Journal of Substance Use, February 2009; 14(1): 49–60 ORIGINAL ARTICLE
Assessing alcohol‐involved adolescents: Toward a developmentally‐relevant diagnostic taxonomy
M. A. FELGUS1, S. B. CALDWELL2, & V. HESSELBROCK3
1Department of Psychiatry, University of Wisconsin Medical School, Wisconsin, USA, 2Adolescent Alcohol/Drug Assessment Intervention Program, University of Wisconsin Hospital & Clinics, Wisconsin, USA, and 3Department of Psychiatry, University of Connecticut School of Medicine, Connecticut, USA
Abstract
Although recent assessment and diagnostic advancements have been made to better reflect the developmental uniqueness of alcohol-involved adolescents, there remains lacking a comprehensive taxonomy to describe the diversity of this large and often at-risk population. This paper presents a taxonomy comprising five typologies of adolescent drinkers based on a continuum of use severity. Each typology is described in terms of alcohol consumption variables, salient risk factors for alcohol problems, and problem symptoms. We argue that the taxonomy provides a useful heuristic for clinicians conducting assessment or screening with alcohol-involved adolescents, and we offer conceptual improvements for making the DSM-IV Alcohol Use Disorder criteria more developmen- tally relevant to adolescents. Implications for matching typologies to service levels are discussed.
Keywords: Adolescent, alcohol use, taxonomy.
Alcohol use among adolescents in the US is ubiquitous. By 12th grade 76.8% of high school students report at least one lifetime episode of alcohol use (Johnson, O’Malley, Bachman, & Schulenberg, 2004). A growing consensus among experts suggests that experimental alcohol use by teens reflects developmentally normative behaviour (Newcomb, & Bentler, 1989; Shedler, & Block, 1990; Milgram, 2002). Although most teens who use alcohol do not develop clinically significant problems (Martin, & Winters, 1998), there is a subgroup who do. In a nationally representative sample of adolescents aged 12–17, 11% met diagnostic criteria for an Alcohol Use Disorder (AUD; Kilpatrick, Acierno, Saunders, Resnick, Best, & Schnurr, 2000). Adolescent AUD is associated with poor academic achievement, co-morbid psychopathology, risk for sexually transmitted diseases, and threats to health and psychosocial development (Clark, 2004). Moreover, these and related problems can persist into adulthood creating great costs to individuals and society.
A recent proliferation of screening and assessment instruments has allowed better identification of adolescent AUDs [e.g. Leccese & Waldron, 1994; Center for Substance Abuse Treatment (CSAT), 1999; Meyers, Hagan, Zanis, Webb, Frantz, Ring-Kurtz, Rutherford, & McLellan, 1999; Winters, 2001]. Underscoring these advancements is the understanding that there are important developmental differences between adolescent and adult drinkers (Bukstein & Kaminer, 1994; Deas, Riggs, Langenbucherr, Goldman, & Brown, 2000). However, within the currently accepted diagnostic classification system, as represented by the Diagnostic and Statistical Manual, Fourth Edition [DSM-IV; American Psychiatric Association (APA), 1994], AUD is defined almost entirely on the basis of clinical research with adult populations. For adolescents, a problem may result from a single, acute episode of alcohol intoxication reflecting inexperience and carelessness rather than pathology. Conversely, adolescents who appear clinically to have a significant problem may not meet DSM-IV criteria for an AUD (Pollock & Martin, 1999). Thus, as Martin and colleagues note, ‘little is known about the validity of taxonomic systems for AUDs when applied to adolescents’ (Martin, Kaczynsksi, Maisto, Bukstein, & Moss, 1995, p. 672).
Emerging evidence suggests there are several limitations to the diagnostic validity and clinical utility of DSM-IV in assessing alcohol-involved adolescents. First, the DSM-IV implicitly posits that the onset of alcohol abuse precedes alcohol dependence—presumably the more severe disorder. However, epidemiological and clinical data show that the existence of dependence symptoms often precedes abuse symptoms among teen drinkers (Hartford et al., 1995; Martin et al., 1995; Lewinshon, Rohde, & Seeley, 1996; Harrison, Fulkerson, & Beebe, 1998; Martin & Winters, 1998) and that the prevalence of some dependence symptoms may be due to the low-specificity of criteria (Chung & Martin, 2005). Secondly, the DSM-IV explicitly states that a dependence diagnosis is mutually exclusive to an abuse diagnosis. Yet among clinical and community samples of adolescents abuse and dependence symptoms are moderately correlated, thus blurring meaningful distinction between the two categories (Chung, Martin, Armstrong, & Labouvie, 2002; Harrison, Fulkerson, & Beebe, 1998; Martin et al., 1995). Third, categorical problem definitions do not adequately capture the spectrum of teen alcohol use. For example, an estimated 10% to 30% of teen drinkers exhibit one or two dependence symptoms (Winters, 2001), but because they do not exhibit any abuse symptoms they cannot meet formal diagnostic criteria. This subclinical population comprising ‘diagnostic orphans’ (Pollock & Martin, 1999) leaves a large and potentially at-risk group of teen drinkers undetected within the DSM system. Fourth, DSM-IV problem definitions tend to decontextualize an individual’s symptomology (Ivey & Ivey, 1998) yet environmental and interpersonal contexts are critically important to understanding the dynamic interplay between adolescent psychosocial development, alcohol consumption, and problem symptoms.
The purpose of this paper is to present a taxonomy of alcohol-involved adolescents that will contribute to clinical utility and diagnostic validity. Although recent clinical and epidemiological studies on adolescent drinkers have greatly increased diagnostic and assessment understandings, we are not aware of a taxonomy that comprehensively describes alcohol-involved adolescents in a manner that captures the diversity of this large population. We begin by describing five typologies of adolescent drinkers along a severity- based continuum of alcohol involvement that includes normative, subclinical, and clinically significant adolescent alcohol use. Validity improvements are suggested to the DSM-IV problem definitions by including cognitive and contextual factors in the description of AUDs, thus creating more homogeneous subgroups of problem drinkers. Because the aetiological processes underlying experimental or normative alcohol use by adolescents are likely different than those underlying clinically significant drinking problems (Newcomb & Bentler, 1989; Petraitis, Flay, & Miller, 1995), we include in the description of typologies selected risk factors known to be predictive of adolescent AUD.
As practitioners working with youth in a variety of clinical settings we believe a developmentally-relevant and descriptive taxonomy of alcohol use could be useful for general practitioners screening adolescents for alcohol problems in primary health care settings or for specialists conducting comprehensive assessments in treatment settings. Such a taxonomy could greatly contribute to optimizing allocation of heath care services.
