1) Let’s start with some basic physiology and some definitions

How does alcohol affect the body?

Alcohol works on many organ systems in the body to produce its effects. It is absorbed quickly from the stomach (within minutes) and carried to all parts of the body through the bloodstream. Broadly speaking, there are approximately 10 grams of alcohol in one drink, with one drink being one 12-ounce bottle of beer, 5 ounces of wine (about one glass), or 1.5 ounces of 80-proof liquor — this is around the amount of vodka in a “standard-sized screwdriver.” However, keep in mind that drinks are different in potency as the alcohol strength and content differs. One drink will increase the blood alcohol concentration (BAC) in an average person roughly about 20–25 mg/dl or between 0.020 and 0.025 percent, but this is extremely variable and depends on an individual’s body weight, gender, tolerance, food status, and the period of time during which the alcohol is drunk. For example, women, who may be smaller and have less total body water than men, may have higher BACs than men after consuming similar amounts of alcohol. Also, eating food could slow the entry of alcohol into the bloodstream. Drinking on an empty stomach may cause a person to become intoxicated more rapidly. Also, it is important to be aware of the fact that all mixed drinks are not the same.

“Some drinks, such as martinis, can have a significantly larger amount of alcohol than others, and yet are often considered ‘standard’ drinks.”

What is alcohol intoxication?

Legal intoxication for driving is defined as a blood alcohol concentration of 0.08 percent (blood alcohol level of 80 mg/dl).⁹ Zero-tolerance laws make it illegal in many states for anyone under the age of 21 to operate a motor vehicle with a blood alcohol concentration of more than 0. Other states allow a BAC of up to 0.02 percent.

Alcohol’s primary effect is on the brain. It produces a condition called alcohol intoxication. Initial effects are a lowering of inhibitions and a feeling of pleasure; many adolescents report that alcohol relieves tension and makes them feel more relaxed and more socially at ease. These effects usually occur with blood levels between 0.05 and 0.10 percent, but in many teens are felt after just one drink. Later symptoms of alcohol intoxication, with blood levels between 0.10 and 0.20 percent, include impaired coordination, irritability, slurred speech, poor balance and delayed reflex time. Most teenagers at this stage are visibly drunk – they may stagger and have trouble expressing themselves. Nausea and vomiting are common. Although alcohol is a central nervous system depressant, paradoxically, adolescents, when drunk, can often be loud and aggressive. However, it is important to note that many adolescents who have been drinking will not have the obvious signs of “being drunk,” but will nonetheless suffer many physical and psychological effects.

As blood alcohol concentrations increase to levels in excess of 0.20 percent, confusion and decreased concentration can occur. As more alcohol is ingested, people become sleepier and slower; body functions, including breathing, can become dangerously depressed. Extreme sleepiness, slow shallow breathing, or an inability to be awoken are red flags for severe alcohol intoxication; immediate medical attention may be necessary at this stage.¹⁰

What is alcohol poisoning?

At or above alcohol levels of 0.30 percent, the water and salt concentrations in the body become critically imbalanced. In spite of drinking a lot of liquid, an intoxicated person may become dehydrated. On examination, an alcohol-poisoned youth may have pinpoint pupils and slow breathing. Low blood pressure and decreased heart rate are also present with high alcohol levels. An intoxicated person may vomit and then choke on this vomit and suffocate. Coma can occur at higher levels; blood alcohol levels above 0.40 percent can be lethal.

What is binge drinking?

This term has generally meant drinking a lot of alcohol in a short period of time. Most experts now define binge drinking as drinking five or more drinks in one stretch of time for males, and four or more for females.¹¹ However, this definition does not take into account the time period during which the drinking occurs (some teens will drink their drinks quickly over several hours, and others may sip them over the course of an entire night). Blood alcohol concentrations can certainly vary, but impairment is probable with binge drinking.

How do you know if a teen is experiencing problem drinking?

