or gun; and hurt badly enough to need bandages or care from a doctor or nurse. For these questions, a date was broadly defined as hanging out with someone, eating out, playing a game, watching a movie, or doing other things with someone they like. Same-gender peers were defined as other people about the student's age and of the same gender. The same-gender peers could be strangers, friends, or other people the student knew but not siblings or other family members.

The 4 revised violence scales had high levels of internal consistency, with Cronbach's {alpha} values ranging from .89 to .92. Dichotomous outcome measures reflected any involvement versus no involvement in behaviors within each scale. A scale (from 0 to 6) that reflected the total number and mean number of violent behaviors that participants reported across all 6 outcomes was also created. Participants were also asked whether they had seriously considered attempting suicide (ideation) or had made a suicide attempt (attempt) in the past year.1

Control variables included age (mean: 12.9 years; range: 12–16 years), gender (54% female), and race/ethnicity. Of those who responded to questions about their racial/ethnic background, 51% were Hispanic (alone or in combination with a racial group), 24% were non-Hispanic black, 20% were non-Hispanic white, and 5% reported another racial/ethnic category. Heavy episodic drinking was defined as reporting drinking ≥5 drinks in a row on ≥1 day in the past 12 months, and other substance use was defined by 1 question that asked whether participants had used any inhalants or illegal drugs (such as marijuana, cocaine, or heroin) in the past 12 months.

The modified peer delinquency scale30 included 3 questions ({alpha} = .85) that asked participants about their close friends' involvement in skipping school without an excuse, stealing, or selling marijuana or drugs. Response options ranged from none of their friends (score: 1) to most of their friends (score: 5). The peer delinquency scale was scored by taking the mean value for the 3 items, resulting in a range of 1 to 5. Peer alcohol use, which was assessed as part of the peer delinquency scale, was included as a separate variable in the statistical analyses.

The modified parental monitoring scale30,31 included 7 questions ({alpha} = .76) about whether participants let a parent know where they were going (by telephone or with a note) when they were not at home, how often their parents knew who they were going out with, how often their parents knew what time they would be home, and how often a parent knew what they were doing within the past 30 days. Response options included almost never (score: 1), sometimes (score: 2), and almost always (score: 3). The parental monitoring scale was also scored by taking the mean value for the included items, resulting in a range of 1 to 3.

Depressive symptoms (depression)32,33 within the past 30 days included 6 items ({alpha} = .85) that assessed whether participants felt very sad, were grouchy or irritable, felt hopeless about the future, did not feel like eating, slept more or less than usual, or had difficulty concentrating on their schoolwork. Response options ranged from never (score: 1) to always (score: 6), and results were scored by taking the sum of the 6 items, resulting in a range of 1 to 6.

Impulsivity33,34 was assessed by asking participants 4 questions ({alpha} = .79) about whether they generally have a hard time sitting still, whether they start things without finishing them, whether they do things without thinking, and whether they need to use a lot of self-control to keep out of trouble. Response options ranged from never (score: 1) to always (score: 5), and results were scored by taking the sum of the 4 questions, resulting in a range of 5 to 20.

Analyses
Logistic and multinomial logistic regression analyses were conducted to determine the association between preteen alcohol use initiation and involvement in the 6 violent outcome measures, relative to nondrinkers. The analyses were conducted with 4 different regression models. Model 1 included demographic control variables (age, gender, and race/ethnicity); model 2 included demographic and substance use variables (ie, heavy episodic drinking, other substance use, and peer drinking); model 3 included demographic, substance use, and other individual-level variables (ie, depression and impulsivity); and model 4 included demographic, substance use, and individual-level variables and other peer and parental influences (ie, peer delinquency and parental monitoring). Before the logistic regression analyses were conducted, exploratory logistic regression models were used to verify whether these additional psychosocial factors were statistically associated with early alcohol use initiation. The logistic regression models confirmed that depression, impulsivity, peer delinquency and parental monitoring were associated with early alcohol use initiation. Finally, a scale was created to examine the range of the violent behaviors that adolescents report. One point was given for any involvement in each of the 6 violent behaviors examined (ie, peer violence victimization, peer violence perpetration, dating violence victimization, dating violence perpetration, suicidal ideation, and suicide attempts). This scale ranged from 0 to 6 in scores. Because of the small cell sizes for those reporting ≥3 forms of violent behaviors, the scale was grouped into the following 4 levels: 0, 1, 2, and ≥3 forms of violent behaviors. Respondents missing more than one third of the scale items for depression, impulsivity, peer delinquency, or parental monitoring (n = 25) were omitted from the analysis. Analyses of respondents with missing data on the depression and impulsivity scales (which were among the last scales assessed in the questionnaire) suggested that both age and race/ethnicity were associated with missing data, so that those who were in seventh grade and those who were either black or Hispanic were less likely to complete the full scales.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Among our seventh-grade study participants, 35.2% (n = 302) had their first drink of alcohol before 13 years of age (preteen alcohol use initiators) and 64.7% (n = 554) reported no use of alcohol. In the first logistic regression model, preteen alcohol use initiation was significantly associated with involvement in all 6 violent outcome behaviors, relative to nondrinkers, after controlling for age, gender, and race/ethnicity (Table 2). Our second model, adjusted for demographic characteristics, heavy episodic drinking, other substance use, and peer drinking, showed that preteen alcohol use initiation was significantly associated with dating violence perpetration and victimization, peer violence perpetration and victimization, suicidal ideation, and suicide attempts, relative to nondrinkers (Table 2). Our third model, adjusted for demographic characteristics, heavy episodic drinking, other substance use, peer drinking, depression, and impulsivity, showed that preteen alcohol use was significantly associated with dating violence perpetration and victimization, peer violence perpetration, suicidal ideation, and suicide attempts, relative to nondrinkers. In this model, peer violence victimization was no longer significant. In our final model, controlling for peer delinquency and parental monitoring in addition to all previously included confounders, preteen alcohol use initiation was significantly associated only with dating violence victimization, suicidal ideation, and suicide attempts, relative to nondrinkers. In this final model, there were no significant associations between preteen alcohol use initiation and violence perpetration in either dating or same-gender peer contexts.


