How & Why Alcohol Use Disorders (AUDs) Develop in Adolescents


Alcohol Medical Scholars Program


Hayley Treloar Padovano, Ph.D.


Center for Alcohol & Addiction Studies

Brown University



I. Introduction (SLIDE 2)

      A. Alcohol use by teens is common

            1. Alcohol is most used substance by teens1

a. 80% high school seniors ever drink

b. 30% high schoolers (freshmen through seniors) ever drunk

            2. Drinking to drunkenness escalates during adolescence1

a. 10% 8th grade ever drunk

b. 50% 12th grade ever drunk

B. Alcohol use by teens can be harmful (SLIDE 3)

1. Immediate consequences2–4

a. Unintentional injuries

b. Physical or sexual assault

c. Depressive symptoms & suicidal ideation

d. Blackouts (periods of memory loss for events while drinking)

e. ↓academic performance

f. Risky sexual behavior

g. Alcohol poisoning & death

2. Long-term consequences5,6

a. Heavy drinking in late adolescence persists into adulthood

b. Early problems → later problems & ↑ risk Alcohol Use Disorders (AUDs)

C. This lecture covers (SLIDE 4)

1. Definitions of heavy drinking & AUDs

2. How AUDs might develop in general

3. Why adolescents are particularly vulnerable to AUD development

4. Unique challenges & solutions for adolescent alcohol research

5. Clinical example

       D. Clinical Case (Joanne): Is she at risk for AUDs? [HAVE A PICTURE] (SLIDE 5)

            1. We’ll follow her from age 12 to 17

            2. A typical child of a well-functioning family

            3. At 12 no experience with alcohol

            4. Familial history of AUD

II. Definitions (SLIDE 6)

A.    Heavy drinking: many definitions (SLIDE 7)

1. Typically

a. Amount: 5+ drinks

b. Timeframe: “in a row” or “in a sitting”7

2. National Institute on Alcohol Abuse and Alcoholism definition

a. Pattern of drinking alcohol →BAC .08 g/%

b. 4+/5+ drinks for women/men

c. 2-hour period

B.     Alcohol use disorder (SLIDE 8)

1. Recurring problems

2. Affecting multiple life areas

3. DSM-5 (5th diagnostic manual of American Psychiatric Assn)

4. Diagnosis associated with

a. Long-term alcohol problems

b. Earlier death

5. 2+ of 11 symptoms (in same 12 months) (SLIDE 9)

a. Taken in larger amounts or over longer periods than intended

b. Unsuccessful efforts to cut down or control use

c. Much time spent obtaining, using, or recovering

d. Craving or strong desire/urge to use (new)

e. Failure to fulfill major role obligations (e.g. in school or work)

f. Continued use despite negative social consequences (e.g., arguments with parents)

g. Important activities are reduced or given up

h. Use in physically hazardous situations (e.g., driving)

i. Use despite knowledge of physical/psychological problem (e.g., depression)

j. Tolerance defined by either

1’. ↑ amounts needed for same effect

2’. ↓ effect with continued use of same amount

h. Withdrawal manifested by either

1’. Withdrawal syndrome; opposite of acute effects for 4+ days include:

   a’. Insomnia, anxiety, ↑ blood pressure, heart rate, etc.

   b’. Develops when ↓ BAC

2’. Drinking to relieve/avoid withdrawal

III. How AUDs might develop in general (SLIDE 10)

A. Why do people drink?  (Ask audience to participate, list reasons.) (SLIDE 11)

1. Positive expectations/motives8,9 (SLIDE 12)

a. Expectations:  If _________; then _________. (Using Joanne (J) as example)

b. Can have expectations for drinking outcomes without ever drinking yourself

c. But expectancies can change with experience with alcohol

d. At 12 J’s expectations might be: (SLIDE 13)

1’. What do I think happens when people drink?

2’. If people drink, they fall down, slur words, act funny.

d. At 17 and after some alcohol experience expectations might be:

1’. What happens when I drink?

2’. Drinking makes me more social.

3’. If I drink, then I have a better time at parties, can relax.

2. Motives:  Reasons for drinking: I drink to _________. (Again use J) (SLIDE 14)

a. What do I want to happen when I drink?

b. I drink to feel less anxious around people, to be more social.

c. Motivational = requires that you drink yourself

B. AUD Risk is both genetic & environmental (SLIDE 15)

             1. Genes explain 50-70% 10

             2. But no single gene explaining entire risk

             3. Operate through intermediate characteristics, including:

                  a. How a person responds to alcohol (e.g., their level of response or LR)

                  b. Impulsivity (e.g., spur of moment acting without thinking of consequences)

