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Evidence-Based Strategies for Common Clinical Questions

May 2019

Wasted Youth: What We Know about Alcohol Abuse in Underage Patients, and How We Can Intervene


Author: Charles Spear, MD | Chief Resident, Children’s Mercy Kansas City

Column Editor: Rupal Gupta, MD | Medical Director, Operation Breakthrough Clinic | General Academic Pediatrics | Assistant Professor, UMKC School of Medicine

Most physicians know someone or have taken care of a patient who has suffered the negative impact of alcohol abuse. This may be a person who self-identifies as an alcoholic, uses alcohol as a coping mechanism, or has had a license taken away while driving impaired. Care could even involve someone who has lost his or her life from a devastating incident involving alcohol. Looking back, how many of these instances have involved a child or adolescent? Unfortunately, members of our youth may identify with some or all of these scenarios.

While enormous attention is paid to alcohol use and abuse in adults, children and adolescents are just as susceptible to the influence of alcohol-related problems. That’s why it is so important to review the scope of the issue, screening methods for alcohol abuse in kids and teens, and targeted interventions and prevention strategies to combat this growing problem.

Among all drugs of abuse in teenagers, alcohol remains the most available and widely used substance. Over half of all 12th graders report alcohol consumption in their lifetime, and 89% of 12th graders stated it would be “fairly easy or very easy” for them to obtain alcohol.1 Episodic heavy drinking (i.e., binge drinking), defined as having upward of five alcoholic beverages within a span of several hours, has emerged as the most common pattern of alcohol use. A recent CDC report on teenage alcohol use showed that one-third of all high-schoolers had partaken in binging 30 days preceding the survey.2 To shed light on how early these children commence with underage drinking, a 2015 nationwide report surveying people requiring medical admission for treatment of alcohol abuse found that 86% of these individuals had started drinking before the legal drinking age of 21, with one-third of them first becoming intoxicated by age 14.3

Several factors contribute to alcohol use and abuse in teens. Not only do teens experience peer pressure from classmates to drink alcohol, but they also use alcohol to reduce inhibitions and to engage in sexual activity.4 The marketing of alcohol-related products through global and social media campaigns has also gained traction as a strong influence on underage alcohol use. Knowing that up to 80% of 12- to 17-year-olds participate in online social networking sites,5 it is easy to see why alcohol advertising companies choose to market their products through the Internet. A study published in 2016 in Pediatrics demonstrated a prospective association between adolescent receptivity to Internet alcohol marketing and future drinking outcomes, which included having higher odds of initiating binge drinking.6

Given all this information, it is incumbent on pediatricians to screen for these problems and intervene when necessary in order to prevent not only the short-term consequences of underage drinking, but also the long-term medical, behavioral and psychosocial impairments associated with alcohol abuse. The American Academy of Pediatrics (AAP) Subcommittee on Substance Abuse advises all pediatricians to screen every adolescent for alcohol use during office visits.7

During visits with teens, providers can utilize a tool developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This tool asks two age-based questions to identify:

1. If they have any friends who drink alcohol, and
2. If they themselves drink (and if so, to what extent?).

This brief validated approach allows providers to detect early risk of alcohol abuse in children.8 To increase specificity after a patient screens positive for alcohol abuse, use of the six-item CRAFFT (car, relax, alone, forget, friends, trouble) pneumonic tool may be warranted to screen for further substance abuse.9

Lastly, pediatric providers should educate and encourage family members to discuss with their children the dangers of drinking. The AAP recommends initiating this conversation as early as 9 years of age.7 Eighty percent of adolescents reported that their parents are the biggest influence on their decision to consume alcohol; sharing this stark data with parents may help promote a dialogue.10 Pediatricians can also become familiar with and share reliable online resources, such as the Substance Abuse and Mental Health Services Administration campaign, entitled “Talk. They Hear You,” because when all is said and done, talking with your patients and families about underage drinking can never happen too early, but it can be too late.


1. Monitoring the Future: National Results on Adolescent Drug Use. Johnston, LD et al. The University of Michigan Institute for Social Research. 2011.

2. Current and Binge Drinking among High School Students – United States, 1991-2015. Esser MB, Clayton H, et al. MMWR Morb Mortal Wkly Rep 2017;66:474–478. DOI:

3. Treatment Episode Data Set (TEDS) 2005-2015: National Admissions to Substance Abuse Treatment Services. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2017.

4. Alcohol Use and Abuse: A Pediatric Concern. American Academy of Pediatrics Committee on Substance Abuse. Pediatrics. 2001 July; 108(1):185-9.

5. Teens, Kindness and Cruelty on Social Network Sites: How American Teens Navigate the New World of “Digital Citizenship.” Lenhart, A et al. Pew Research Center. 2011 November.

6. Internet Alcohol Marketing and Underage Alcohol Use. McClure, AC et al. Pediatrics. 2016 February; 137(2):1-8.

7. Binge Drinking. Siqueira, L et al. Pediatrics. 2015 September; 136 (3):718-26.

8. Reliability and Validity of a Two-Question Alcohol Screen in the Pediatric Emergency Department. Spirito, A et al. Pediatrics. 2016 December; 138(6):1-10.

9. Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients. Knight, JR et al. Arch Pediatr Adolesc Med. 2002 June; 156(6):607-614.

10. Perceived Legitimacy of Parental Authority and Tobacco and Alcohol Use During Early Adolescence. Jackson, C. Journal of Adolescent Health. 2002 November; 31(5):425-32.