Nat

ion

al In

stit

ute

on

Alc

oh

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bu

se a

nd

Alc

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nal

Inst

itu

te o

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use

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lism

Preventing Underage Alcohol Use: A Four-State Meeting

October 2, 2006

Patricia A. Powell, Ph.D., Health Scientist Administrator

Office of Science Policy and CommunicationNational Institute on Alcohol Abuse and Alcoholism

Adolescent Development and Alcohol Use

Nat

ion

al In

stit

ute

on

Alc

oh

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nd

Alc

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nal

Inst

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lism

Alcohol: Our Most Primitive Intoxicant

• Egypt (el-Guebaly N, el-Guebaly A (1981). Int J Addict.16:1207-21)– barley beer is probably the oldest drink in the world

with its origin in Egypt prior to 4200 BC

• China (McGovern et al., (2004). Proc Natl Acad Sci USA 101:17593-17598)– 7000 BC - the production of a prehistoric mixed

fermented beverage of rice, honey and fruit (Neolithic village of Jiahu in Henan province)

– 2000 BC- unique cereal beverages (Shang and Western Zhou Dynasties)

Nat

ion

al In

stit

ute

on

Alc

oh

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nd

Alc

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nal

Inst

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te o

n A

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use

an

d A

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lism

6,139,957546,540354,548

Apparent U.S. Alcohol Consumption, 2000

(in 1000’s of gallons)

Beer

Wine

Spirits

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

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mN

atio

nal

Inst

itu

te o

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use

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lism

Alcohol

Alcohol Across the Lifespan

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

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atio

nal

Inst

itu

te o

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ho

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use

an

d A

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ho

lism Moderate Drinking

One Drink = 12 ounces of beer 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits

Nat

ion

al In

stit

ute

on

Alc

oh

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nd

Alc

oh

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atio

nal

Inst

itu

te o

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use

an

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lism

Concentration of U.S. Alcohol Consumption

0

10

20

30

40

50

60

70

80

90

100

2.5 5 10 20 30 40 50 60 70 80 90 100

Percentile of Drinkers

Pe

rce

nt

of

To

tal

60+

50-59

40-49

30-39

18-29

Highest Volume Lowest Volume

Greenfield TK & Rogers JD. J Stud Alcohol 60:78 (1999)

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

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mN

atio

nal

Inst

itu

te o

n A

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l Ab

use

an

d A

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lism

Alcohol-related health, personal, and social problems

arise from drinking

too much, too fast, too often

The most harmful pattern is binge drinking: 5 drinks for men, 4 for women, in 2 hours

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

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atio

nal

Inst

itu

te o

n A

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ho

l Ab

use

an

d A

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lism

Actual Causes of Death1, United States - 2000

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA (2004). 29:1238-45; Mokdad AH, Marks JS, Stroup DF, Gerberding JL. (2005). JAMA 19;293:293-4.

0.7%

0.8%

1.2%

1.8%

2.3%

3.1%

3.5%

15.2%

18.1%Tobacco

Alcohol Consumption

Microbial agents

Toxic agents

Motor vehicle

Sexual behavior

Firearms

Illicit drug use

Actual Causes of Death are the major external

(nongenetic) modifiable factors that contribute to

death in the United States

Poor diet and physical inactivity

An estimated 85,000 deaths

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

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atio

nal

Inst

itu

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l Ab

use

an

d A

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lism

Alcohol is a Leading Risk Factor for Disease In Developed Countries

0% 2% 4% 6% 8% 10% 12% 14%

Iron deficiency

Unsafe sex

Illicit drugs

Physical inactivity

Low fruit and vegetable intake

Overweight

Cholesterol

Alcohol

Blood pressure

Tobacco

% Total Number of Health Years Lost to Death/Disability

Alcohol

The World Health Report 2002: http://www.who.int/whr/2002/en/whr2002_annex14_16.pdf

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

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lism

U.S. Adult Drinking Patterns and Alcohol Use Disorders (AUD)*

(NESARC 2001-2002)

DRINKING PATTERNBased on the following limits – number of

drinks:

On any DAY—4 (men), 3 (women)

In a typical WEEK—14 (men), 7 (women)

Percent of U.S. adults

aged 18+

An Individual’s Chance of

having an AUD

Never exceeds the weekly or daily screening limits

72%less than

1 in 100

Exceeds only the daily limit 16% 1 in 5

Exceeds both weekly and daily limits 10%almost

1 in 2

*alcohol abuse, alcohol dependence

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

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atio

nal

Inst

itu

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use

an

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lism

Extent of Alcohol Use Problems in the United States

* Alcohol abuse and/or alcohol dependence

• 18 million Americans (8.5% of the population age 18 and older) suffer from alcohol use disorders (AUDs*)

• Over 4 million of our young (18% of the population age 12-17) report drinking monthly with more than half engaging in high-risk drinking patterns

• Alcohol problems cost U.S. society an estimated $185 billion annually

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescent Alcohol Use

What’s the problem?