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  		TABLE 2 Cross-Sectional Logistic Regression Analyses of Early Alcohol Use Initiation and Involvement in Violent Behaviors Among Seventh-Grade Students

 
The prevalence of involvement in multiple forms of violent behaviors was significantly higher for preteen alcohol use initiators, compared with nondrinkers (Table 3). Preteen alcohol use initiators had greater mean involvement in violent behaviors (mean: 2.82 behaviors), compared with nondrinkers (mean: 1.81 behaviors). Additional multinomial logistic regression analyses of the association between preteen alcohol use initiation and involvement in multiple forms of violent behaviors are presented in Table 4. Preteen alcohol use initiators were 2.5 times more likely (adjusted odds ratio: 2.46; 95% confidence interval: 1.39–4.33) to report involvement in ≥3 forms of violent behaviors concurrently in the past year than were nondrinkers, controlling for heavy episodic drinking, other substance use, peer drinking, and all other psychosocial characteristics.


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  		TABLE 3 Involvement in Multiple Violent Behaviors for Nondrinkers and Preteen Alcohol Use Initiators

 

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  		TABLE 4 Multinomial Regression Models of the Association Between Preteen Alcohol Use Initiation and Involvement in Multiple Forms of Violent Behaviors

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our findings showed that the prevalence of involvement in multiple forms of violent behaviors was higher for preteen alcohol use initiators, compared with nondrinkers. Early alcohol use initiation was associated significantly with dating and peer violence victimization and perpetration, suicidal ideation, and suicide attempts in analyses adjusted for demographic characteristics, heavy episodic drinking, other substance use, and peer drinking. Moreover, the associations between early alcohol use initiation and involvement in 5 of the 6 outcome measures remained statistically significant after controlling for depression and impulsivity. However, the associations between early alcohol use initiation and involvement in most measures of interpersonal violence victimization and perpetration did not remain statistically significant after adjustment for additional peer and parental influences. In contrast, the associations between early alcohol use initiation and dating violence victimization, suicidal ideation, and suicide attempts remained statistically significant in the fully adjusted models. These findings suggest that early alcohol use is an important risk factor for both self-directed violence and dating violence victimization, independent of both peer and parental influences.

The lack of statistically significant associations between early alcohol use and violence perpetration in both dating and same-gender contexts in the fully adjusted model might be explained by the strong link between peer delinquency and involvement in violence. Having antisocial or delinquent peers is one of the strongest predictors of involvement in violent behavior.8 Lack of parental monitoring also facilitates interaction with delinquent peers and involvement in violent behaviors. In our study, early alcohol use initiation was associated with both peer delinquency (R2 = 0.18) and parental monitoring (R2 = 0.12), which suggests that several interrelated factors are important both for the initiation of early alcohol use and for involvement in violent behaviors.

