While many factors contribute to the availability and acceptability of alcohol in a community (cultural, economic, legal, etc.), probably the single, most influential factor that relates to alcohol consumption in adolescents is the attitude of the adult community in the particular geographic location (see review by Newcomb, 1997). For example, the purchase of alcohol by underage drinkers is prohibited in all 50 states. However, in some places, the laws are not regularly enforced by police officers, and the liquor stores and bars do not consistently require identification from minors (Windle, 1999). Underage drinking at family gatherings or special celebrations may be acceptable to parents and relatives in some communities. An in-depth examination of the relationship between community attitudes and alcohol availability (economic and le

gal) is of paramount importance but beyond the scope of this book.

Interpersonal factors that relate to AUD risk are parental (referring to other than heredity), sibling, and peer influences. Despite waning parental influence with the passage of time, parents' level of nurturing, monitoring, communication, and their own alcohol use affects the amounts and patterns of alcohol drinking in their adolescents (see reviews by Gilvarry, 2000; Liepman et al., 2002; Schulenberg & Maggs, 2002; Windle, 1999). That is, although adolescents may reject many of their parents' ideas and behaviors, the majority do not seem to reject their parents' drinking behaviors. Higher levels of maternal and paternal alcohol consumption are related to higher levels of alcohol use among adolescents (e.g., Kilpatrick et al., 2000; Webb & Baer, 1995). However, parents can have a positive influence on their adolescents. Higher levels of emotional support and warmth (nurturance), higher levels of appropriate monitoring and limit setting, more time spent together, and higher levels of parent–adolescent communication have been associated with lower levels of adolescent alcohol-related problems (Windle, 1999).

Siblings represent another familial influence. Older siblings typically serve as role models and there is a greater likelihood that younger siblings will drink alcohol before they are adults if their older siblings drink. This relationship is stronger if the older sibling is closer in age and the same gender (Windle, 1999).

The commonly held notion that peers exert considerable influence on the initiation and maintenance of alcohol use is sustained empirically (Schulenberg & Maggs, 2002). But there is little support for overt peer pressure causing the initiation of alcohol use. Rather, most studies support a more complex, developmental interactional process in which an adolescent selects and unselects peer groups. The individual is influenced by the course of behaviors and attitudes of these groups and in turn influences them (Schulenberg & Maggs, 2002). However, overt peer pressure can play a role in relapse (Brown, 1993).

Newcomb (1997) cites age of onset and comorbid psychopathol ogy as primary psychobehavioral influences in alcohol use. An earlier age of first use of alcohol is frequently associated with increased alcohol-related problems then and later in life. But it is not clear whether excessive drinking in early adolescence is a marker of serious preexisting or coexisting psychopathological factors (e.g., fractured gene pool, flawed personality, poor parental modeling, nurturing, monitoring, etc.), or, alternatively, whether excessive alcohol drinking in adolescence introduces a “toxin” that negatively impacts a person who is still experiencing a critical period of growth toward adulthood.

Recently, Ellickson, Tucker, and Klein (2003) published a 10-year prospective study in which students recruited from 30 Oregon and California schools were assessed at grades 7 and 12, and then later at age 23 (N = 6,338, 4,265, and 3,369, respectively). Young drinkers in both middle school and high school, compared to nondrinkers, were more likely to report academic problems, delinquent behaviors, and other substance use. At age 23, compared to nondrinkers, those who had been adolescent drinkers were more likely to report employment problems, continued “other” substance abuse, and criminal and violent behaviors.

These findings were supported by several retrospective reports as well. According to adults interviewed as part of the National Longitudinal Alcohol Epidemiological Survey, Grant and Dawson (1997) found that over 40% of adults who had reported using alcohol before age 14 had developed alcohol dependence later in their lives. This compared to a rate of less than 10% of alcohol-dependent adults who said they did not start drinking alcohol until after the age of 18. Also, DeWit, Adlaf, Offord, & Ogborne (2000) examined a larger health survey of adult reports. Of 5,856 drinkers, 501 had a DSM-IV diagnosis of lifetime alcohol abuse, and 473 had a DSM-IV diagnosis of lifetime alcohol dependence. Approximately 13.6% of the respondents who said they had their first drink between 11 and 14 years of age met diagnostic criteria for alcohol abuse 10 years later. This compares to only 2% of alcohol abusers who said they had had their first drink after the age of 18. These rates were parallel in adults diagnosable with alcohol de

pendence. That is, 15.9% of the respondents who said they had their first drink between 11 and 12 years of age reported alcohol dependence 10 years later. In comparison, those who said they had their first drink after age 18 represented only 1% of the respondents.

