Youth Alcohol Use Prevention

by National Institute of Health

Designing effective interventions for adolescents with alcohol use disorders (AUDs) presents several challenges, not the least of which is the accurate diagnosis of these disorders. Diagnostic criteria for AUDs have been derived largely from clinical and research experience with adults. When these criteria were tested among adolescents, numerous developmental differences were found that may affect the applicability of AUD criteria to this age group. Despite the absence of clear diagnostic criteria for use with adolescents, research has identified interventions that show promise for use with youth. This article examines both environmental- and individual-level approaches to underage drinking prevention, including school- and family-based programs, and macroenvironmental and multicomponent comprehensive interventions. Finally, it describes brief and complex treatment interventions.

The ultimate goal of research on drinking by youth is to reduce the rates of drinking by adolescents and successfully treat those who develop problems linked to alcohol use. Prevention efforts may be aimed at keeping adolescents from starting to drink or at preventing the escalation of drinking and negative consequences. Research can provide the science on which to base the design of interventions and the means for determining which interventions are effective.

A valid diagnostic system is essential for assessing the nature and magnitude of adolescent problem drinking. Existing diagnostic criteria are derived largely from experience with adults, but developmental differences in alcohol use patterns suggest the need to adapt criteria to make them relevant and informative for an adolescent's stage of maturation.

Prevention efforts approach the issue of youth drinking in two ways: Environmental-level interventions seek to reduce the availability of alcohol to youth and opportunities to drink, increase penalties for violation of minimum legal drinking age laws, and reduce community tolerance for alcohol use by youth. Individual-level interventions seek to change knowledge, attitudes, and skills so that youth are better able to resist influences that support drinking.

In their efforts to reduce adolescent drinking, schools and families can act at both the environmental and the individual level. School curricula operate at the individual level by trying to provide students with the knowledge, skills, and motivation to resist pressures to drink. At the environmental level, schools can make changes to discourage violation of alcohol rules and engage students' involvement in their schools, a factor that has been found to predict less alcohol and other drug involvement.

The ability of parents to influence whether their children drink is well documented and is consistent across racial/ethnic groups. Family interventions encourage parents to be aware of the risks from underage drinking, communicate with children, clarify expectations, set rules and consequences about alcohol use, and monitor children's activities. In addition to changing the knowledge and skills of young people, families can create an environment that reduces alcohol availability and increases the costs associated with drinking.

Research is providing data on the effectiveness of school- and family-based intervention programs and the elements that successful programs incorporate. One goal of continuing research is to improve investigators' ability to measure outcomes and to compare studies and the methods they use as a means of changing adolescent behavior.

Community-level environmental interventions include strategies such as implementing restaurant/bar server training, checking alcohol vendors for compliance with underage laws, deterring adults from purchasing alcohol for minors, strengthening policies to detect and stop underage drinking parties, and instituting publicity for policies aimed at enforcement of laws against driving under the influence (DUI) and underage drinking. Community prevention trials have demonstrated that such efforts can reduce alcohol-impaired driving and fatal crashes among underage drivers and sales of alcohol to minors.

The most comprehensive interventions encompass coordinated school, family, and community programs. One such universal prevention program, Project Northland, was tested in 22 school districts in northern Minnesota in a randomized trial. The intervention included school curricula, peer leadership, parental involvement programs, and communitywide efforts to address community norms and alcohol availability. The intervention was delivered to a single cohort from grades 6 through 12. Comparisons in such measures as "tendency to use alcohol" and drinking five or more drinks in a row revealed differences between intervention and comparison communities.

Although the Project Northland intervention was able to reduce rates of drinking among students who were nondrinkers at the start of the project, the effort had no effect on those who already had been drinking. These very early starters are likely to have particular risk factors that make them more likely to drink and less likely to respond to more broadly targeted interventions; the experience with Project Northland suggests that programs may be needed that are aimed specifically at this group.

Underscoring the need for effective means of prevention are 2002 prevalence data indicating that, among youth ages 12 to 17, 1.4 million met the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for alcohol abuse and dependence. The data, moreover, reveal a major unmet need for treatment for alcohol and related behavioral problems. Only 227,000 of the youth meeting criteria for alcohol problems received any treatment for these disorders in 2002. Data on alcohol problems among youth also may understate the prevalence of these disorders; alcoholism treatment researchers believe that DSM-IV criteria need to be developmentally specific to adequately identify youth with problems.

Adolescents in treatment for alcohol use disorders (AUDs) are likely to have more than one substance use disorder and may have other psychiatric comorbidities; the success of treatment is lower with those who have multiple problems than with other subgroups of youth. To date, treatment for adolescent addiction has involved adapting adult treatments to youth. Ongoing research is testing some innovative and developmentally tailored interventions aimed at improving treatment outcomes.

Some of the most promising interventions for adolescents with AUDs have been complex, multicomponent therapies. The current health care financing system stresses the need for shorter, more cost-effective treatment, however. An alternative to complex treatments, brief interventions can be directed at drinking or the consequences of drinking. An example of a brief intervention is motivational enhancement, which encourages the person to take responsibility for change and provides a menu of options for change. Early evidence suggests that brief interventions can be helpful in reducing both drinking and its consequences in adolescents.

Overall, research points to the importance of applying a more nuanced and detailed understanding of adolescent development to the design of treatments and outcome measures for alcohol use problems in adolescents.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.