The robust associations between early alcohol use and suicidal ideation and suicide attempts support previous research linking alcohol use and suicidal behaviors.35–38 In the context of the current analyses and findings, preteen alcohol use initiation represents a health risk behavior that can have a direct impact on suicidal behaviors but also can work indirectly. More specifically, early alcohol use is likely an indicator of the complex interactions between sociocultural, developmental, psychiatric, psychological, and family/environmental factors that can contribute to suicidal and violent behaviors. In the developmental/transactional model of youth suicidal behaviors,39 multiple factors contribute to suicidal ideation, suicide attempt, and suicide completion, either directly or as potential mediators or moderators of these associations. The association between alcohol misuse and suicidal behaviors can perhaps be best examined and explained in 2 ways,40 which are directly relevant also for explaining the link between alcohol misuse and involvement in violent behaviors. First, alcohol misuse may be viewed as a precursor or predisposing factor acting as a mediator or moderating factor for suicidal behavior; second, alcohol misuse may be viewed as a precipitating factor for suicidal behavior.40 More specifically, alcohol use may be viewed as a predisposing factor for suicidal behaviors because of its comorbidity with other health factors such as depression (perhaps as a result of the depressogenic effect of alcohol).40 Research also shows that depression is an important factor for involvement in violent behaviors among adolescent drinkers.10 Moreover, alcohol misuse is linked to adverse life events (relationship- and work-related problems, leading to social isolation and loss of networks). This is also applicable to involvement in violent behaviors, because adolescents who drink alcohol alone are more likely to engage in violent behaviors.10 In addition, alcohol misuse and suicidal behaviors potentially have shared, underlying, genetic predispositions,40 and researchers have suggested a common pathogenesis, with shared risk and protective factors, for suicidal and violent behaviors.41 Another approach is to examine alcohol misuse as a precipitating factor for suicidal behaviors. It is clear that the acute effects of alcohol contribute to intoxication and psychological distress, constricted thinking and impaired problem-solving abilities, aggression, impulsivity, and other biochemical effects, which can also serve as precipitating risk factors for suicidal behaviors40 and violent behaviors. For example, research showed that frequent heavy drinking is associated with alcohol-related fighting.11

Although the approaches discussed above link alcohol use and misuse to suicidal behaviors and involvement in violent behaviors, less focus has been given to the role of early alcohol use initiation and its role in suicidal and violent behaviors across contexts. It may be the case that early exposure and access to alcohol may be confounded by a range of factors, including other substance use, depression, impulsivity, involvement with delinquent and violent peers, poor parental supervision and monitoring, parental substance use, and lack of adult support and care, that also may contribute to increased risk of suicide attempts and other violent behaviors. Our analyses showed that, when the effects of depression, impulsivity, peer delinquency, and parental monitoring were considered, those who initiated alcohol use early were not at increased risk of involvement in interpersonal dating violence perpetration and peer violence victimization and perpetration. However, those who initiated alcohol use early were still at increased risk of dating violence victimization, suicidal ideation, and suicide attempts when these additional factors were considered. Perhaps early and potentially persistent use of alcohol in childhood negatively affects social connectedness, problem-solving confidence, and the locus of control, which are all protective factors for medically serious suicide attempts.42 Moreover, the association between early alcohol use and dating violence victimization in fully adjusted models indicates that this association is independent of other substance use factors, the individual characteristics examined, and peer and parental influences.

Our findings also show that an early age of alcohol use initiation is associated with the number of violent behaviors that adolescents report. In this study, adolescents who began drinking alcohol early were more likely than nondrinkers to report involvement in ≥2 violent behaviors, most likely reflecting the prevalence of suicidal ideation and suicide attempts and ≥1 type of interpersonal violent behavior (eg, dating violence victimization). The associations between early alcohol use and involvement in violent behaviors are particularly troubling because early alcohol use initiation was common among the seventh-graders included in our analyses (35.2%). However, the prevalence reported in this study is very similar to reports from a nationally representative sample of ninth-grade students in the Youth Risk Behavior Survey, in which 33.9% reported drinking before 13 years of age.1 Therefore, early alcohol use initiation is a prevalent problem, not only in high-risk communities but among adolescents throughout the United States.

There are several limitations that should be considered. Most importantly, the findings are from students living in a high-risk community. Therefore, the findings may not be generalizable to students who live in other settings or to adolescents who have dropped out of school. Moreover, the study is based on self-reported data without corroboration with other sources. Because of the cross-sectional nature of the data and how the questions were asked, we could test only the associations between early alcohol use initiation and involvement in violent behaviors, without inferring causality or even verifying the temporal ordering of these factors. Also, we could not determine whether adolescents were drinking at the time of their involvement in violent behaviors. The current report included only measures of physical violence and did not examine the associations with sexual or psychological violence perpetration and victimization across dating and peer relationships, although these may be associated with an early age of alcohol use initiation. Our analyses did not include all participants because some people reported inconsistent alcohol use initiation and alcohol use information and because some participants did not complete all of the scales included in the current analyses or were missing data on ≥1 covariate. Young black or Hispanic male subjects were significantly less likely to be included in the analyses because they did not complete all of the scales. Also, we used a very conservative cutoff point for early alcohol use initiation. However, several previous studies examined a range of ages for early alcohol use (eg, 13–21 years of age),20–23 and it will be important for future research to examine multiple years of drinking onset and the associations with violence victimization and suicide attempts. Finally, it is important to note that the factors examined, including early drinking onset, violence victimization, suicidal ideation, and suicide attempts, as well as the confounders, may share common antecedents in the form of genetic factors, adverse childhood experiences, and other psychosocial factors that we were not able to examine in these analyses. Moreover, some of the variables for which we controlled in our analyses (eg, depression, impulsivity, heavy episodic drinking, other substance use, and peer delinquency) could represent both etiologic precursors and potential mechanisms through which early initiation of alcohol use is related to current risks for violence victimization and perpetration (ie, mediators) and for suicide attempts. Our cross-sectional analyses showed that early initiation continued to have significant associations as an independent correlate of dating violence victimization, suicidal ideation, and suicide attempts even when we controlled for most of these factors.