A diagnostic taxonomy of adolescent alcohol use
In this section we present a diagnostic taxonomy which defines typologies of adolescent drinkers along a severity-based continuum of alcohol use. As depicted in Figure1, the taxonomy comprises five typologies, or ‘Zones’, along this continuum: at one end is the initiation of alcohol use followed by occasional alcohol use (Zone A); at the other end is heavy alcohol use with high levels of impairment related to physical dependence (Zone E). Each Zone is given a brief identifier, then is described in terms of the following:
Zone A: Experimental/occasional use
This Zone is characterized by the initiation of alcohol use as an experiment followed by occasional, non-pattern drinking. By the last year of high school 76.8% of students have tried alcohol in their lifetime. The initiation of alcohol use as an experiment likely reflects developmentally normative adolescent behaviour. Reasons for experimentation include trying adult-like behaviour, testing limits of adult-norms and standards, seeking independence from conventional norms and authority, and establishing one’s own definition of appropriate behaviour (Wagner, 2004). In a national survey over half of 12th graders (52%) reported experimentation (i.e. ‘see what it’s like’) as the most important reason for drinking alcohol (O’Malley et al., 1998). Moreover, continued occasional drinking after initial use is likely for reasons of recreation or socializing with peers. Yet Zone A drinkers do not drink alcohol every time they socialize and they often acknowledge preferring to have fun without drinking alcohol. Teens here tend to see potential consequences for alcohol use and consider its effects on various aspects of their lives (e.g. relationship with parents, physical well-being), thus they may be inclined to endorse a perception of risk for alcohol effects.
1Department of Psychiatry, University of Wisconsin Medical School, Wisconsin, USA, 2Adolescent Alcohol/Drug Assessment Intervention Program, University of Wisconsin Hospital & Clinics, Wisconsin, USA, and 3Department of Psychiatry, University of Connecticut School of Medicine, Connecticut, USA
Abstract
Although recent assessment and diagnostic advancements have been made to better reflect the developmental uniqueness of alcohol-involved adolescents, there remains lacking a comprehensive taxonomy to describe the diversity of this large and often at-risk population. This paper presents a taxonomy comprising five typologies of adolescent drinkers based on a continuum of use severity. Each typology is described in terms of alcohol consumption variables, salient risk factors for alcohol problems, and problem symptoms. We argue that the taxonomy provides a useful heuristic for clinicians conducting assessment or screening with alcohol-involved adolescents, and we offer conceptual improvements for making the DSM-IV Alcohol Use Disorder criteria more developmen- tally relevant to adolescents. Implications for matching typologies to service levels are discussed.
Keywords: Adolescent, alcohol use, taxonomy.
Alcohol use among adolescents in the US is ubiquitous. By 12th grade 76.8% of high school students report at least one lifetime episode of alcohol use (Johnson, O’Malley, Bachman, & Schulenberg, 2004). A growing consensus among experts suggests that experimental alcohol use by teens reflects developmentally normative behaviour (Newcomb, & Bentler, 1989; Shedler, & Block, 1990; Milgram, 2002). Although most teens who use alcohol do not develop clinically significant problems (Martin, & Winters, 1998), there is a subgroup who do. In a nationally representative sample of adolescents aged 12–17, 11% met diagnostic criteria for an Alcohol Use Disorder (AUD; Kilpatrick, Acierno, Saunders, Resnick, Best, & Schnurr, 2000). Adolescent AUD is associated with poor academic achievement, co-morbid psychopathology, risk for sexually transmitted diseases, and threats to health and psychosocial development (Clark, 2004). Moreover, these and related problems can persist into adulthood creating great costs to individuals and society.
A recent proliferation of screening and assessment instruments has allowed better identification of adolescent AUDs [e.g. Leccese & Waldron, 1994; Center for Substance Abuse Treatment (CSAT), 1999; Meyers, Hagan, Zanis, Webb, Frantz, Ring-Kurtz, Rutherford, & McLellan, 1999; Winters, 2001]. Underscoring these advancements is the understanding that there are important developmental differences between adolescent and adult drinkers (Bukstein & Kaminer, 1994; Deas, Riggs, Langenbucherr, Goldman, & Brown, 2000). However, within the currently accepted diagnostic classification system, as represented by the Diagnostic and Statistical Manual, Fourth Edition [DSM-IV; American Psychiatric Association (APA), 1994], AUD is defined almost entirely on the basis of clinical research with adult populations. For adolescents, a problem may result from a single, acute episode of alcohol intoxication reflecting inexperience and carelessness rather than pathology. Conversely, adolescents who appear clinically to have a significant problem may not meet DSM-IV criteria for an AUD (Pollock & Martin, 1999). Thus, as Martin and colleagues note, ‘little is known about the validity of taxonomic systems for AUDs when applied to adolescents’ (Martin, Kaczynsksi, Maisto, Bukstein, & Moss, 1995, p. 672).
Emerging evidence suggests there are several limitations to the diagnostic validity and clinical utility of DSM-IV in assessing alcohol-involved adolescents. First, the DSM-IV implicitly posits that the onset of alcohol abuse precedes alcohol dependence—presumably the more severe disorder. However, epidemiological and clinical data show that the existence of dependence symptoms often precedes abuse symptoms among teen drinkers (Hartford et al., 1995; Martin et al., 1995; Lewinshon, Rohde, & Seeley, 1996; Harrison, Fulkerson, & Beebe, 1998; Martin & Winters, 1998) and that the prevalence of some dependence symptoms may be due to the low-specificity of criteria (Chung & Martin, 2005). Secondly, the DSM-IV explicitly states that a dependence diagnosis is mutually exclusive to an abuse diagnosis. Yet among clinical and community samples of adolescents abuse and dependence symptoms are moderately correlated, thus blurring meaningful distinction between the two categories (Chung, Martin, Armstrong, & Labouvie, 2002; Harrison, Fulkerson, & Beebe, 1998; Martin et al., 1995). Third, categorical problem definitions do not adequately capture the spectrum of teen alcohol use. For example, an estimated 10% to 30% of teen drinkers exhibit one or two dependence symptoms (Winters, 2001), but because they do not exhibit any abuse symptoms they cannot meet formal diagnostic criteria. This subclinical population comprising ‘diagnostic orphans’ (Pollock & Martin, 1999) leaves a large and potentially at-risk group of teen drinkers undetected within the DSM system. Fourth, DSM-IV problem definitions tend to decontextualize an individual’s symptomology (Ivey & Ivey, 1998) yet environmental and interpersonal contexts are critically important to understanding the dynamic interplay between adolescent psychosocial development, alcohol consumption, and problem symptoms.
