Adolescent alcohol use and abuse is a serious public health problem that shows no signs of abating. Alcohol use by teens is defined as at least one drink in the past 30 days; binge use is five or more drinks on the same occasion at least once in the past 30 days, and heavy use is five or more drinks on the same occasion on at least five different days in the past 30 days.¹ Alcohol dependence is characterized by tolerance, withdrawal, and psychological/physical problems.^1,2
Most young people begin drinking at about age 13 with some starting even younger.¹ Among all youth aged 12 to 20, 10.7 million reported drinking alcohol at least once in the past year, and of these, nearly 7.2 million were binge drinkers, and 2.3 million were heavy drinkers. By the time teens are finishing high school, 77% have consumed alcohol (more than just a few sips), and nearly half (46%) have done so by 8th grade. In fact, 58% of the 12th graders and 20% of the 8th graders reported having been drunk at least once in their life.

Of concern to researchers is the sharp increase of alcohol use associated with increasing age. For example, 2.0% of 12-year-olds used compared to 6.5% of 13-year-olds, 13.4% of 14-year-olds, and 29% of 16-year-olds. The rate of binge drinking also rose with age; 7% of the 14-year-olds, 17.9% of the 16-year-olds, and 25% of the 17-year-olds drank heavily in at least one episode.¹

These same studies reveal demographic differences and similarities. Males were more likely than females to report drinking, 57% to 45%, but differences for binge drinking were not as large, with males at 22% and females at 17%.^1,3 Adolescents from rural counties showed only slight differences in alcohol use from their metropolitan counterparts, 46% to 50%, respectively. Higher education of parents was associated with increased rates of adolescent alcohol consumption and being drunk. Among teens whose parents have advanced degrees, 60% use alcohol.⁴

African-American teens had the lowest rates for drinking and being drunk (35%), while Caucasian teens had the highest at 56%. Hispanic adolescents were intermediate in their use, at about 52%.⁴These findings indicate that alcohol use, and in some cases abuse, has infiltrated all sociodemographic groups in the U.S. and that race, locale, or age group is not a protective factor.

One of the most ominous predictions about youth drinking is that 40% of children who start drinking before age 15 will develop problems with alcohol at some point in their lives.⁵If the child delays drinking until at least age 20, his or her risk of serious alcohol-related problems is half that of those who use and abuse alcohol before age 20.

Adolescent alcohol use has been associated with self-reported health problems, both physical and emotional. Adolescents who abuse alcohol may have sleep disturbances and mood and anxiety disorders.⁶As a general health status measure, periodontal disease and dental caries often are an early indicator of alcohol abuse in adolescents, appearing before symptoms that may develop later, such as elevated liver enzymes. The most common mood disorders for adolescents are major depressive and post-traumatic stress disorder.⁶ The diagnosis of major depressive disorder is cause for concern because some studies indicate alcohol-abusing teens are at much greater risk for suicidal ideation.^7,8
Adolescents who engage in alcohol use or sexual activity are more likely to experience suicidal ideation and consider suicidal acts.^7,8 According to a national study, 19.3% of students aged 10 to 18 had considered attempting suicide. Female adolescents were more likely (24.9%) than males (13.7%) to have contemplated suicidal acts.^7,8 Because alcohol is a central nervous system depressant, teens experiencing depressive episodes who drink are at greater risk for self-destructive behaviors.
Sexual activity is associated with alcohol misuse, and regrets over these actions can add to existing depressive states. Sexual intercourse, multiple partners, unprotected sex, and sexual assault (for example, date rape) are related to alcohol-use disorders in teens. Forty-four percent of the sexually active teens reported they were more likely to have sexual intercourse if they had been drinking, and 17% indicated they were least likely to have safe sex after using alcohol.^7,9 Researchers estimate that alcohol use is implicated in one-third to two-thirds of sexual assault cases among teens and college students.^7,9

The relationship between teen violence and alcohol has been demonstrated in states that raised the minimum drinking age, with incidents of violence decreasing.^7,9

Developmental risk factors
Several elements and attributes are developmental risk factors in adolescent alcohol misuse. According to several investigators, the risk elements and attributes fall into following major categories: genetic factors, childhood behavioral and psychiatric disorders, parental influences, peer relationships, and adolescent expectancies.^10-12

Some sources report that children of alcoholics are significantly more likely to start drinking during adolescence and to develop alcohol-use disorders, leading them to conclude that genetics is a risk factor.⁹Some researchers indicate that the dopamine receptor (DRD2) gene has demonstrated strong implication for vulnerability to substance abuse and that specifically the A1 allele of the DRD2 gene has been associated with alcoholism.¹⁰

Others point out that in children of alcoholics, drinking behavior is more profoundly influenced by parents, siblings, and friends, just as with other adolescents, but once alcohol has been ingested, genetic factors affect the frequency and quantity of use.¹¹However, the interaction between environmental influences and genetics has not been determined, and individual differences may result in wide variability in youth alcohol use and abuse.⁹

Childhood temperament is associated with alcohol abuse. Children who are restless and impulsive at age 3 are more likely to be diagnosed with alcohol abuse at 21. Aggressiveness in children as young as 5 to 10 is related to alcohol and other drug use in adolescence.^9,11 Associated with these findings are adolescent psychiatric disorders such as conduct disorder—an antisocial mental disorder characterized by aggressive acts that cause or threaten physical harm to other people or animals and nonaggressive conduct that causes property damage, deceitfulness or theft and serious violations of rules.^12,13 These coexisting mental disorders may precipitate alcohol-use disorders or result from them.