Longitudinal research is needed for a better understanding of the mechanisms through which early alcohol use initiation influences risks for both self-directed and interpersonal violence. In particular, research examining protective factors such as social connectedness and problem-solving skills42 and how these factors may be affected adversely by early alcohol use could guide future prevention and intervention efforts. Moreover, future studies should examine individual- and community-level factors that were not included in our analyses, to facilitate understanding of the associations between early alcohol use initiation, dating violence victimization, and suicidal behaviors. Research focused on help-seeking behaviors and the potential benefits of early screening and intervention among young adolescents may be particularly important.

The most commonly missed pediatric diagnosis is adolescent substance abuse.43 In a 1995 periodic survey by the American Academy of Pediatrics, 45% of fellows reported routine screening for substance abuse among adolescent patients 12 to 17 years of age.44 A smaller proportion of fellows likely would report routinely screening even-younger patients. The high prevalence of alcohol initiation before 13 years of age among seventh-graders in our study (35.2%) and in a nationally representative study of ninth-graders (33.9%) demonstrates the importance of screening for alcohol use in the younger age group as well as among teens. In the American Academy of Pediatrics policy statement on alcohol use and abuse, it is recommended that pediatricians should advise strongly against the use of alcohol and should discuss the hazards of alcohol with their patients as a routine part of risk behavior assessment.45 The findings in our study show that such discussions should start before the preteen years, in an effort to avoid or to delay first alcohol use and the associated adverse events. Additional efforts are needed to determine what other clinical interventions can delay and reduce early alcohol use and involvement in both interpersonal and self-directed violence.

This study is the first to examine the associations between early alcohol use initiation and multiple violence outcomes, including violence victimization and perpetration in peer and dating contexts, suicidal ideation, and suicide attempts. Our findings showed important consistent associations between early alcohol use initiation and suicidal behaviors. Findings from this study and other reports19,21–23 highlight the importance of delaying and reducing alcohol use among youths. A number of evidence-based strategies, including increasing excise taxes on alcohol,46 restricting physical access to alcoholic beverages for minors,47 enforcing minimum legal drinking age laws,48 and screening and brief intervention,49 are available but have not been fully implemented.50

The alcohol-related interventions that seem most promising for reducing interpersonal violence and suicides involve treatment for alcoholism, enforcement of the minimum legal drinking age, and increased prices for alcohol.51 One study showed that increases in excise taxes on beer were associated with reduced numbers of male suicides but did not affect female suicides.52 However, because of limited evaluation of these interventions specifically for suicidal ideation and suicide attempts among youths, it is not clear whether these interventions are effective in reducing suicidal behaviors among youths. Increased efforts to evaluate existing suicide interventions and prevention programs are needed, because of the paucity of evaluated suicide prevention programs.41 In contrast, there are numerous evaluation studies of interpersonal violence prevention programs for children and adolescents that incorporate risk factors relevant for suicide prevention.41 Existing violence prevention programs may already have positive effects on other outcomes, including suicide attempts, and should be evaluated to determine their potential effects on multiple outcomes.41 Meanwhile, because alcohol advertising contributes to alcohol use among adolescents53,54 and many adolescents (29%) report that alcohol is easily available to them in their homes,55 additional efforts are needed to reduce and to delay adolescents' alcohol use and the many associated negative health risk behaviors and outcomes.


   FOOTNOTES
 
Accepted Jul 17, 2007.

Address correspondence to Monica H. Swahn, PhD, Partnership for Uban Health Research and the Institute of Public Health, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995. E-mail: mswahn{at}gsu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

Dr Swahn's current affiliation is the Institute of Public Health and the Partnership for Urban Health Research, Georgia State University. Dr Bossarte's current affiliation is the Department of Community Medicine, West Virginia University.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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