Why we care

What we know

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Alcohol is the Drug of Choice Among Adolescents

0

5

10

15

20

25

30

35

40

45

50

8th 10th 12thGrade

Pe

rce

nt Alcohol

Cigarettes

Marijuana

Source: Monitoring the Future, 2005

(Past Month Use)

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism Experience with Alcohol

Begins Early for Many

• Approximately 50% of kids start drinking (have had a full drink) by the 8th grade

• By the time they graduate from high school, the vast majority of young people (about 80%) have experience with alcohol

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

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ho

l Ab

use

an

d A

lco

ho

lism

5.94.9

7.9

4.2

8.7

2.6

0

2

4

6

8

10

Drinking days/ month Usual # of drinks/occasion

Underage 12-20 Young Adult 21-25 Adult 26 and older

Adolescents Drink Less Frequently than Adults But More Per Occasion

Source: SAMHSA National Survey on Drug Use and Health 2006

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

0

10

20

30

40

50

60

70

80

12 13 14 15 16 17 18 19 20 21

Age Category

Pe

rce

nt

Past Month Use

Past Month Binge

Past Month Heavy

Alcohol Use and Binge Drinking Increase Dramatically During

Adolescence

Source: SAMHSA National Survey on Drug Use and Health 2006

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

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ho

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use

an

d A

lco

ho

lism Drinking Trends Among

High School Seniors, 1975-2004

0102030405060708090

100

Per

cen

t

Yearly

Monthly

5+ Drinks

Source: Monitoring the Future, 2004

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

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ho

l Ab

use

an

d A

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ho

lism

15-16 Year Old Students in Countries Throughout Europe Binge Drink

0 10 20 30 40 50 60 70

Denmark

Finland

Norway

Sweden

Romania

Russia

Ukraine

Poland

Turkey

Greece

Italy

Portugal

Germany

Switzerland

Netherlands

Belgium

France

Ireland

UK

USA

1-2

3-5

6-9

10+

Percent

Number of Binge Occasions in thePast Month

The European School Survey Project on Alcohol and Other Drugs, 2000.

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

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ho

l Ab

use

an

d A

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lism

• 5,000 deaths among youth under 21 per year from alcohol related injuries including homicides (1,600) and suicides (300)

• Physical and sexual assaults; unwanted/unintended sexual activity

• Altered academic/vocational trajectories

• Possible adverse effects on developing brain

Direct Consequences of Underage Drinking

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

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ho

l Ab

use

an

d A

lco

ho

lism Second-Hand Effects

• Half of all persons who die in traffic crashes involving drinking drivers under age 21 are persons other than the drinking driver

• Among college students under age 21 alone, 50,000 experience alcohol-related date rape, and 430,000 are injured by another student who has been drinking

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

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ho

lism

Prevalence of Past-year DSM-IV Alcohol Dependence by Age – United States

0%

2%

4%

6%

8%

10%

12%

14%

12-1

7

18-2

0

21-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

Age

%

Pre

va

len

ce

18 + yrs. - NIAAA NESARC ( Grant, et al., (2004) Drug and Alcohol Dependence, 74:223-234)12-17 yrs - U.S. Substance Abuse and Mental Health Services Administration 2003 National

Survey on Drug Use and Health (NSDUH)

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

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atio

nal

Inst

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te o

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use

an

d A

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lism

Fetus

Child

AdolescentYoung Adult

Middle Age

Senior

Alcohol Across the Lifespan

To understand the trajectory of AUDs we must consider drinking in a developmental context

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescence and Alcohol Use

Why does alcohol have such a strong appeal to so many youth?

Are young people more vulnerable to alcohol’s effects?