The purpose of this paper is to present a taxonomy of alcohol-involved adolescents that will contribute to clinical utility and diagnostic validity. Although recent clinical and epidemiological studies on adolescent drinkers have greatly increased diagnostic and assessment understandings, we are not aware of a taxonomy that comprehensively describes alcohol-involved adolescents in a manner that captures the diversity of this large population. We begin by describing five typologies of adolescent drinkers along a severity- based continuum of alcohol involvement that includes normative, subclinical, and clinically significant adolescent alcohol use. Validity improvements are suggested to the DSM-IV problem definitions by including cognitive and contextual factors in the description of AUDs, thus creating more homogeneous subgroups of problem drinkers. Because the aetiological processes underlying experimental or normative alcohol use by adolescents are likely different than those underlying clinically significant drinking problems (Newcomb & Bentler, 1989; Petraitis, Flay, & Miller, 1995), we include in the description of typologies selected risk factors known to be predictive of adolescent AUD.
As practitioners working with youth in a variety of clinical settings we believe a developmentally-relevant and descriptive taxonomy of alcohol use could be useful for general practitioners screening adolescents for alcohol problems in primary health care settings or for specialists conducting comprehensive assessments in treatment settings. Such a taxonomy could greatly contribute to optimizing allocation of heath care services.
A diagnostic taxonomy of adolescent alcohol use
In this section we present a diagnostic taxonomy which defines typologies of adolescent drinkers along a severity-based continuum of alcohol use. As depicted in Figure1, the taxonomy comprises five typologies, or ‘Zones’, along this continuum: at one end is the initiation of alcohol use followed by occasional alcohol use (Zone A); at the other end is heavy alcohol use with high levels of impairment related to physical dependence (Zone E). Each Zone is given a brief identifier, then is described in terms of the following:
- alcohol quantity and frequency variables;
- risk factors predictive of alcohol use problems, such as individual (e.g. perception of risk, alcohol expectancies) and contextual factors (alcohol-involved peers);
- consequences associated with drinking, including the identification of DSM-IV AUD symptoms.
Zone A: Experimental/occasional use
This Zone is characterized by the initiation of alcohol use as an experiment followed by occasional, non-pattern drinking. By the last year of high school 76.8% of students have tried alcohol in their lifetime. The initiation of alcohol use as an experiment likely reflects developmentally normative adolescent behaviour. Reasons for experimentation include trying adult-like behaviour, testing limits of adult-norms and standards, seeking independence from conventional norms and authority, and establishing one’s own definition of appropriate behaviour (Wagner, 2004). In a national survey over half of 12th graders (52%) reported experimentation (i.e. ‘see what it’s like’) as the most important reason for drinking alcohol (O’Malley et al., 1998). Moreover, continued occasional drinking after initial use is likely for reasons of recreation or socializing with peers. Yet Zone A drinkers do not drink alcohol every time they socialize and they often acknowledge preferring to have fun without drinking alcohol. Teens here tend to see potential consequences for alcohol use and consider its effects on various aspects of their lives (e.g. relationship with parents, physical well-being), thus they may be inclined to endorse a perception of risk for alcohol effects.
Due to a likely combination of low tolerance and inexperience, a teen may experience an episode of acute alcohol intoxication within Zone A. For example, in a group of adolescents who did not exhibit DSM-IV-defined AUDs, 26% reported experiencing unintended excessive drinking, that is, ‘loss of control’ alcohol use (Martin et al., 1995). Although such an episode may be associated with a negative consequence (e.g. a blackout, disapproval from parents), a learning curve for the effects of alcohol intoxication allows that, within the context of experimental use, a single consequence is not indicative of a clinically significant problem. As Bukstein and Kaminer (1994) state, ‘assigning pathologic status to a behaviour with such a high prevalence becomes dubious’ (p. 6).
Zone B: Subclinical/pattern use
Drinking in Zone B is characterized by the emergence of a pattern of alcohol consumption. Although not every episode of a teen’s drinking reflects a global pattern of use, there is at least one element (e.g. time, place, specific peers, subjective experience) in which the pattern holds. Accompanied by patterned alcohol use here may be the emergence of alcohol-related problems. In a national survey of 12th graders, the most common alcohol- related problems reported (52% of the sample) was that alcohol caused behaviour that was later regretted (O’Malley, Johnston, & Bachman, 1998).
Approximately 10–30% of adolescent drinkers from community-based samples exhibit one or two DSM symptoms of problem drinking without meeting clinical criteria for an AUD, for example:
Although these symptoms reflect DSM-IV dependence criteria, the experience for adolescent drinkers may reflect developmental processes (Clark, 2004). For example, spending much time in obtaining alcohol may reflect access difficulties related to being underage as opposed to a pathological status. Likewise, developing tolerance to the effects of alcohol likely reflects a normative developmental process (Martin & Winters, 1998; Winters, Latimer, & Stinchfield, 1999) and has not been shown to differentiate adolescents with or without a DSM-IV AUD (Martin et al., 1995).
Zone B drinking reflects a diversity of alcohol use experiences among a heterogeneous group of teens. With the development of patterned alcohol use and of emerging problems a potentially large subclinical population of alcohol-involved adolescents exists here. It is important to note that alcohol-related problems may not be evaluated negatively by teen drinkers. To the contrary, these experiences, such as tolerance and drinking more than intended may be perceived as positive by teens, especially within peer group contexts. As in Zone A, reasons for alcohol use here are primarily for purposes of recreation and socializing. Yet increasingly salient for adolescents within Zone B are positive expectancies for alcohol’s effects. That is, based on the adolescent’s personal experiences with alcohol the perceived benefits of drinking likely outweigh any perceived costs. Perceived benefits and positive expectancies for alcohol effects are robust predictors of future drinking behaviour (Darkes & Goldman, 1993; Goldberg, Halpern-Felsher, & Millstein, 2002).
Zone C: Abuse/negative consequence use
We consider drinking within this Zone to be ‘abuse’ of alcohol with an established pattern of alcohol-related consequences. Drinking to get drunk or binge drinking is commonplace here. National survey data show that the prevalence of current binge drinking—defined as at least one episode of drinking 5 or more drinks within a couple of hours during the past 30 days—was 6.2% for 8th graders, 18.5% for 10th graders, and 32.5% for 12th graders (Johnson et al., 2004). Martin and colleagues (1995) showed that within a clinical sample of adolescents who met diagnostic criteria for alcohol abuse the number of average standard drinks consumed was 6.7 drinks.
Although assessing for frequency and quantity of alcohol consumption is important, these variables are not sufficient to ascertain Zone C drinking. Within a clinical sample of teen drinkers alcohol abuse symptoms were only weakly associated with consumption variables (Winters et al., 1999). The critical variables in defining abuse here are the number of consequences and the adolescent’s perceptions of those consequences. The DSM-IV defines alcohol abuse as the presence of at least one of the following four consequences:
In a review of clinical and community samples of adolescents, hazardous use and interpersonal problems were the most prevalently reported DSM-IV symptoms (Chung, Martin, Armstrong, & Labouvie, 2002). Martin and colleagues (1995) also showed that other alcohol-related consequences such as blackouts, cravings, and drop in school grades adequately differentiated teens with an alcohol abuse diagnosis from teens with no diagnosis.