Although all alcohol use in adolescents is illegal, certain situations are cause for immediate alarm. When a teen drinks more than he/she feels comforable with and feels guilty about it, when a teen loses control over the amount or frequency of drinking, when a teen blacks out (loses memory) and does something regrettable, when a teen vomits and embarrasses him/herself, when a teen engages in regrettable/unsafe sexual experiences — all of these are examples of problem drinking. Certainly, the need for an early morning drink indicates dependence. Binge drinking, too, is usually viewed as problem drinking, as is daily drinking or drinking when alone. Particularly for teens with a family history of alcoholism, problem drinking may be a red flag that can signal future substance abuse problems. Also, for teenagers who may be depressed or suffer from other psychiatric disorders, alcohol use may become problematic if it becomes a means for self-medication.¹²

Medical signs of problem drinking are rare in teens. Occasionally, adolescents who drink to excess may complain of morning headaches and fatigue and some may develop stomach irritation, peptic ulcer symptoms, or even inflammation of the pancreas. Behavioral signs are much more common and may include school truancy and failure, lethargy, mood swings and depression.

What is alcohol tolerance?

This is when a drinker needs more and more alcohol to achieve a particular state of intoxication. Someone who drinks regularly may notice that the usual amount of alcohol no longer gives the desired feeling of intoxication, and that it takes more alcohol to feel the effects of drinking. Significant tolerance is often seen in the condition of alcohol dependence.

What is alcohol dependence?

This is a medically worrisome condition that may predict more long-term, serious medical and psychological consequences related to chronic drinking. It occurs when at least three of the following conditions or behaviors are present:

• tolerance
• withdrawal
• habitually drinking more than was initially intended
• constantly desiring to cut down or control the pattern of drinking
• spending a lot of time drinking or recovering from the effects of alcohol
• finding that normal social, recreational, educational or occupational activities are being given up in pursuit of alcohol
• continuing to drink in spite of knowing how detrimental it is to one’s health and life

What is alcohol withdrawal?

This condition may occur if a chronic drinker either slows down or stops drinking completely, and is related to a drop in blood alcohol level. Withdrawal usually begins several hours after a chronic drinker’s last drink. Tremors, known as “the shakes,”may be present within the first two days. This may be accompanied by high blood pressure, rapid pulse, nausea, vomiting and intense anxiety. Seizures are possible in the condition of alcohol withdrawal, and may occur approximately 24 hours after last alcohol use.

What is alcoholic withdrawal delirium?

This is a serious withdrawal syndrome, also known as delirium tremens or DTs, that usually occurs after daily alcohol use and years of dependence. It is quite rare in teenagers because most have not been drinking for long enough. There is a significant death rate (approximately 20%) associated with this condition. Agitation, insomnia, tremors, confusion, fever and delusions are usually present. The hallmark of this delirium is the presence of vivid and usually frightening visual hallucinations.

2) Effects of alcohol on the body — by organ system

The Brain

Alcohol causes central nervous system depression — it slows down all the functions of the brain. As adolescents’ brains are still developing, alcohol may interrupt important processes, leading to a decrease in thinking ability. Alcohol seems to affect a part of the brain called the hippocampus — a part of the brain responsible for learning and memory, making it less likely to fully develop. The hippocampus has been noted to be smaller in adolescents who are alcohol dependent. Possible learning disabilities in the adolescent brain can result. Alcohol use has been linked to impairment in thinking, short-term and long-term memory problems, cerebellar degeneration (a wasting away of the part of the brain responsible for balance), and peripheral neuropathy (nerve problems causing numbness and pain). Long-term use may result in dementia; this may be related to nutritional deficiencies from chronic drinking. Korsakoff’s syndrome is a type of dementia seen in alcoholics related to a deficiency of one of the B vitamins called thiamine.

The Cardiovascular System

Low heart rate and low blood pressure are seen in intoxication; rapid pulse and high blood pressure occur during alcohol withdrawal. Various heart conditions such as arrhythmias (irregular heartbeat), cardiomyopathy (a sickness of the muscles in the heart), and hypertension (high blood pressure) occur with long-term chronic use.

The Stomach

Alcohol is toxic to the stomach lining and may result in inflammation of the lining (gastritis) or even ulcer disease. Esophageal varices (these are swollen blood vessels in the esophagus — the upper swallowing tube) can occur with liver cirrhosis; this may cause a person to vomit blood. Mallory-Weiss tears are esophageal tears that occur from forceful vomiting. Certain gastrointestinal cancers are linked to long-term alcohol use, such as cancer of the esophagus, which is even more common when alcohol use is combined with chronic cigarette smoking.

