The consumption of alcohol by underage youth in America constitutes a public health problem with serious social and economic costs and often tragic personal consequences. Alcohol is the most widely used substance of abuse among America's youth. Over 4 million of our young people ages 12–17 (18%) report drinking monthly with more than half engaging in high-risk drinking patterns. Approximately 50% of young people have had a full drink by the 8th grade. By high school graduation, this number rises to approximately 75%. The amount of alcohol consumed also increases dramatically between the ages of 12 and 20, as measured by binge drinking (typically consuming 5 or more drinks per occasion) and the frequency of binge drinking.
The number of young people who drink and the way in which they drink, creates problems both for themselves and for others. The physical consequences of underage alcohol use range from medical problems to death by alcohol poisoning; alcohol also plays a significant role in risky sexual behavior, physical and sexual assaults, and various types of injuries, including suicide. Underage drinking can also contribute to academic failure and altered vocational and career trajectories, thereby diminishing our most essential national resource, human capital. Secondhand effects of underage drinking impinge on others, drinkers and nondrinkers alike, in many ways, most significantly in the form of car crashes from drunk driving.
Perhaps most alarming is the recent finding that underage alcohol use is not just associated with a temporary surge in risky behavior, and its immediate consequences. The prevalence and extent of binge drinking among young people makes them more vulnerable to development of full-blown alcohol dependence as well (that is, alcohol dependence of the kind that is diagnosable according to standards described in the Diagnostic and Statistical Manual of the American Psychiatric Association). The earlier the onset of drinking, the higher the risk of developing future dependence. In fact, data from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative survey of over 40 000 participants conducted in 2001–2002, showed that the highest prevalence of alcohol dependence in the US population occurs in youth ages 18–20.
As we learn more from research about the acute and later consequences of drinking during this early period of vulnerability, it has become clear that underage drinking must be addressed, not as an isolated phenomenon, but as an issue fully embedded in the context of child and adolescent development. From birth, every individual experiences dynamic biological changes in the body and brain as well as changes in the environments in which they grow up (e.g., family, school, and neighborhood, among others). And, as these more obvious changes occur, so do changes in peer groups.
The complex interaction of biology with changing environmental factors leads to behavior that may either move individuals toward or away from underage drinking. For example, certain temperamental characteristics that can be identified in very early childhood are associated with greater risk for early alcohol use. This risk can be compounded by a dysfunctional home environment. In addition, long before individuals begin drinking, childhood experiences may influence the formation of expectancies about the effects of alcohol that are also related to future adolescent alcohol use.
In early adolescence, we also need to consider the multiple effects of puberty, including hormonal changes, overt physical changes, differential maturation of specific regions of the brain, and a shift in reward sensitivity which may contribute to increased risk-taking and sensation-seeking. Combined with greater access to alcohol and less supervision, these shifts can increase the risk for alcohol initiation. Other important changes include increasing responsibility at home, at school and elsewhere, coupled with an increasing personal need for independence. Indeed, by later adolescence most youth are driving and many work outside the home. All these developmental changes, perhaps most importantly peer influences, intersect with alcohol use in complex ways.
This supplement provides important information for understanding and addressing underage drinking in the context of overall development. The information in this group of articles forms some of the scientific foundation of both the National Institute on Alcohol Abuse and Alcoholism's Underage Drinking Research Initiative, as well as the recently released Surgeon General's Call to Action To Prevent and Reduce Underage Drinking. Because a Surgeon General's Call to Action is intended to be a concise document that focuses the Nation's attention on an important public health issue, the articles in this supplement can be viewed as a means of beginning to access the more extensive scientific literature on which the Call to Action To Prevent and Reduce Underage Drinking is based. We hope you will find the information in this supplement useful as you work with your patients to foster healthy child and adolescent development. You may also find the recently released Surgeon General's Guide to Action series (www.surgeongeneral.gov/topics/underagedrinking/) helpful in these discussions.