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Keywords:

  • Age at first drink;
  • alcohol;
  • alcohol expectancies;
  • dependence;
  • development;
  • treatment

Alcohol remains adolescents' drug of choice and most have consumed alcohol by 12th grade [1]. Underage drinkers risk adverse consequences ranging from death and injury to physical/sexual assault, academic problems and possible persistent neurological impairments [2]. Moreover, earlier age of first drink (AFD) predicts increased risk of later alcohol dependence [3–5]. Additionally, rather than a problem of middle age, alcohol dependence peaks in incidence [6] and prevalence [7] in late adolescence/early adulthood. Collectively, these findings have focused attention upon early initiation of drinking as an indicator of risk for later alcohol and alcohol-related problems and suggested that delaying AFD might reduce the prevalence of dependence. It is equally clear, however, that the path from first drink to treatment/dependence crosses many bridges during a time of great developmental change in many areas.

The drinking career begins with the first real drink of alcohol [8] but, although necessary, that first drink is not sufficient to lead to treatment/dependence in late adolescence; escalation is a multi-step process that occurs in the context of a wide range of developmental changes [9]. Jackson [10] extends work by Grant & Dawson [3,4] and Sartor et al.[11], among others, and begins to articulate a developmental perspective regarding the AFD/dependence relationship by exploring adolescents' progression from initial drinking to treatment/dependence via a series of milestones [i.e. first intoxication, persistent monthly drinking, increased occurrence of weekly or persistent daily heavy episodic drinking (HED)] in adolescents in treatment. Consistent with previous work, earlier AFD increased the probability of alcohol dependence diagnosis, but was associated with slower progression through intermediate drinking milestones than later-onset adolescents. This suggests that the propensity for developing dependence must be considered in light of the emergence of other developmental considerations [8], and that potential neurological and social disruption associated with early AFD may influence the ultimate emergence of dependence but not to rapidity of progression. Girls reached early milestones later but showed accelerated achievement of later milestones, again due perhaps to specific social and physical developmental processes. Patterns for ethnicity were also complex; Caucasian teens showed overall accelerated progression, while African American teens began later and more slowly, but progressed more rapidly on more severe milestones (from weekly to daily HED).

Fleshing out the complex picture of timing and acceleration through intermediate milestones on the path from early AFD to treatment/dependence acknowledges the close link between drinking across this period and other developmental processes, a step considered essential ‘. . . for successfully preventing and treating the causes, problems, and consequences associated with excessive alcohol consumption’ ([9], p. S286). Examining the role of gender, ethnicity and age of onset in this aspect of development enhances the potential for risk prediction and effective targeted prevention.

Clearly, Jackson's [10] observation of one possible developmental path from AFD to treatment/dependence engenders as many questions as it answers. The use of archival retrospective data from a clinical sample provides a limited view of this process, albeit an important one; adolescents in treatment vary in pace and progression through drinking milestones, as well as end-point, as a function of gender, ethnicity and AFD; but might other milestones be more central to the development of alcohol use and problems? Additionally, many factors, co-existing with alcohol use, might increase the likelihood of treatment. Both referral to treatment and assignment of polythetic (and ever-evolving) diagnosis can result from a variety of symptom patterns. Hence, a wide constellation of behaviors might lead to treatment or diagnosis. Early initiation may be one in a constellation of risky behaviors that put a teen ‘on the radar’—any one of which increases likelihood of treatment or diagnosis.

As important as it is to explore the drinking landscape that treated adolescents traverse, it will also be informative to examine divergence along this path; many who drink early leave this path. How generalizable is this set of milestones? What processes predict protection from early initiation, continued or accelerated progression, or dependence or treatment? In this regard, a number of candidate mediators (or alternative milestones) exist, such as changes in alcohol expectancies during adolescence [12], which might also suggest targets for prevention [13].

Adolescents taking their first ‘real’ drink of alcohol early are at increased risk for later problems. Jackson [10] delineates one set of potential developmental steps intrinsic to that path; a path that runs concurrently with a wide range of developmental changes. With increased knowledge of who starts when and how they progress among a sample in treatment, this process can be embedded in the larger developmental landscape and tracked more broadly, hopefully identifying specific target groups, trajectories and other milestones and transitions as deflection points ripe for intervention.

References

  1. Top of page
  2. Declaration of interest
  3. References