The Liver

Alcohol is broken down in the liver. Alcohol use has been related to the conditions of fatty liver, alcoholic hepatitis and cirrhosis. Some of these syndromes may cause abdominal pain; others may exist without symptoms until the end stages. Severe cirrhosis can present as jaundice (yellow skin and eyes), bloated stomach and vomiting of blood.

The Pancreas

This is a small organ that secretes digestive hormones and insulin. Chronic alcohol use can result in pancreatitis (a toxic inflammation of the pancreas). Symptoms are nausea, vomiting, and a severe pain that occurs when anything is eaten. Pancreatitis can lead to weight loss and malnutrition.

The Blood

Anemia (or low blood count) is common in patients who use alcohol chronically; this is related to blood loss from bleeding and gastritis, as well as folate and vitamin deficiency. Low platelets from alcohol’s toxic effect on the bone marrow can result in easy bruising and bleeding. Prolonged alcohol use also affects the immune system and causes increased susceptibility to infection.

The Skin

Flushing of the skin occurs during alcohol intoxication and sweating during withdrawal syndromes.

The Reproductive System

Alcohol use has been related to inability to have an erection in males, and long-term use can decrease the sperm count. Some studies suggest that cancers of the breast and prostate may be associated with chronic alcohol use.^13,14 Women who are pregnant and drink have a risk of bearing a child with a congenital problem called “fetal alcohol syndrome.”

Psychiatric Effects

Anxiety and depression have been linked to alcohol abuse. As alcohol can lower inhibitions,
adolescents who are depressed and under the influence of alcohol may even attempt suicide. Delirium, hallucinations and psychosis are seen in severe alcohol withdrawal syndromes.

1) Tempering the conversation to an adolescent’s stage of development

Just as adolescents go through the tumultuous progression of physical changes that comprise puberty, they also develop, both cognitively and psychologically, in a progressive manner. Adolescent Medicine specialists tend to divide the teen years into three stages: early (approximate ages 11–14 years), middle (ages 15–17 years) and late (ages 18–21...although some young people remain adolescents, psychologically, way into their 20s!). These psychological stages are marked by characteristic developmental phenomena with respect to body image, cognition, dependence/independence issues, peer interactions and identity development. And if and how a teen chooses to engage in risky behaviors, or respond to peers’ risk-taking behaviors, depends on where he/she is psychologically at the moment.

Any conversation an adult has with an adolescent must take into account where that teen is psychologically and cognitively. And to further complicate matters, where a teen is physically may not correspond to where he/she is psychologically. For example, a physically mature-looking teenager who is cognitively immature may be at particular risk of finding him/herself in an uncomfortable social situation because people may think that he/she is, in fact, older. Recognizing this and talking about it before it occurs is an important way an adult can help a teen develop the skills to manage these challenging experiences.

2) The Early Adolescent (Ages 11–14)

Early adolescents tend to be teens who struggle with body image concerns as they maneuver their way through the beginning stages of puberty. They are preoccupied with themselves and their changing bodies, often magnifying their imperfections, and they may walk around feeling as if they are at “center stage.” Their behavior can be erratic as they start to struggle with emancipation issues — one minute slamming their door and insisting on independence and privacy, the next minute running to their parents for comfort. Peer acceptance begins to be important to them; kids at this stage tend to want to dress and act like their friends, and looking different or individualistic is undesirable. However, early adolescents are still at the stage when crazy, risk-taking behaviors can seem ridiculous and self-destructive.

Early adolescents are often idealistic, questioning, critical of their environment, and quick to call adults hypocrites if what they observe adults saying and doing don’t match. It is important for adults to understand, though, that cognitively, these young teenagers are still concrete thinkers, and are often unable to conceive of the future consequences of present actions.

A young teenager may ask:
What is so bad about alcohol — it’s legal isn’t it?
And you drink sometimes...

You may answer: “Yes, it’s legal — but for anyone over 21.” Teenagers’ bodies and their minds are still maturing, and alcohol affects all parts of the body, especially the brain. Teenagers who drink often can’t handle the effects of alcohol. They may have trouble thinking clearly and show really poor judgment — and make serious mistakes. They also can lose their balance and have impaired coordination. People who drink alcohol often lose control, and teenagers can do really stupid things when they lose control.