Parental and peer/sibling relationships have a far greater influence on adolescent alcohol use than other factors.¹³ Parental drinking is one of the best predictors of alcohol use among preadolescents. Sibling alcohol misuse, especially an older sibling, also influences childhood alcohol use.

Influencing factors
Several prominent social and environmental factors have been examined for their influence on underage drinking: peer groups, media/advertising, and adolescent social behaviors related to novelty-seeking/risk-taking and positive alcohol-use expectations. Peer influence includes modeling alcohol use by friends, friends’ making alcohol or other drugs available, and peers’ creating norms and expectancies that encourage or condone alcohol use.¹⁴ Teens who have friends who use alcohol are much more likely to misuse alcohol, with 58% of the students aged 11 to 16 reporting some lifetime history of use.¹⁴

Complicating peer influence are the media messages that bombard adolescents. According to some sources, 90% of the 200 most popular movie rentals in the last five years depicted alcohol use. In more than 57% of these films, no consequences were associated with alcohol consumption.^8,15 In the music medium, 47% of the top-selling popular songs mention alcohol.⁹To large corporations, adolescents represent a potential $150 billion market.¹⁴ Teen income from employment totaled $121 billion in 1998, and adolescent spending is expected to exceed $155 billion in the next decade.¹⁶ Through the entertainment industry companies can market their products to teen-agers. Health care providers can counter glamorized messages about alcohol and drugs with accurate and age-appropriate information.

.Adolescent development includes a high degree of novelty-seeking behaviors that create excitement, pleasure, and risks in this age group, more so than any other.⁷ Associated with these behaviors are teens’ expectations that alcohol use is positive and that it results in either no consequences or rewarding ones.¹⁶ Even heavy drinking does not equate to identification of negative results. In one study, 13.4% of the adolescents met the criteria for heavy alcohol consumption, but only 15.9% of this group acknowledged having a substance-abuse problem.¹⁵

Risk reduction
Family relationships and parental monitoring, peer associations, health beliefs, and life skills are the most powerful risk-reduction protective factors for adolescents. Family and parental monitoring becomes crucial as teens attempt to identify with and develop the adult role. Adolescence is a high-risk period as the child moves toward independence while struggling to master a unique identity. The family exerts a strong influence in reducing adolescent risk behaviors while helping the child move forward developmentally.^17,18 Families can support adolescent development with communication, boundaries, cohesion, and parental involvement and monitoring.¹⁵

Families that confront their own minimization of teen alcohol abuse and encourage teens to discuss their problems create a protective climate for role socialization through adulthood.¹⁷ Modeling constructive communication patterns is an effective teaching tool for children and adolescents. Behavioral boundaries that reduce risk factors and exert a protective function include parental monitoring of the child’s activities and parental presence at key times during the day (such as in the morning, after school, at dinner, and at bedtime). A family routine provides a sense of predictability important to the adolescent’s sense of security.¹⁷ Family cohesion is expressed through communication, shared activities, and a routine that includes the child. Parental involvement and monitoring also includes consistently enforced limits and rules when behavior needs to be modified.^17,19 Nurses can encourage parent-teen communication and emphasize the importance of the family as a source of support during adolescent development.

Peer associations have been discussed in terms of their negative effects, but positive outcomes result when such relationships are based on shared health values and beliefs. Teens involved in peer sports and social/religious activities that exclude alcohol and other drugs benefit from these relationships. These peer associations exert a protective influence to reduce the migration to peers who abuse alcohol.¹⁴

Life skills such as alcohol-refusal strategies and anger-coping methods are important. Teaching teens ways to refuse alcohol is associated with reduced alcohol misuse when combined with other preventive approaches such as accurate and age-appropriate alcohol/drug information.¹⁹ The effectiveness of those skills differs developmentally, with alcohol-refusal training best provided during junior high rather than later. Refusal techniques can be taught through role play with assertive communication. A clear “No, I do not want any,” a firm tone and consistent body language such as shaking the head and making direct eye contact are important for success.

Adolescents who don’t know how to express anger appropriately show higher rates of alcohol consumption and spend fewer hours a week in health-focused physical activities.²⁰ This shows the importance of encouraging the discussion of problems and concerns in the home and modeling good communication skills by parents and other adults. Health care providers, in numerous roles, are adult models for adolescents and their families.

Nursing implications
Prevention and early intervention are keys to reducing the consequences of teen drinking, and nurses can play a critical role. One intervention is to involve the adolescent in making health decisions by providing accurate information and guidance as he or she moves through developmental phases. Encouraging the appropriate expression of feelings and the identification of problems and concerns reduces the known risk for alcohol abuse and models constructive communication and problem-solving methods.

It is critical to reach the parents, and nurses can take advantage of opportunities to teach them about teen alcohol abuse and the value of parenting skills. The risk-reduction elements previously discussed can become the structure for teaching parenting skills such as presence and monitoring at crucial times during the day. Formal teaching opportunities may be available through the PTA, sports activities, and community events such as health fairs.

Knowing the protective elements inherent to supportive families helps the nurse assess family functioning such as communication methods, boundaries, cohesion, and parental monitoring. School and community affiliations are important to an adolescent’s abstinence from alcohol and other drugs.
School and pediatric nurses have opportunities to promote healthy behaviors by providing early intervention and crisis intervention and incorporating teaching into the care of youth. Community/public health nurses and other nurses can help by establishing a community action plan. (See table.)