Studies examining the DSM-IV alcohol abuse category as applied to adolescents show that the one-symptom threshold captures an excessively heterogeneous group of adolescent drinkers, thus diminishing the clinical utility of the diagnosis (Bukstein & Kaminer, 1994; Martin et al., 1995; Martin & Winters, 1998; Winters et al., 1999; Winters, 2001). To create a more homogenous subgroup of problem drinkers here an adolescent’s cognitions regarding alcohol use experiences should be assessed (Winters, 2001) in addition to drinking among the peer group. Drinkers within Zone C likely show heightened positive expectancies for alcohol effects, over-estimate the prevalence of binge drinking among same-aged peers, and perceive low risk for adverse consequences from alcohol use. One aspect of alcohol abuse is that although there is a pattern of alcohol-related consequences, teen drinkers may not attribute future risks to continued drinking. Relatedly, within Zone C adolescents tend to show strong associations with others abusing alcohol (peer selection), thus reinforcing positive expectancies and other cognitive biases which justify continued alcohol use. Windle’s (1996) study of adolescent drinkers found that the percentage of friends who drank alcohol did not significantly differ for those defined as either problem (92%) or heavy (90%) drinkers. However, those defined as moderate (79%) or light (54%) drinkers had significantly less friends who drank.
Although a teen’s stated reason to use alcohol probably includes having fun and socializing, drinking in Zone C is tied more strongly to internal psychological processes than in earlier Zones. Perceived benefits may also relate to a teen’s effort to find relief from negative emotions or to temporarily escape otherwise stressful psychosocial experiences. Thus, an aspect of heightened positive expectancies here is that alcohol use is perceived as an effective coping strategy in the face of stressful experiences. Indeed, the co-occurrence of AUDs and psychopathology is highly prevalent among youth (Clark & Bukstein, 1998).
Zone D: Psychologically dependent use
This Zone is characterized by a well-developed pattern of negative consequences associated with frequent and heavy alcohol consumption. Average number of standard drinks consumed by teens who met alcohol dependence criteria was 10.8 drinks (Martin et al., 1995). Eleven drinks translates into a blood alcohol level associated with severe impairments in cognitive functioning and motor co-ordination.
Adolescent drinkers within Zone D show diminished ability to control use. For example, the most prevalent symptom reported by a clinical sample of adolescents diagnosed with alcohol dependence was drinking more or longer than intended, that is, ‘loss of control’ drinking (93.5%; Martin et al., 1995). With high levels of consumption on a regular basis, alcohol has become central to the teen’s life. Martin and colleagues’ showed that alcohol dependent adolescents frequently endorsed DSM-IV symptoms such as much time spent in using or obtaining alcohol (79.0%) and social or occupational activities diminished by drinking (58.1%). Furthermore, consequences such as blackouts, passing out, cravings, and risky sexual activity differentiated those with alcohol dependence from those with alcohol abuse.
Zone D focuses on the psychological dimension of the dependence syndrome. Martin and colleagues (1995) analysed the DSM-IV symptom continued use despite physical or psychological problems (endorsed by 45.2% of those with an alcohol dependence diagnosis), and differentiated between physical and psychological problems. They found that adolescents reported psychological problems, such as depression (27.4%), suicide attempt (17.7%), and anxiety (11.3%) with much higher prevalence than physical problems were reported (6.5%).
Because adolescent AUDs are strongly associated with psychopathology (Clark & Bukstein, 1998) reasons for drinking within Zone D include coping with pre-existing psychological problems. Alcohol use as a coping strategy adequately differentiated adolescents defined as ‘problem drinkers’ from those in less severe drinking typologies (i.e. heavy, moderate, and light drinkers; Windle, 1996). Because the high level of impairment from alcohol and the corresponding severity of consequences, pre-existing psychosocial problems are made worse. For example, alcohol may be used to cope with difficulties related to poor parent-teen attachment, however, increased consumption of alcohol by adolescents is strongly related to increased family conflict (Bray, Adams, Getz, & Baer, 2001).
Drinking within Zone D interrupts critical adolescent developmental processes and tasks, such as individuation, identity formation, mastery, and intimacy (Deas et al., 2000; Bray et al., 2001; Clark, 2004). Because dependence takes time to develop, these adolescents likely initiated regular alcohol use at a relatively early age and engaged in regular binge drinking throughout mid-adolescence (Guo, Hawkins, Jill, & Abbott, 2001).
Zone E: Physically dependent use
This final Zone represents the most severe level of impairment and problems related to alcohol dependence. The DSM-IV recognizes a subgroup of dependent alcohol users as possessing ‘physiologic features’ based on the presence of tolerance or withdrawal symptoms (APA, 1994). The prevalence of adolescents from community and clinical samples with a DSM-IV AUD meeting the ‘physiologic’ criteria ranged from 21.9 to 100% (with median 83.2%; Chung et al., 2002). However, if limited to the experience of withdrawal, base rates for physical dependence are very low. For example, in Lewinsohn and colleagues’ (1996) community sample, only a small percentage of high school students endorsed difficulties associated with physical withdrawal, including ‘shakes or felt sick all over’ (2.3%), ‘had hallucinations’ (0.3%), and ‘had fits or seizures’ (0.1%). Moreover, clinical samples of adolescents diagnosed with alcohol dependence showed low base rates of physical withdrawal from alcohol with 16% to 23% of teens reporting alcohol use to relieve or avoid withdrawal symptoms (Martin et al., 1995; Winters et al., 1999). The presence of physical withdrawal from alcohol is likely a highly salient marker for identifying the most severely dependent adolescents (Clark, 2004; Chung et al., 2002) as characterized by Zone E drinking.
Zone movement along the continuum of severity
In this section we describe inter-Zone movement along the continuum of alcohol use severity. Every teen drinker starts in Zone A with the initiation of alcohol use. Movement proceeds contiguously from there. The amount of time an adolescent spends within a particular Zone is highly variable. Some teens will remain in Zone A throughout their adolescence with occasional and non-consequence alcohol use. Many other teens will progress to Zone B, and some will progress further. Zone B is characterized by a pattern of alcohol use with the possible emergence of consequences. With the experience of a consequence in Zone B many adolescents will make changes to avoid future problems, thus returning to Zone A drinking or to abstinence. Conversely, some adolescents will continue developing patterned alcohol use and risk experiencing repeated alcohol-related con- sequences characteristic of Zone C drinking. Zone B is therefore considered a bridge between patterned, but non-problematic alcohol consumption and clinically significant alcohol use.
