Progression through early drinking milestones in an adolescent treatment sample

Although the legal drinking age in the United States is age 21, initiation of alcohol use generally occurs well before then. Prevalence of initiating drinking at age 12 or younger ranges from 23.4% to 36.8% across national surveys [1]. Drinking prevalence among “tweens” is alarmingly high, with 9.8%, 16.1%, and 29.4% of fourth, fifth, and sixth graders, respectively, reporting having tried more than a sip of alcohol [2]. Early alcohol consumption is particularly worrisome, as excessive alcohol use has acute, prolonged neurobiological effects specific to the adolescent brain [3]. In addition, early drinking initiation may interfere with cognitive and social development necessary for healthy functioning [4,5] and may also expose adolescents to risk factors that promote or sustain problem behaviors [6]. Research using nationally representative and community samples has documented associations between early onset of drinking and increased likelihood of short- and long-term adverse outcomes. Early onset is associated with greater alcohol use, problems, and alcohol use disorders [7–10]. Early onset also predicts tobacco and other drug involvement [11,12], psychopathology [12], poor school achievement [11], unintentional injury [13], violence [14,15], and suicidality [15,16]. These associations are generally observed even controlling for demographics, history of substance involvement, and normative influences. Based on risks associated with early drinking onset, many researchers conclude that a delay in debut age will lead to fewer adverse outcomes. However, some research suggests that the association between early drinking and adverse outcomes is noncausal [17] and may be a manifestation of general vulnerability to behavioral deviance [11]. Yet, length of time between first drink and a given outcome may not be as informative as drinking behavior during that interval. Although research has characterized the development of alcohol-related problems in adolescents [18,19], only limited work has examined progression through earlier drinking milestones such as regular and heavy alcohol consumption. For youth who become alcohol dependent and/or end up in treatment, understanding drinking transitions along the way can pinpoint critical opportunities for intervention. We can characterize progression through various landmark events, or “milestones,” by exploring the time to attainment of these milestones. Little attention has focused on the nature of progression through different drinking events [20]. One exception is work on the telescoping of problematic alcohol use in treatment-seeking women. Progression from use to abuse/dependence is accelerated in women [20–22], with a shorter latency between first or regular use and problematic use/dependence. This has been labeled “telescoping” (a term adopted by the present study), which is not to be confused with “forward telescoping,” the tendency to report events to have occurred closer to the assessment than is true [23]. Few studies have examined sex differences in drinking milestones that precede alcohol dependence. Although Piazza et al. [22] found in a treatment sample that women had a shorter interval between first alcohol-related problems and treatment seeking than men, they found no sex difference between the earlier milestones of first drink and first drunk. Johnson et al. [24] noted that progression between any drinking and drinking to intoxication in a treatment sample was accelerated in women. In that study, progression was also accelerated in Blacks, suggesting race differences in telescoping as well. Similarly, Hesselbrock et al. [25] found in alcohol dependent inpatients that Whites had earlier age of first alcohol use but Blacks had earlier onset of alcohol problems. Youth vary both in age of first drink and age of treatment entry. Although early age of first drink confers risk for alcohol dependence, it may not necessarily indicate rapid progression to alcohol dependence. Early age of first drink may be associated with a more rapid uptake, as suggested by work indicating common influences underlying onset and heavy or problematic drinking [17,26]. However, progression (at least, initially) could be slower in those with early initiation due to limited social and physical availability at a young age. In a study exploring progression from first use to alcohol abuse and dependence in a general population sample, more rapid escalation occurred for those with earlier onset (age 11–14) [5]. In contrast, progression from first full drink to alcohol dependence was slower for adolescents with early first drink in high-risk [27] and community samples [28]. There may be a developmental period of risk independent from years of exposure [27,29]. Another study using a high-risk sample demonstrated greater telescoping from first drink to alcohol use disorder among those who began drinking later (≥ age 14) [30]; the authors suggest telescoping is due to the socio-contextual environment of later adolescence with normative peer drinking, accessible alcohol, and stronger imitation of adult behaviors such as heavy drinking. Although early onset may indicate a propensity for problematic alcohol involvement, this propensity may not manifest itself until conducive conditions are present later in adolescence [29]. Examination of the progression from first drink to milestones that precede alcohol dependence would help pinpoint whether there is a key developmental period of risk.