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

• Brain maturation – development of self-regulation

• Endocrine changes

• Shift in reward sensitivity; increased risk taking, sensation seeking, impulsivity

• Sexuality/romantic interest

• Environmental changes – e.g., school transitions, increase social interactions, peer affiliations, driving

• The balance of self to other monitoring shifts

The Multiple, Complex Dynamics of Adolescence

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Structural and Functional Changes in the Brain

Plasticity/ ability to change in response to the environment; creates a period of great learning potential

• Overproduction in number of synapses (till about age 11 in girls, 12 in boys)

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Structural and Functional Changes in the Brain

Increased Efficiency• Decrease in gray matter - dendritic

pruning/ competitive elimination of synapses

• Increase in white matter - increased myelination

Use it or lose it

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Maturation Is Not Uniform Across the Developing Brain

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Frontal Cortex:decision-making, self-control

Limbic System: learning, emotions

The limbic system governing emotions matures relatively early in adolescence and its development may be triggered by pubertal hormones. It may also be responsible for the shift in reward sensitivity that drives adolescents to seek higher levels of novelty and stimulation than they did as children.

The Limbic System

Develops Early in Adolescence

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Frontal Cortex: decision-making, self-control

Limbic System: learning, emotions

Maturation of the prefrontal cortex is more gradual and is linked to age and experience. This region is responsible for integrating input from the senses, memories, values, and aspirations to help us control impulses and make decisions. Reviewed in Steinberg, Lawrence (2004) Ann. N.Y. Acad. Sci. 1021: 77-85.

Maturation of the Prefrontal Cortex

Continues Into the 20’s

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescent Brain Development, Decision-Making, and Risk

• Immaturity of cognitive processing may lead to risky decisions.

• The presence of peers influences decision-making.

• Strong emotions may override rational decision-making.

• Risk-taking may facilitate adolescent transitions.

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescent Brain Development and Alcohol

• The adaptability of the adolescent brain makes it well-suited for the processes of adolescence.

• Do adolescents ‘learn’ addiction more readily?

• Do adolescents respond differently to alcohol compared with adults?

• Are adolescent brains more vulnerable to the effects of alcohol?

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

0

10

20

30

40

50

60

<=13 14 15 16 17 18 19 20 >=21

Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol

Use

0

10

20

30

40

50

60

<=13 14 15 16 17 18 19 20 >=21

Family History Positive

Total

Family History Negative

Age at First Alcohol Use Age at First Alcohol Use

% P

reva

len

ce

Source: Grant and Dawson. J Subst Abuse. 1998. 10(2):163-73.

Source: 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions

1991-1992 2001-2002

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Extent of Influence

Initiation of Drinking

Social Drinking

Alcoholic Drinking

Environmental (familial and non familial)

Personality/Temperament

Pharmacological effects of ethanol

Drinking Behavior and Alcohol Dependence are Complex Traits Influenced by both

Genes and Environment

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Age of Onset of Psychiatric Disorders

Developed from Time Magazine, January 20, 2003, p.82

Conduct DisorderDepression

Anxiety

Brain Disorders

13

Infancy to 5 Years

Infancy to 5 Years

10 – 13 Years

10 – 13 Years

AutismAttention Deficit Hyperactivity Disorder

Obsessive Compulsive Disorders

Eating Disorders

5 – 10 Years5 – 10 Years

– 20 Years

–13 20 Years

AgeAgeAgeAge

Panic DisorderSocial Phobias

Bipolar Disorder

Conduct DisorderAnti-social Behavior

DepressionAnxiety

Brain Disorders

Brain Disorders

Brain Disorders

13

Infancy to 5 Years

Infancy to 5 Years

Infancy to 5 Years

Infancy to 5 Years

10 – 13 Years

10 – 13 Years

10 – 13 Years

10 – 13 Years

AutismAttention Deficit Hyperactivity Disorder

Eating Disorders

5 – 10 Years5 – 10 Years5 – 10 Years5 – 10 Years

– 20 Years

–– 20 Years

–13 20 Years

13 20 Years

AgeAgeAgeAgeAgeAgeAgeAge

Panic DisorderSocial Phobias

Bipolar Disorder

Developed from Time Magazine, January 20, 2003, p.82

Alcohol and Drug

Use Disorders

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescent Alcohol SensitivityDo Adolescents Respond Differently to Alcohol

From Adults?

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Biphasic Properties of Alcohol as Intoxicant

GABA

NMDA

DA

Binge DrinkingBinge Drinking

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism (Animal Research)

less sensitive to some of the aversive effects of acute alcohol intoxication (sedation, hangover, ataxia)

but more sensitive to alcohol’s effects on--

• social facilitation

• disruption of spatial memory

Adolescent Alcohol Sensitivity

Compared with adults, adolescents are:

Reviewed in: Spear, LP and Varlinskaya E(2005). Recent Dev Alcohol. 17:143-59.