C. Example:  Low level of response (low LR) to alcohol11–13 (SLIDE 16)

1. Focus on initial alcohol responses

2. Need more alcohol than most to get desired effect

3. Can be seen first time drink: is sensitivity, not tolerance

4. To get desired effect drinks more & spend more time drinking

5. Most friends also drink heavily/spend more time drinking

6. That changes expectations14,15

D. As noted, LR changes expectations (SLIDE 17)

1. JoAnne required more alcohol to get desired effect

2. Drank more heavily and more often

3. Associated with friends who drank more heavily

4. Developed more positive expectations for alcohol’s effects

IV. Adolescent vulnerability to AUDs (SLIDE 18)

A. Adolescent heavy drinking predicts later problems (SLIDE 19)

1. AUDs typical onsets prior to legal drinking age5

2. Not all “mature out”; 1 in 3 persistent problems6

3. At 17, JoAnne may have experienced (SLIDE 20)

a. Blackouts

b. Risky sexual behavior

c. Use in hazardous situations, e.g., driving while drunk

d. Trouble with police, e.g. minor in possession of alcohol

            4. In college, JoAnne’s positive expectations & drinking persist despite these experiences

B. Adolescent brain development18 (SLIDE 21)

1. Transform immature brain into a more efficient, mature brain      

2. Brains develop back to front

a. Emotional regions before planning regions

b. “Gas pedal before brakes”

c. Forebrain critical for restricting behaviors before targeting rewards

3. Adolescent brains focus on

a. Social interactions and peer affiliations

b. Novelty-seeking and risk-taking behaviors

C. Adolescent sensitivity to alcohol’s effects (SLIDE 22)

            1. Primarily preclinical (animal) studies

2. ↓ sensitivity aversive & impairing effects

3. ↑ sensitivity social-facilitation & rewarding effects

D. Adolescence and the development of alcohol expectancies8 (SLIDE 23)

1. Expectancies learned at early ages, prior to direct experience

2. What we think happens when we drink à later problems

3. Expectations of positive outcomes ↑ in adolescence

4. Predict intentions to drink and onset of drinking

E. Summary: Why this matters? (SLIDE 24)

      1. Drinking often starts & increases rapidly in adolescence

      3. Sensitivity to alcohol’s effects & expectancies related to AUD development

      4. Adolescent brains differ from adults

5. Adolescence sets stage for AUD development

V. Unique challenges & solutions for adolescent research (SLIDE 25)

A. Human adolescent drinking laboratory studies often prohibited (SLIDE 26)

      1. Legal and ethical restrictions

      2. Precludes real-time understanding of key components of AUD development

a. Example: What are J’s responses to alcohol in the moment in daily life?

b. Example: What are her motivations to drink at the daily level?

B. Ecological Momentary Assessment (EMA)19: Observations in daily life (SLIDE 27)

1. Repeated collection of real-time data in the real-world environment19,20

a. Evolution of delivery methods

      1’. Paper-and-pencil diaries

      2’. Repeated online surveys

      3’. Interactive voice response

      4’. Smartphones

      5’. Physiological assessment, e.g., heart rate, breathalyzer

b. Various report formats (SLIDE 28)

      1’. User-initiated or device-prompted

      2’. Types of reports (Visual scales, check boxes, forced choice, text or # entry)

      3’. Schedule (When? Where? How many? How often?)

c. Example data stream from JoAnne (SLIDE 29)

2. Benefits19,21,22 (SLIDE 30)

a. Increased “ecological” validity: study adolescents in their typical drinking settings

b. Avoids retrospective recall bias: “Here and now” rather than “There and then”

c. Not only whether alcohol à effect, but also for whom & under what conditions

VI. Clinical example (SLIDE 31)

A. Summary of JoAnne (SLIDE 32)

1. Typical teenager, well-functioning family, genetic risk for AUD

2. Insensitivity to alcohol, drinks more, associates with heavy drinking peers

3. Expectations and social norms change to be more positive

4. By 17, JoAnne experienced consequences, but positive expectations persist

5. What will her future hold?

a. Likely to drink heavily in college

b. Mature out or persistent AUD?

B. How might we intervene for JoAnne? Brief Motivational Interviewing (SLIDE 33)

1. A particular type of conversation about change well-suited for JoAnne

2. Non-confrontational, collaborative style [SEE EXAMPLE TEXT] (SLIDE 34)

3. Guide JoAnne to strengthen her own motivations/reasons to change drinking

a. Identify her + & − expectations about drinking (SLIDE 35)

b. Understand her reasons for & against drinking

c. Draw out her own motivations and goals for change (SLIDE 36)

d. Explore her ambivalence about changing her drinking (SLIDE 37)

            4. JoAnne’s Outcomes (SLIDE 38)

a. J identified goal to ↓ drinking amount & frequency but not abstinence

b. Drank socially in college, but limited amounts & no harms

c. Went on to get law degree & lives with son

C. Lecture covered (SLIDE 39)

1. Definitions of heavy drinking & AUDs

2. How AUDs might develop in general

3. Why adolescents are particularly vulnerable to AUD development

4. Unique challenges & solutions for adolescent alcohol research

5. Clinical example

D. Takeaway points (SLIDE 40)

      1. Adolescent drinking is common but not without harms

2. Adolescents are not tiny adults: differences set stage for AUD

3. Research & intervention during adolescence is key


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