“Any conversation an adult has with an adolescent must take into account where that teen is psychologically and cognitively.”

Why do people drink? They look sloppy when they do, and they smell like alcohol...

Remember — children at this age are quite concrete, and discussing the obvious negative physical effects of alcohol may make more of an impression than talking about the more abstract long-term physical and psychological consequences of underage drinking. So, yes, this might be a time to explore the young adolescent’s concrete perceptions of drinkers. Have they seen teenagers who were drunk, and who vomited, smelled bad, and made fools of themselves? Have they heard about car accidents in which teenagers were driving while intoxicated? It is never too early to begin talking to teens and sharing real stories about why underage drinking is dangerous to health and safety.

This also might be a good time to talk about peer pressure, and what some teenagers may do to fit in. Explore ways to resist peer pressure and provide answers that they can offer to friends who are pressuring them to do something with which they are not comfortable.

Early adolescence is a good time to give teens concrete strategies for negotiating uncomfortable situations. For example, if someone offers them a drink and they feel uncomfortable saying “no,” you can suggest that they just hold the drink and not drink it, or quietly pour it out. Also, tell them that they can always call home asking for help, and blame it on their parents.

3) The Middle Adolescent (Ages 15 – 17)

Teenagers during the middle adolescent years struggle more with peer relationships and independence from their parents. Physically, many of these kids have completed puberty and have adult-type bodies with which they are becoming comfortable. However, psychologically, many changes are in process. The search for peer acceptance, the struggle for independence from parents, and the testing of limits can consume these years, and make middle adolescence a challenge for any parent. Cognitively, these teenagers tend to bounce back and forth between concrete and abstract thought. They are just beginning to sense that there are future consequences for present actions; however, in spite of this, they still consider themselves omnipotent and invulnerable — immune from harm. These are the “it can’t happen to me” years, often dominated by risk-taking and experimentation. Many of the serious problems of adolescence, associated with experimentation with drugs, tobacco, drinking and sexual activity, occur during these years as teens seek to define their own identities. Additionally, psychological problems, such as depression, may manifest themselves during the middle-adolescent years, and teenagers may attempt to self-medicate using drugs or alcohol.

“Parents and adults need to keep up an ongoing dialogue with the teenager throughout adolescence.”

What kind of conversations can be had with a middle adolescent?

During these years, fitting in with peers and rebelling against parental figures becomes the norm. Teens may pretend that they don’t value your opinion, but they really do! Often, the conversation will have to take place on the teen’s terms — at whatever moment they will give you their attention. A wise adult will create opportunities for this to happen. Perhaps these conversations will occur while driving in the car together (when the adolescent is not looking at you directly), or during dinnertime, or late at night, right before the teenager goes to bed.

Teens may appear to share less during these years; however, it is crucial for the adult to step back, be available for conversations, and be tuned in to hints that the teen is willing to discuss these issues. Mutual respect is key. Try not to talk down to the teenager; offer your opinions and beliefs in as non-patronizing a manner as possible.

Statement: There’s nothing wrong with drinking — everyone does it!

Oftentimes, the teenager is fishing for your response and hoping you can offer a sound rebuttal that he/she can use in the future. You may need to ask the questions in order to enable the teen to sort out his/her beliefs: Who is everybody? How do they handle their alcohol? Have you seen anyone get into trouble after drinking? What happens to people who don’t drink; are they mocked or ostracized, or are they respected? Do you respect kids who stick up for what they believe in?

This is also the time to offer the facts in more detail — middle adolescents are usually mature enough to understand them. You can talk about the physiological effects of alcohol on the body, especially the brain, as well as the consequences of alcohol misuse.

Because kids are more independent during this stage, it is not unlikely that they will find themselves in social situations where they will need to rely on their own judgment to make their own decisions; the parent’s role is to facilitate smart decision-making.

