His parents had the best of intentions when they handed Cameron (not his real name) his first beer at age 16 years. By supervising his drinking at home, they reasoned, they could satisfy their son’s curiosity about alcohol and show him how to drink responsibly. They thought it would help when he inevitably came across alcohol-fueled parties as an older teen. But their tactic was premature.
“It’s a myth that you can teach kids to drink,” Sharon Levy, MD, MPH, director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and associate professor of pediatrics at Harvard Medical School, said in an interview.
Teenagers, Levy noted, aren’t developmentally equipped for moderate drinking. “Adolescents are neurologically and biologically driven to tap into the brain’s pleasure centers with extreme behaviors. The neurological hardware in the frontal lobe that tempers that pleasure-seeking doesn’t fully develop until the mid-20s,” so teens often can’t put the brakes on their drinking.
Although underage drinking has steadily declined over the past decade—according to the National Survey on Drug Use and Health (NSDUH), 33.5% of teens in 2019 said they drank during the past year compared with 44.7% in 2009—the COVID-19 pandemic may have steered teenage drinking into troublesome territory. Social isolation during lockdowns likely kept some teens from drinking with friends or at parties, but for others the concentrated family time at home included a new ritual: happy hour.
A New Privilege for Teens at Home
After COVID-19 shut down the US in spring 2020, investigators with the longitudinal Parent and Adolescent Sibling Study thought it plausible that more parents would allow their adolescent children to drink at home. To learn more, the investigators surveyed 456 parents in 5 Midwestern states whose families included 2 adolescent siblings. Surveys taken during the year prior to the pandemic and then again 6 weeks into the shutdowns asked parents whether they allowed their children to drink alcohol at family meals or on special occasions.
The investigators’ recent study in the Journal of Adolescent Health reported that none of the parents had given an okay for their children to drink before the pandemic, yet 16% of them had relaxed their no-drinking rule during the shutdowns.
That the pandemic caused 1 in 6 parents to abandon a zero tolerance stance on their children drinking was surprising enough to the researchers. But even more alarming was that among the parents who allowed teen drinking, 63% permitted both their older teen—on average about 16 years old— and his or her younger sibling, at an average age of 13 years, to consume alcohol.
“Parents initiating alcohol use in younger teens is particularly worrisome, since early exposure to alcohol is associated with binge drinking and other alcohol-related problems later,” Shawn Whiteman, PhD, the study’s principal investigator and a professor in the Department of Human Development and Family Studies at Utah State University, said in an interview.
Premature drinking at home paves the way for excessive drinking at parties with friends, lead author Jennifer Maggs, PhD, professor of human development and family studies at Pennsylvania State University, added during an interview. “They have their parents’ permission to drink, they’ve developed a taste for alcohol, and they haven’t suffered any negative consequences from light, monitored drinking at home.”
Cameron’s story illustrates her point. After his parents gave tacit approval of his drinking, he binged alcohol outside of the home during high school and drank even more heavily in college. Now in his 20s, Cameron has an addiction to alcohol that has deflected his career path, for which his parents blame themselves, Levy said.
Maggs’ recent research in the UK demonstrated the risk adolescents face if they’re even younger than Cameron was when he started drinking at age 16 years. The study found that 14-year-olds whose parents allowed them to have alcohol were more than twice as likely within a year to drink heavily and binge drink than kids who didn’t get parental permission to drink. And a JAMA Pediatrics study found that 47% of people who began drinking before age 14 years experienced lifetime dependence on alcohol compared with 9% of those who began drinking at age 21 years or older.
Maggs, Whiteman, and their colleagues plan to examine whether their sample of US teens will follow a path of heavy drinking and using other substances as they get older. Additional questions the investigators want to answer are whether parents’ decisions to allow drinking was pandemic specific—a compromise during an extraordinarily challenging time or a way to prevent teens’ exposure to SARS-CoV-2 by sneaking out—and if they will continue to permit alcohol consumption at home, which could increase their children’s risk of substance use disorder.