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Adolescent Sensitivity to Alcohol

• Adolescents exhibit:– Attenuated sensitivity to alcohol effects that normally

serve as cues to moderate drinking, but

– Greater sensitivity to ethanol-induced social stimulation

– Greater disruption in brain plasticity and memory

Attenuated sensitivity to ethanol effects may permit relatively high levels of alcohol intake in adolescence, potentially leading to adverse consequences during and outlasting adolescence.

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

A Low Level of Response to Alcohol Can Predict Future Alcoholism

(Human Studies)

Individuals with a low level of response to alcohol– experience less intense negative effects

of alcohol– require a higher blood alcohol

concentration to feel intoxicatedTherefore, they may drink more heavily and more frequently, and are more likely to develop alcoholism

Source: Schuckit, MA and Smith, TL (2000) J Stud Alcohol 61: 827-835.

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

Potential Effects of Adolescent Alcohol Use

Nat

ion

al In

stit

ute

on

Alc

oh

ol A

bu

se a

nd

Alc

oh

olis

mN

atio

nal

Inst

itu

te o

n A

lco

ho

l Ab

use

an

d A

lco

ho

lism

• Binge-like drinking affects memory, alters sensitivity to motor impairment, and damages frontal-anterior cortical regions.

• Prolonged ethanol exposure produces long-lasting neurophysiological changes in cortex and hippocampus.

(Animal Research)

Reviewed in: Monti, PM et al (2005) Alcohol Clin Exp Res. 29(2):207-20. Spear, LP (2002) J Stud Alcohol Suppl 14: 71-81.

Consequences of Adolescent Alcohol Use on the Developing Brain

Nat

ion

al In

stit

ute

on

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Consequences of Adolescent Alcohol Use on the Developing Brain

Adolescents with severe alcohol abuse/ dependence disorders may have:

• neuropsychological impairments

• reduced brain hippocampal volumes

Reviewed in: Monti et al. (2005) Alcohol Clin Exp Res. 29(2):207-20. DeBellis MD et al. (2000) Am J Psychiatry. 2000 May;157(5):737-44.

Questions remain... Are these the result of alcohol abuse

or did they precede it? Do they go away with time?

(Human Studies)

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(Animal Research)

Alcohol and Stress

• Under stress, adolescent monkeys double their alcohol intake

• Excessive alcohol consumption is related to changes in stress hormones and serotonin

Reviewed in Barr, CS et al. (2004) Ann. N.Y. Acad. Sci. 1021: 221-233.

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Potential adverse effects of adolescent alcohol use:

• Impact on functioning during adolescence – Greater sensitivity to alcohol-induced

disruptions in memory and brain plasticity

– Mutual synergism: alcohol risk-taking

– Increased level of stress?

– Circumvention of normal developmental tasks?

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adolescent alcohol use:

• Lasting consequences

– Lasting neurocognitive consequences?

– Increased susceptibility to alcohol use disorders?

Early alcohol use as Marker vs. Causality?

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• Brain maturation – development of self-regulation

• Endocrine changes• Environmental changes – e.g., school

transitions, peers, driving• Sexuality/romantic interest• Increased risk taking, sensation seeking• The balance of self to other monitoring shifts• Pharmacological effects of alcohol

The Multiple, Complex Dynamics of Adolescence

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lism Environmental Influences

• What they see and hearMedia including movies,

television programs, music, etc.Advertising/ PromotionsProduct Placements

• Alcoholic beverages with youth appeal

• Price

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Intervening Is Challenging, Because…

• adolescence is complicated

• multiple systems are involved in complex behaviors

• what resonate with children and adolescents change frequently and differ for different individuals

• we want enduring effects

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Scaffolding For Healthy Adolescent Development

Individuals may be protected from extremes in emotion or drive by a context that provides adequate external regulation in the form of support, control, predictability.

Provided by Ron Dahl

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Scaffolding For Healthy Adolescent Development

Thus, while many individuals may experience emotions and drives whose intensity and duration exceeds their regulatory competence, those adolescents who enjoy supportive home, peer, school and neighborhood contexts are buffered from the ill effects …

Provided by Ron Dahl

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Scaffolding For Healthy Adolescent Development

• Presence of a Caring Adult

• Positive Peer Groups• Parental Monitoring• School Connectedness• Alternative Activities

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Part II (coming in 2006)

Alcohol and Development in Youth: Future Research Directions

Fetus

Child

AdolescentYoung Adult

Middle Age

Senior

NIAAA’s Underage Initiative

Part IAlcohol and Development in Youth: A Multidisciplinary Overview

www.niaaa.nih.govPublications