4) The Late Adolescent (Ages 18–21)

The late adolescent is usually physically and cognitively mature. Pubertal development is complete and adult height has been attained. Teens at this stage can usually think abstractly and reason logically, and have enhanced memory and decision-making skills. Many of the crazy, risky behaviors of middle adolescence have abated, and the teen is usually seen as more serious and goal-oriented. These may be the college years, and/or the early working years. Psychologically, the teen has begun to reintegrate certain family and peer values into a personal code of behavior. Identity formation is usually settled, as these older adolescents come to terms with who they are and where they are headed.

What kind of conversations can you have with a late adolescent?

Often, late teens will not ask you the questions; they may believe that they know more than you (and in some respects, they may be right!). You may need to ask them the questions, and then gently guide them as they struggle with the answers.

What can you ask them? Have you ever drunk any alcohol? What’s the most you drank at any one time (over a period of hours or during an evening/night)? Have you ever been drunk? Do you think alcohol use can be dangerous? How? How do your friends act when they drink? Have any of your friends ever lost control and done something that they regretted later? Has anyone ever gotten into a fight, or been involved in a car accident, or taken risks after drinking? What do you think about it? If one of your friends was drinking and then got into trouble, how would you help? What would you do if you needed to get home, but the driver who was supposed to bring you home had been drinking?

For teenagers who go away to college, campus drinking is often a fact of life. Although many who drink are above the age of 21, younger undergraduates will find themselves in settings around drinking or with easy access to alcohol. Many will also be away from home for the first time and will use their newfound freedom to experiment and engage in behavior that was considered off-limits while in high school. Unfortunately, drinking — and sometimes heavy drinking — is common on college campuses; college students tend to drink in order to get drunk. The harmful consequences of this type of drinking (unplanned and unprotected sexual activity, assaults and car accidents) are similar to those of high school drinking; however, they may be more common on college campuses where parents and authority figures are less present. It is important to speak frankly with the older adolecent about how he/she will react to the possibility of college alcohol use. Preparing strategies for safety, in advance, can be helpful. Learning how to access student health services and discovering the channels for reporting safety issues within the college system can be helpful ways to prepare a teen for potentially dangerous situations.

“For teenagers who go away to college, campus drinking is often a fact of life.”

For older adolescents who do not go to college but live at home or on their own, the issues may be similar. The risks of underage drinking are the same, and although more adults may be present in these childrens’ lives, older teens may feel independent and reluctant to listen to parents. When children reach the age of 18 and are legally emancipated, they believe they are grown up and may resent when parents or other adults try to tell them how to behave. You must still try to have these conversations — but remember, older teens may think they know more than you do. Again, it may help to ask them their opinions rather than speak down to them or lecture them, and then help them figure out ways to avoid illegal and unsafe behavior.

Driving is more common among older adolescents, and so the risk of alcohol-related car accidents increases in this age group. Alcohol seems to impair the driving skills of teenagers to a greater extent than adults. This may have something to do with teens’ relative lack of tolerance to the effects of alcohol, as well as with their overall inexperience with driving. The alcohol-involved fatality rate is twice as high among adolescents as among adult drivers. The raising of the legal drinking age to 21 from 18, as well as the enactment of zero-tolerance laws for adolescent drinking, are legal measures intended to prevent alcohol-related driving accidents. Older children need to know this; sharing the facts can help.

Last Thoughts

Anyone under stress may regress psychologically. Mature adolescents may intermittently think like younger teens and revert to more immature behavior; subsequently, they may have holes in their decision-making capabilities when they are in new, stressful situations. An adult’s role can be to listen carefully, offer guidance, allow the teen to be frank, and then help them learn from any mistakes they may have made. Know the facts and share them. Using these facts, you can help the teenager prepare strategies in advance to deal with potentially illegal and dangerous situations.

And Remember

Parents and adults need to keep up an ongoing dialogue with the teenager throughout adolescence. They need to revisit issues as they come up, tailoring their approach according to the adolescent’s psychological stage and circumstances. Parents and adults are not powerless. They have much to offer in helping teens navigate through the adolescent years safely.

Author

Karen Soren, MD
Associate Clinical Professor of Pediatrics and Public Health,
Columbia University Medical Center
Director of Adolescent Health Care,
Morgan Stanley Children’s Hospital of NewYork-Presbyterian

Health Alliance on Alcohol

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