Certainly not all teens who start drinking in their early to mid-teens—with or without their parents’ permission—develop an alcohol use disorder. “The concern isn’t that your kid had a glass of wine with you at the dinner table,” said Levy. “But when parents give kids the message that it’s okay to drink, it’s very common for teens to escalate their drinking when they are with their friends.” More than 90% of the alcohol consumed by young people is through binge drinking, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Adolescent and addiction medicine specialist Scott Hadland, MD, MPH, warned that COVID-19 lockdowns also have exacerbated existing problems for some teens. “It’s very clear that problematic substance use and substance use disorders are intensifying in teens who are suffering from mental health problems due to social isolation,” Hadland, an associate professor of pediatrics at the Boston University School of Medicine, said in an interview. When kids already are struggling with depression and anxiety during the pandemic, drinking at home with their parents’ permission only increases their risk of abusing alcohol, he added.
Also worrisome is the message teens get from parents who suddenly allowed them to have alcohol during the COVID-19 shutdown. It “reinforces the idea that during difficult times we should turn to alcohol to help us cope,” Gerrit van Schalkwyk, MBCHB, medical director for Pediatric Behavioral Health Crisis Stabilization at Intermountain Primary Children’s Hospital and assistant professor of pediatrics at the University of Utah, said in an interview. “Kids become less resilient when they understand they should be relying on substances during hard times rather than each other and their families.”
Early initiation to alcohol can harm the structure and function of the developing brain. “In adolescents who are heavy drinkers, there is evidence that the neurons in their prefrontal cortex are culled more quickly than normal and the connections to the brain stem are compromised,” George Koob, PhD, director of the NIAAA, said in an interview. These neural alterations affect impulse control, emotional regulation, and decision-making.
“Alcohol and drug use in the teen years can interfere with the development of skills to regulate emotions and behavior, which, in turn, leads to impulsivity, escalation of alcohol and drug use, and further impairment of brain development,” Craig Colder, PhD, professor of psychology at the State University of New York at Buffalo, said in an interview.
Impulsivity and poor decision-making also lead to a variety of other problems, such as using other drugs, academic difficulties, early sexual activity and risk of sexually transmitted infections, fighting and trouble with the law, injuries, and death. And the longer a teen has been drinking, the more potential damage may occur in critical brain areas. “Kids who struggle with impulse control and executive function are also at higher risk for mood disorders, attention-deficit disorders, and more difficulties at school,” said van Schalkwyk.
Prior to the pandemic, 21.3% of 12- to 20-year-olds who reported drinking said they received alcohol from a parent or other family member, according to 2019 NSDUH data. And 40.7% of kids 12 to 14 years old who drank said that a parent or other family member gave them alcohol.
Screening Teens for Alcohol Use
Pediatricians should be especially mindful now to screen their teen patients for alcohol use, van Schalkwyk said, given the pandemic-related increase in substance abuse disorders. Clinicians should also consider screening a teen’s younger siblings, who may have been allowed to drink during the COVID-19 shutdown, Whiteman added.
Citing insufficient evidence, the US Preventive Services Task Force does not advocate screening children aged 12 to 17 years for alcohol use. But the American Academy of Pediatrics advises screening adolescents for substance use at every annual physical examination, which should also include a brief intervention designed to prevent, reduce, or stop substance use. “Simply telling a teen patient that it would be best if you didn’t drink because alcohol can interfere with the development of your brain can be very effective and can motivate kids to get counseling for their alcohol use,” Levy said.
Pediatricians should also screen teens for mental health disorders, advised adolescent and addiction medicine specialist Steven Matson, MD, associate professor of pediatrics at The Ohio State University College of Medicine. “Most kids who are drinking benefit from antidepressants or antianxiety medications, so they don’t feel the need to make their lives better with substances,” he said in an interview. “It’s far easier to treat a substance use disorder in teens than in adults who develop a chronic addiction from years of drinking or using other substances.”
Screening an adolescent for alcohol use is also valuable for accurate diagnosis and treatment of other health problems, Levy said. “If an adolescent is having trouble in school, is impulsive, and is inattentive, the diagnosis might be ADHD [attention-deficit/hyperactivity disorder], or it might be substance abuse. Treatment-resistant depression may be due to substance abuse. And I would certainly want to know if a patient is using nicotine or alcohol before I prescribe medication.”
But how should parents who want to reverse course on their kids’ pandemic-related drinking break the news? It’s best if parents are honest and admit to their child that they made a decision based on the information they had at the time, but it wasn’t the right thing to do and the practice will stop, Hadland said. “Most young people will understand when a parent explains that drinking alcohol has harmful effects on a developing brain,” and that’s why it’s easier for adults than for teens to drink responsibly, he said.