We view the rate of inter-Zone movement as a function of the complex interaction between adolescent development, drinking experiences, and the presence of risk factors. A multitude of empirically-established individual and contextual risk factors exist for adolescents developing AUDs (Hawkins, Catalano, & Miller, 1992; Swadi, 1999). The more risk factors present in a young person’s life, the greater the likelihood that the person will progress along the continuum of severity and the greater the rate of progression will be. For example, an adolescent presenting with Zone B drinking who has a family history of alcoholism, initiated regular alcohol use before age 13, and who sees little to no risk from binge drinking is very likely to progress at a faster rate to Zone C drinking relative to an adolescent presenting in Zone B who does not have these risk factors.
We view adolescents’ Zone movement as flexible and dynamic along the continuum of severity, including ‘forward’ movement (increasing severity), as well as ‘backward’ movement (lessening severity). At 1-year follow-up, adolescents who completed alcohol treatment showed less symptom severity than at entry (Chung & Martin, 2001). The notion of adolescents successfully reducing drinking with subsequent decreases in problem severity is increasingly receiving empirical attention by proponents of harm reduction (Miller, Turner, & Marlatt, 2001). Yet the consideration of ‘backward’ movement along the continuum is antithetical to conventional definitions of the alcohol dependence syndrome. Furthermore, the DSM-IV course qualifiers (e.g. ‘remission’) do not allow for regression from dependence (Zone D) to abuse (Zone C). Accurate assessment of alcohol- involved adolescents requires flexibility in viewing an individual’s movement along the continuum. This viewpoint is not only developmentally-relevant for alcohol-involved adolescents, but also has important clinical implications for ascertaining level of care and the subsequent allocation of limited treatment resources.
Discussion
Although an AUD is considered a ‘developmental disorder’ (Tarter & Vanyukov, 1994), the DSM-IV shows several limitations in diagnostic validity and clinical utility when applied to adolescent drinkers. The taxonomy presented below integrates recent advancements in diagnosis and assessment to create severity-based typologies (Zones) of alcohol-involved adolescents. Along a continuum we described five Zones of teen drinking:
This taxonomy improves diagnostic validity of the DSM-IV in several ways. First, adolescent drinking was characterized by a severity-based continuum as opposed to a categorical dichotomy. Consistent with recent empirical findings (Chung & Martin, 2001), we placed emphasis on the number of AUD symptoms present within a given Zone instead of the type of symptom (i.e. abuse versus dependence; see Table I). Chung and Martin’s (2001) data showed three typologies of adolescent drinkers based on AUD symptom identification: no symptoms, mild symptoms, or severe symptoms. This statistically- derived model embodies parsimony and, therefore, is important from an empirical point of view. However, we believe that the five Zones comprising this taxonomy is more useful clinically to comprehensively describe alcohol-involved adolescents. Secondly, we identified normative (Zone A) and subclinical (Zone B) alcohol use typologies, thus eliminating the problem of ‘diagnostic orphans’ (Pollock & Martin, 1999). That is, any adolescent who is alcohol-involved can be located within this taxonomy. Thirdly, we created more homogenous groups of adolescents who show AUDs than the DSM-IV allows. The inclusion of cognitive domains, such as risk perception and positive expectancies were used to differentiate alcohol abusing teens (Zone C) from teens who show emerging, but subclinical problems symptoms (Zone B). For alcohol dependence, we differentiated psychologically dependent drinkers (Zone D) from the much smaller subgroup of physically dependent drinkers (Zone E) by identifying the symptom of withdrawal as a marker for the latter. The symptom of tolerance has limited diagnostic validity when applied to teen drinkers (Chung & Martin, 2001, 2002; Martin & Winters, 1998), thus, by eliminating it as a specifier of physical dependence the most severe cases of alcohol dependence are more clearly defined. Fourthly, we considered an adolescent’s involvement with alcohol as dynamic as opposed to static. Consistent with recent outcome data suggesting that, for many adolescents, AUDs have a time limited course (Chung & Martin, 2001; Clark, 2004) we identified the possibility of ‘backward’ movement from a more severe to a less severe Zone.
Zone B: Subclinical/pattern use
Drinking in Zone B is characterized by the emergence of a pattern of alcohol consumption. Although not every episode of a teen’s drinking reflects a global pattern of use, there is at least one element (e.g. time, place, specific peers, subjective experience) in which the pattern holds. Accompanied by patterned alcohol use here may be the emergence of alcohol-related problems. In a national survey of 12th graders, the most common alcohol- related problems reported (52% of the sample) was that alcohol caused behaviour that was later regretted (O’Malley, Johnston, & Bachman, 1998).
Approximately 10–30% of adolescent drinkers from community-based samples exhibit one or two DSM symptoms of problem drinking without meeting clinical criteria for an AUD, for example:
- much time spent in obtaining, using, or recovering from alcohol effects;
- drinking larger amounts or for a longer period of time than intended;
- the development of tolerance to alcohol effects (Harrison et al., 1998; Lewinsohn et al., 1996).
Although these symptoms reflect DSM-IV dependence criteria, the experience for adolescent drinkers may reflect developmental processes (Clark, 2004). For example, spending much time in obtaining alcohol may reflect access difficulties related to being underage as opposed to a pathological status. Likewise, developing tolerance to the effects of alcohol likely reflects a normative developmental process (Martin & Winters, 1998; Winters, Latimer, & Stinchfield, 1999) and has not been shown to differentiate adolescents with or without a DSM-IV AUD (Martin et al., 1995).
Zone B drinking reflects a diversity of alcohol use experiences among a heterogeneous group of teens. With the development of patterned alcohol use and of emerging problems a potentially large subclinical population of alcohol-involved adolescents exists here. It is important to note that alcohol-related problems may not be evaluated negatively by teen drinkers. To the contrary, these experiences, such as tolerance and drinking more than intended may be perceived as positive by teens, especially within peer group contexts. As in Zone A, reasons for alcohol use here are primarily for purposes of recreation and socializing. Yet increasingly salient for adolescents within Zone B are positive expectancies for alcohol’s effects. That is, based on the adolescent’s personal experiences with alcohol the perceived benefits of drinking likely outweigh any perceived costs. Perceived benefits and positive expectancies for alcohol effects are robust predictors of future drinking behaviour (Darkes & Goldman, 1993; Goldberg, Halpern-Felsher, & Millstein, 2002).
Zone C: Abuse/negative consequence use
We consider drinking within this Zone to be ‘abuse’ of alcohol with an established pattern of alcohol-related consequences. Drinking to get drunk or binge drinking is commonplace here. National survey data show that the prevalence of current binge drinking—defined as at least one episode of drinking 5 or more drinks within a couple of hours during the past 30 days—was 6.2% for 8th graders, 18.5% for 10th graders, and 32.5% for 12th graders (Johnson et al., 2004). Martin and colleagues (1995) showed that within a clinical sample of adolescents who met diagnostic criteria for alcohol abuse the number of average standard drinks consumed was 6.7 drinks.
