A new report offers new information of what influences children's behavior toward alcohol and what pediatricians can do to curb underage drinking.
Nearly 80% of children and adolescents consume alcohol by the end of high school, and up to 60% admit to binge drinking, according to a new report, which highlights the increased risks of underage drinking and what pediatricians can do to help.
“They are inexperienced and they are more likely to drink heavily when they do drink. Given their smaller bodies, they are more likely to reach much higher blood alcohol levels than adults drinking the same amount,” says lead author Lorena Siqueira, MD, MSPH, FAAP, FSAHM. “The younger they start to drink and binge drink the more likely they are to continue drinking, increasing their risks of having an alcohol use disorder in the future.”
The report, published this month in Pediatrics, reveals that alcohol is the leading cause of serious death and accidents among children and adolescents, and 21% of children and teenagers say they have tried alcohol by age 13. That percentage increases to 79% by their senior year of high school, according to the report. Not only are children in these age groups drinking, but Siqueira, director of adolescent medicine and professor of pediatrics at the Herbert Wertheim College of Medicine and Florida International University Nicklaus Children’s Hospital, says they are binge drinking at higher levels than adults.
Binge drinking is defined as having 5 drinks in 2 hours, but that classification is based on the size and metabolism of an adult male. Binge drinking is further defined as drinking to a point where the blood-alcohol concentration exceeds 0.08%. In children, the parameters for binge drinking are not as clear, Siqueira says, but are generally about 3 drinks for girls aged 9 to 17 years and for boys aged 9 to 13 aged. For boys aged 14 to 17 years, that cutoff rising to 4 or 5 drinks. Siqueira also notes in the study that adolescent and college males typically consume 9 drinks before experiencing a blackout, while females consume 5.
Not only are children and adolescents more susceptible to the effects of alcohol, but they are also in a period of their life that lends itself to rebellion and experimentation. This combination has resulted in 22.9% of adolescents aged 12 years and older, and 14.2% aged 12 to 20 years admitting to binge drinking. An estimated 36% to 50% of high school students reported drinking alcohol, with 28% to 60% of them classifying their levels as binge drinking. Siqueira says 1 in 10 high school seniors reported drinking 10 or more drinks in a row, and 5.6% reported drinking 15 or more drinks at a time.
Although binge drinking among females is increasing, Siqueira says rates among girls are still lower than that of boys and adolescent males, and boys are more likely to participate in binge drinking while in high school than their female peers.
Race and geography also play a role in the trends, Siqueira reports, with 23.8% of white high school students reporting binge-drinking episodes compared to 7.6% of black students; 22.4% of Hispanic students; and 21.7% of non-Hispanic white students. Young men in rural areas reported the highest rates of binge drinking, with the Midwest being a particularly strong area. The states reporting the highest rates of underage binge drinkers were Massachusetts, New Hampshire, Rhode Island, Vermont, the District of Columbia, Florida, West Virginia, Indiana, North Dakota, Ohio, and Wyoming. Additionally, adolescents in higher socioeconomic groups were more likely to binge drink, but teenagers in lower socioeconomic groups or in rural areas were most at risk for extreme binge drinking, according to the report.
Siqueira found that most of these adolescents obtained their alcohol from adults of legal drinking age, and typically drank in their own homes or the home of a friend. In 44% of the cases, 13- to 20-year-olds say their drink of choice was hard liquor-particularly vodka. Beer was consumed in less than a third of binge drinking episodes, Siqueira says.
Risk factors for binge drinking identified in the report include the youth’s “alcohol expectancies,” or how they perceive the alcohol will affect them.
“These expectancies may be both positive and negative. Positive expectancies are often shaped by alcohol advertising, which is ubiquitous and portrays its use as being a normal part of adolescent and adult social life. As a result, the negative expectancies usually present in children are slowly replaced by positive expectancies as they enter adolescence,” Siqueira says.
Positive expectancies were noted most often in males, while females with a history of childhood maltreatment cite the reduction of tension as a positive expectancy.
Drinking motives are also a factor, and teenagers cite enhanced positive emotional states as a reason for drinking. These include the thrill of risk seeking, lower inhibitions, and sensation seeking.
Peer pressure is also an important and widely noted risk factor among youths, Siqueira says.
“As opposed to drinking alone, group involvement leads to greater perceived euphoria and also greater consumption. As a cautionary note, adolescents who drink alone are in a very high-risk group and need referral for treatment,” Siqueira says. “Studies indicate that students often seek out others to drink with, and when they enter college this tendency may influence their choice of living arrangements. Living in dormitories correlates with higher drinking levels than living off campus.”
There are biological issues, as well. Developing youths respond to alcohol much differently than adults, and hormones may play a role. Binge drinkers are also more sensitive to positive euphoric effects of alcohol in the early stages of drinking, and not the sedative effects, compared to non-binge drinkers, who experience the sedating effects first. Therefore, Siqueira says, young people who already are more sensitive to the euphoric effects of alcohol in the early phases of their drinking may be more prone to becoming binge drinkers.
Siqueira notes the adolescents who binge drink are also more likely to exhibit poor judgment in other areas, as well, engaging in a number of risky behaviors. Alcohol use is implicated in number of causes of mortality in teens, from automobile crashes to suicides. Alcohol use was also associated with 50% of all head injuries in adolescents, and drinking before the age of 15 puts adolescents at a 4 times greater risk of developing alcohol dependency than if they waited until after age 20, according to Siqueira. Other consequences of adolescent drinking include lower grades in school and higher rates of unwanted pregnancies. Even more startling, says Siqueira, is the evidence of brain volume reduction in youths who drink heavily. The report cites a study that demonstrated significant volume reductions in the brain’s frontal region and cerebellar white matter among youths who drank heavily compared to non-drinkers.
Pediatricians play an important role in prevention, Siqueira says. Prevention efforts should focus on limiting alcohol advertising, limiting access to alcohol, promoting healthy alternatives to drinking, and education programs that highlight the dangers of drug and alcohol use. Siqueira says research indicates that children begin to think positively about alcohol between ages 9 and 13, and that discussion within the pediatric office setting should begin as early as age 9. Parental education is also an important component, as 80% of teenagers report that their parents are their biggest influence on their decision to drink.
“Parents need to be reminded that even though alcohol is a legal drug and widely used safely in adults, its use in children and adolescents is associated with serious consequences,” Siqueira says. “Early and continuous preventive messages using teachable moments can hopefully delay use of alcohol and prevent heavy drinking.”
Pediatricians should also screen youths for alcohol use during office visits, and Siqueira references the National Institute on Alcohol Abuse and Alcoholism/American Academy of Pediatrics screening tool which involves 2 questions. For those in elementary school (9 to 11 years of age), ask the “friends (any drinking)” question first: “Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year?” Ask the “patient (any drinking)” question next: “How about you-have you ever had more than a few sips of beer, wine, or any drink containing alcohol?” For those in middle school (11 to 14 years of age), after the same “friends (any drinking)” question, the patient question is, “How about you-in the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?” For those in high school (14 to 18 years of age), ask the “patient (any drinking)” question first, followed by the “friends (how much?)” question: “If your friends drink, how many drinks do they usually drink on an occasion?”
Depending on the answers, pediatricians should offer brief advice, motivational interviewing, and referrals to treatment programs, if needed, according to the report.