Comorbid psychiatric disorders frequently co-occur with AUDs (Deas & Thomas, 2002; Gilvarry, 2000), but it is often difficult to distinguish etiological from consequential associations. For example, it is easy to imagine that a psychiatric disorder can result from continual, excessive alcohol consumption, especially in a physiological and psychological developmental period such as adolescence. In this example, the AUD would precede the comorbid disorder. Another scenario, however, is drinking alcohol to treat the symptoms of a psychiatric disorder; this is called “self-medication.” For example, an individual with a social phobia may desire the relaxing and disinhibitory effects of a few drinks prior to attending a social gathering. In this case, if an AUD is identified, it is likely that the comorbid disorder preceded the AUD. Finally, both AUD and a psychiatric disorder may have the same etiology (e.g., genetic, neurochemical). Naturally, an understanding of the etiology of both concomitant disorders can guide treatment decisions.

Behavioral disorders, mood disorders, and anxiety disorders have been frequently associated with AUDs (Deas & Thomas, 2002; Gilvarry, 2000). Attention deficit-hyperactivity disorder (ADHD) has been associated with AUDs, but its independence from conduct disorder (CD) has not been well established (Gilvarry, 2000). In a 4-year longitudinal study of ADHD children and controls (6 to 15 years old), there was no difference in the prevalence of AUDs between youths with and without ADHD (Biederman et al., 1997). Conduct disorder proved to be a significant predictor of AUDs in the target and control groups. In another study, Moss and Lynch (2001) used structural modeling to illustrate an association between ADHD and AUD for adolescent males but not females, yet CD symptoms had the strongest association with AUD in adolescents.

As implied above, there is strong empirical evidence relating CD and similar disorders (e.g., oppositional defiant disorders [ODD]) with AUDs (Clark, Vanyukov, & Cornelius, 2002). Clark, Bukstein, and Cornelius (2002) provide convincing evidence that childhood antisocial behaviors precede and predict adolescent AUDs. They argue that the association between the behavior disorders and AUDs is best understood as manifestations of common underlying causes. These include poor behavioral regulation (possibly related to prefrontal cortex abnormalities), common genetic pathways (for instance, genetic variations influencing the dopamine system), and similar environmental factors (for instance, low levels of parental monitoring). Early identification and intervention efforts for these individuals with childhood antisocial behaviors may ameliorate later AUDs.

In adults, a person with alcohol dependence is nearly four times more likely to have major depression than a person without alcohol dependence (Petrakis, Gonzalez, Rosenheck, & Krystal, 2002). Gilvarry (2000) reported that up to one third of adolescents in addiction treatment facilities are diagnosed with mood disorders, especially major depression and dysthymia. Deas-Nesmith, Campbell, and Brady (1998) reported that 73% of inpatient adolescents who used substances met diagnostic criteria for depression. Furthermore, in 80% of those cases, the depressive symptoms predated the substance use, suggesting that the mood disorder for these adolescents was an important risk factor for developing a subsequent AUD. In the Biederman et al. (1997) study, bipolar disorder predicted substance use disorders, independent of ADHD. Although not all studies have found that mood disorders predate substance use disorders (e.g., Rohde, Lewinsohn, & Seeley, 1996), these observations suggest that mood disorders may be a risk factor for developing an AUD in some adolescents.

Anxiety disorders, especially social phobia and posttraumatic stress disorder (PTSD), may also be risk factors for AUDs. Rohde and colleagues (1996) reported that alcohol use among female high school students was associated with anxiety disorders that preceded the alcohol problems. Deas-Nesmith, Brady, and Campbell (1998) found that 60% of adolescents seeking treatment for addiction met diagnostic criteria for a social anxiety disorder. Furthermore, the

anxiety symptoms generally predated substance dependence by about 2 years.

Posttraumatic stress disorder has also been implicated as a risk factor for AUDs. Kilpatrick and colleagues (2000) explored PTSD as a risk factor for substance use problems in adolescents. These investigators found that physical or sexual abuse, assault, or the witnessing of violence (e.g., murder, sexual assault) increased the risk of abuse of several illicit drugs, including alcohol. In another study, Clark et al. (1997) found that adolescents with an AUD were more likely to have a history of physical and sexual abuse compared to an adolescent control group. Furthermore, the association of PTSD and alcohol dependence was stronger in females than in males.