Although assessing for frequency and quantity of alcohol consumption is important, these variables are not sufficient to ascertain Zone C drinking. Within a clinical sample of teen drinkers alcohol abuse symptoms were only weakly associated with consumption variables (Winters et al., 1999). The critical variables in defining abuse here are the number of consequences and the adolescent’s perceptions of those consequences. The DSM-IV defines alcohol abuse as the presence of at least one of the following four consequences:
- failure to fulfill major role obligations (e.g. at home or school);
- hazardous use;
- continued drinking despite repeated social or interpersonal problems;
- alcohol-related legal difficulties.
In a review of clinical and community samples of adolescents, hazardous use and interpersonal problems were the most prevalently reported DSM-IV symptoms (Chung, Martin, Armstrong, & Labouvie, 2002). Martin and colleagues (1995) also showed that other alcohol-related consequences such as blackouts, cravings, and drop in school grades adequately differentiated teens with an alcohol abuse diagnosis from teens with no diagnosis.
Studies examining the DSM-IV alcohol abuse category as applied to adolescents show that the one-symptom threshold captures an excessively heterogeneous group of adolescent drinkers, thus diminishing the clinical utility of the diagnosis (Bukstein & Kaminer, 1994; Martin et al., 1995; Martin & Winters, 1998; Winters et al., 1999; Winters, 2001). To create a more homogenous subgroup of problem drinkers here an adolescent’s cognitions regarding alcohol use experiences should be assessed (Winters, 2001) in addition to drinking among the peer group. Drinkers within Zone C likely show heightened positive expectancies for alcohol effects, over-estimate the prevalence of binge drinking among same-aged peers, and perceive low risk for adverse consequences from alcohol use. One aspect of alcohol abuse is that although there is a pattern of alcohol-related consequences, teen drinkers may not attribute future risks to continued drinking. Relatedly, within Zone C adolescents tend to show strong associations with others abusing alcohol (peer selection), thus reinforcing positive expectancies and other cognitive biases which justify continued alcohol use. Windle’s (1996) study of adolescent drinkers found that the percentage of friends who drank alcohol did not significantly differ for those defined as either problem (92%) or heavy (90%) drinkers. However, those defined as moderate (79%) or light (54%) drinkers had significantly less friends who drank.
Although a teen’s stated reason to use alcohol probably includes having fun and socializing, drinking in Zone C is tied more strongly to internal psychological processes than in earlier Zones. Perceived benefits may also relate to a teen’s effort to find relief from negative emotions or to temporarily escape otherwise stressful psychosocial experiences. Thus, an aspect of heightened positive expectancies here is that alcohol use is perceived as an effective coping strategy in the face of stressful experiences. Indeed, the co-occurrence of AUDs and psychopathology is highly prevalent among youth (Clark & Bukstein, 1998).
Zone D: Psychologically dependent use
This Zone is characterized by a well-developed pattern of negative consequences associated with frequent and heavy alcohol consumption. Average number of standard drinks consumed by teens who met alcohol dependence criteria was 10.8 drinks (Martin et al., 1995). Eleven drinks translates into a blood alcohol level associated with severe impairments in cognitive functioning and motor co-ordination.
Adolescent drinkers within Zone D show diminished ability to control use. For example, the most prevalent symptom reported by a clinical sample of adolescents diagnosed with alcohol dependence was drinking more or longer than intended, that is, ‘loss of control’ drinking (93.5%; Martin et al., 1995). With high levels of consumption on a regular basis, alcohol has become central to the teen’s life. Martin and colleagues’ showed that alcohol dependent adolescents frequently endorsed DSM-IV symptoms such as much time spent in using or obtaining alcohol (79.0%) and social or occupational activities diminished by drinking (58.1%). Furthermore, consequences such as blackouts, passing out, cravings, and risky sexual activity differentiated those with alcohol dependence from those with alcohol abuse.
Zone D focuses on the psychological dimension of the dependence syndrome. Martin and colleagues (1995) analysed the DSM-IV symptom continued use despite physical or psychological problems (endorsed by 45.2% of those with an alcohol dependence diagnosis), and differentiated between physical and psychological problems. They found that adolescents reported psychological problems, such as depression (27.4%), suicide attempt (17.7%), and anxiety (11.3%) with much higher prevalence than physical problems were reported (6.5%).
Because adolescent AUDs are strongly associated with psychopathology (Clark & Bukstein, 1998) reasons for drinking within Zone D include coping with pre-existing psychological problems. Alcohol use as a coping strategy adequately differentiated adolescents defined as ‘problem drinkers’ from those in less severe drinking typologies (i.e. heavy, moderate, and light drinkers; Windle, 1996). Because the high level of impairment from alcohol and the corresponding severity of consequences, pre-existing psychosocial problems are made worse. For example, alcohol may be used to cope with difficulties related to poor parent-teen attachment, however, increased consumption of alcohol by adolescents is strongly related to increased family conflict (Bray, Adams, Getz, & Baer, 2001).
Drinking within Zone D interrupts critical adolescent developmental processes and tasks, such as individuation, identity formation, mastery, and intimacy (Deas et al., 2000; Bray et al., 2001; Clark, 2004). Because dependence takes time to develop, these adolescents likely initiated regular alcohol use at a relatively early age and engaged in regular binge drinking throughout mid-adolescence (Guo, Hawkins, Jill, & Abbott, 2001).
Zone E: Physically dependent use
This final Zone represents the most severe level of impairment and problems related to alcohol dependence. The DSM-IV recognizes a subgroup of dependent alcohol users as possessing ‘physiologic features’ based on the presence of tolerance or withdrawal symptoms (APA, 1994). The prevalence of adolescents from community and clinical samples with a DSM-IV AUD meeting the ‘physiologic’ criteria ranged from 21.9 to 100% (with median 83.2%; Chung et al., 2002). However, if limited to the experience of withdrawal, base rates for physical dependence are very low. For example, in Lewinsohn and colleagues’ (1996) community sample, only a small percentage of high school students endorsed difficulties associated with physical withdrawal, including ‘shakes or felt sick all over’ (2.3%), ‘had hallucinations’ (0.3%), and ‘had fits or seizures’ (0.1%). Moreover, clinical samples of adolescents diagnosed with alcohol dependence showed low base rates of physical withdrawal from alcohol with 16% to 23% of teens reporting alcohol use to relieve or avoid withdrawal symptoms (Martin et al., 1995; Winters et al., 1999). The presence of physical withdrawal from alcohol is likely a highly salient marker for identifying the most severely dependent adolescents (Clark, 2004; Chung et al., 2002) as characterized by Zone E drinking.
Zone movement along the continuum of severity
In this section we describe inter-Zone movement along the continuum of alcohol use severity. Every teen drinker starts in Zone A with the initiation of alcohol use. Movement proceeds contiguously from there. The amount of time an adolescent spends within a particular Zone is highly variable. Some teens will remain in Zone A throughout their adolescence with occasional and non-consequence alcohol use. Many other teens will progress to Zone B, and some will progress further. Zone B is characterized by a pattern of alcohol use with the possible emergence of consequences. With the experience of a consequence in Zone B many adolescents will make changes to avoid future problems, thus returning to Zone A drinking or to abstinence. Conversely, some adolescents will continue developing patterned alcohol use and risk experiencing repeated alcohol-related con- sequences characteristic of Zone C drinking. Zone B is therefore considered a bridge between patterned, but non-problematic alcohol consumption and clinically significant alcohol use.
We view the rate of inter-Zone movement as a function of the complex interaction between adolescent development, drinking experiences, and the presence of risk factors. A multitude of empirically-established individual and contextual risk factors exist for adolescents developing AUDs (Hawkins, Catalano, & Miller, 1992; Swadi, 1999). The more risk factors present in a young person’s life, the greater the likelihood that the person will progress along the continuum of severity and the greater the rate of progression will be. For example, an adolescent presenting with Zone B drinking who has a family history of alcoholism, initiated regular alcohol use before age 13, and who sees little to no risk from binge drinking is very likely to progress at a faster rate to Zone C drinking relative to an adolescent presenting in Zone B who does not have these risk factors.
We view adolescents’ Zone movement as flexible and dynamic along the continuum of severity, including ‘forward’ movement (increasing severity), as well as ‘backward’ movement (lessening severity). At 1-year follow-up, adolescents who completed alcohol treatment showed less symptom severity than at entry (Chung & Martin, 2001). The notion of adolescents successfully reducing drinking with subsequent decreases in problem severity is increasingly receiving empirical attention by proponents of harm reduction (Miller, Turner, & Marlatt, 2001). Yet the consideration of ‘backward’ movement along the continuum is antithetical to conventional definitions of the alcohol dependence syndrome. Furthermore, the DSM-IV course qualifiers (e.g. ‘remission’) do not allow for regression from dependence (Zone D) to abuse (Zone C). Accurate assessment of alcohol- involved adolescents requires flexibility in viewing an individual’s movement along the continuum. This viewpoint is not only developmentally-relevant for alcohol-involved adolescents, but also has important clinical implications for ascertaining level of care and the subsequent allocation of limited treatment resources.
Discussion
Although an AUD is considered a ‘developmental disorder’ (Tarter & Vanyukov, 1994), the DSM-IV shows several limitations in diagnostic validity and clinical utility when applied to adolescent drinkers. The taxonomy presented below integrates recent advancements in diagnosis and assessment to create severity-based typologies (Zones) of alcohol-involved adolescents. Along a continuum we described five Zones of teen drinking:
- Zone A described the initiation of alcohol use followed by occasional drinking to reflect normative adolescent behaviour;
- Zone B described the development of patterned alcohol use with emerging problem symptoms to reflect a subclinical level of alcohol use;
- Zone C described an established pattern of alcohol use accompanied by recurrent problem symptoms characteristic of alcohol abuse;
- Zone D described frequent and heavy alcohol use accompanied by numerous problems symptoms characteristic of psychological dependence;
- Zone E described a subgroup of dependent drinkers with withdrawal symptoms marking physical dependence.
This taxonomy improves diagnostic validity of the DSM-IV in several ways. First, adolescent drinking was characterized by a severity-based continuum as opposed to a categorical dichotomy. Consistent with recent empirical findings (Chung & Martin, 2001), we placed emphasis on the number of AUD symptoms present within a given Zone instead of the type of symptom (i.e. abuse versus dependence; see Table I). Chung and Martin’s (2001) data showed three typologies of adolescent drinkers based on AUD symptom identification: no symptoms, mild symptoms, or severe symptoms. This statistically- derived model embodies parsimony and, therefore, is important from an empirical point of view. However, we believe that the five Zones comprising this taxonomy is more useful clinically to comprehensively describe alcohol-involved adolescents. Secondly, we identified normative (Zone A) and subclinical (Zone B) alcohol use typologies, thus eliminating the problem of ‘diagnostic orphans’ (Pollock & Martin, 1999). That is, any adolescent who is alcohol-involved can be located within this taxonomy. Thirdly, we created more homogenous groups of adolescents who show AUDs than the DSM-IV allows. The inclusion of cognitive domains, such as risk perception and positive expectancies were used to differentiate alcohol abusing teens (Zone C) from teens who show emerging, but subclinical problems symptoms (Zone B). For alcohol dependence, we differentiated psychologically dependent drinkers (Zone D) from the much smaller subgroup of physically dependent drinkers (Zone E) by identifying the symptom of withdrawal as a marker for the latter. The symptom of tolerance has limited diagnostic validity when applied to teen drinkers (Chung & Martin, 2001, 2002; Martin & Winters, 1998), thus, by eliminating it as a specifier of physical dependence the most severe cases of alcohol dependence are more clearly defined. Fourthly, we considered an adolescent’s involvement with alcohol as dynamic as opposed to static. Consistent with recent outcome data suggesting that, for many adolescents, AUDs have a time limited course (Chung & Martin, 2001; Clark, 2004) we identified the possibility of ‘backward’ movement from a more severe to a less severe Zone.
This taxonomy is clinically useful in several ways. First, each Zone included clinically rich descriptions of adolescent alcohol use, including frequency and quantity variables, and the identification of DSM-IV problem symptoms, cognitive variables, and other empirically-established risk factors. Second, linking assessment and diagnosis with service level determinations for adolescents has been argued as important clinically (CSAT, 1999; Meyers et al., 1999; Clark, 2004), as well as economically through the efficient allocation of limited health care resources (Winters, 2001). Placement criteria have recently been developed to match adolescents presenting with an AUD to appropriate service levels using several clinical dimensions (Mee-Lee, Shulman, Fishman, Gastfriend, & Griffith, 2001). As depicted in Table II, the taxonomy may provide a useful heuristic for linking assessment with service level. For example, a teen drinker in Zone A may be appropriate for general or targeted prevention services, whereas a teen in Zone B may be appropriate for indicated prevention or brief intervention. For teens who meet criteria for an AUD, location in either Zone C, D, or E have implications for level of treatment services. For example, a teen in Zone C may be appropriate for standard outpatient treatment services, whereas a teen in Zone D may be appropriate for intensive outpatient or inpatient treatment services, and a teen in Zone E would likely require detoxification services within inpatient treatment or partial hospitalization settings. The third way this taxonomy is clinically useful is that each Zone identifies targets for intervention and has implications for treatment planning. For example, the description of Zone C drinking included diminished risk perception for negative alcohol effects, thus, treatment planning could include providing information on the risks associated with alcohol. The taxonomy itself could be used to provide personalized feedback to an adolescent in terms of location along the continuum.
There are several limitations to this taxonomy of adolescent drinking. First, the identification of developmental (e.g. age, maturity) and demographic variables (e.g. gender, race), as well as co-occurring problems, such as mental health and conduct are critical for a comprehensive assessment, and should be integrated into a diagnostic system. However, these variables not accounted for within this taxonomy. Second, trajectories of movement to more or less severe involvement with alcohol were not identified. Whereas each Zone description provided a ‘snapshot’ location along the severity-based continuum, ideally, a diagnostic model should link specific clinical characteristics of adolescent subgroups to unique developmental trajectories, thus, indicating course and prognosis (Martin et al., 1995). Thirdly, this taxonomy was limited to alcohol, yet alcohol-involved adolescents are commonly involved with other substances and adolescent AUDs are closely related to the presence of other substance use disorders (Clark, 2004). Fourthly, this taxonomy focused on establishing a conceptual understanding of alcohol-involved adolescents without considering symptom-level definitions or diagnostic thresholds, thus greatly diminishing its reliability as a clinical tool.
The conceptual development of this taxonomy parallels recent empirical work to establish a more valid diagnostic understanding of alcohol-involved adolescents. Research to establish diagnostic thresholds for adolescent AUDs on the symptom-level should be considered within the context of clinical utility for practitioners in the field. Use of this taxonomy has potential to increase clinical utility by linking Zones with type of services and by informing treatment planning or intervention strategies. This taxonomy could also be utilized with existing instruments that screen or assess alcohol-involved adolescents.
Acknowledgements
This paper was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (AA03510 and U10-AA08401). We thank Dr Pamela Bean for her helpful comments on an earlier draft.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders, 4th edition. Washington, DC: APA.
Bray, J. H., Adams, G. J., Getz, G., & Baer, P. E. (2001). Developmental, family, and ethnic influences on adolescent alcohol usage: A growth curve approach. Journal of Family Psychology, 15, 301–314.
Bukstein, O., & Kaminer, Y. (1994). The nosology of adolescent substance abuse. American Journal of Addiction, 3, 1–13.
Center for Substance Abuse Treatment (CSAT) (1999) Screening and assessing adolescents for substance use disorders (Treatment Improvement Protocol Series, No.31). Rockville: Substance Abuse and Mental Health Services Administration.
Chung, T., & Martin, C. S. (2001). Classification and course of alcohol problems among adolescents in addictions treatment. Alcoholism: Clinical and Experimental Research, 25, 1734–1742.
Chung, T., & Martin, C. S. (2005). What were they thinking? Adolescents’ interpretations of DSM-IV alcohol dependence symptom queries and implications for diagnostic validity. Drug and Alcohol Dependence, 80, 191–200.
Chung, T., Martin, C. S., Armstrong, T. D., & Labouvie, E. W. (2002). Prevalence of DSM-IV alcohol diagnoses and symptoms in adolescent community and clinical samples. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 546–554.
Clark, D. B. (2004). The natural history of adolescent alcohol use disorders. Addiction, 99(Suppl 2), 5–22. Clark, D. B., & Bukstein, O. (1998). Psychopathology in adolescent alcohol abuse and dependence. Alcohol Heath & Research World, 22, 117–122.
Darkes, J., & Goldman, M. S. (1993). Expectancy challenge and drinking: Experimental evidence for a mediational process. Journal of Consulting and Clinical Psychology, 61, 344–353.
Deas, D., Riggs, P., Langenbucher, J., Goldman, M., & Brown, S. (2000). Adolescents are not adults: Developmental considerations in alcohol users. Alcoholism: Clinical and Experimental Research, 24, 232–237.
Goldberg, J. H., Halpern-Felsher, B. L., & Millstein, S. G. (2002). Beyond invulnerability: The importance of benefits in adolescents’ decision to drink alcohol. Health Psychology, 21, 477–484.
Guo, J., Hawkins, J. D., Hill, K. G., & Abbott, R. D. (2001). Childhood and adolescent predictors of alcohol abuse and dependence in young adulthood. Journal of Studies on Alcohol, 62, 754–762.
Harford, T. C., Grant, B. F., Yi, H., & Chen, C. M. (2005). Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: Results from the 2001 National Household Survey on Drug Abuse.
Alcoholism: Clinical and Experimental Research, 29, 810–828.
Harrison, P. A., Fulkerson, J. A., & Beebe, T. J. (1998). DSM-IV substance use disorder criteria for adolescents: A critical examination based on a statewide survey. American Journal of Psychiatry, 155, 486–492.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64–105.
Ivey, A. E., & Ivey, M. B. (1998). Reframing DSM-IV: Positive strategies from developmental counseling and therapy. Journal of Counseling and Development, 76, 334–350.
Johnson, L. D., O’Malley, P. M., Bachman, J. D., & Schulenberg, J. E. (2004, December). Overall teen drug use
continues gradual decline; but use of inhalants rises. Ann Arbor: University of Michigan News and Information Services. Available at: www.monitoringthefuture.org (accessed on September 12, 2005).
Kilpatrick, D. G., Acierno, R., Saunders, S., Resnick, H. S., Best, C., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68, 19–30.
Leccese, M., & Waldron, H. B. (1994). Assessing adolescent substance use: A critique of current measurement instruments. Journal of Substance Abuse Treatment, 6, 553–563.
Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1996). Alcohol consumption in high school adolescents: Frequency of use and dimensional structure of associated problems. Addiction, 91, 375–390.
Martin, C. S., Kaczynski, N. A., Maisto, S. A., Bukstein, O. M., & Moss, H. B. (1995). Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. Journal of Studies on Alcohol, 56, 672–680. Martin, C. S., & Winters, K. C. (1998). Diagnosis and assessment of alcohol use disorders among adolescents. Alcohol Health & Research World, 22, 95–105.
Mee-Lee D., G. D. Shulman, M. Fishman, D. R. Gastfriend, & J. H. Griffith (Eds.). (2001). ASAM placement
criteria for the treatment of substance-related disorders, second edition-revised. Chevy Chase: American Society of
Addiction, Inc.
Meyers, K., Hagan, T. A., Zanis, D., Webb, A., Frantz, J., Ring-Kurtz, S., Rutherford, M., & McLellan, A. T. (1999). Critical issues in adolescent substance use assessment. Drug and Alcohol Dependence, 55, 235–246. Milgram, G. G. (2002). Youthful drinking. Alcoholism Treatment Quarterly, 20, 143–146.
Miller, E. T., Turner, A. P., & Marlatt, G. A. (2001). The harm reduction approach to the secondary prevention of alcohol problems in adolescents and young adults: Considerations across a developmental spectrum. In: P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 58–79). New York: Guilford Press.
Newcomb, M. D., & Bentler, P. M. (1989). Substance use and abuse among children and teenagers. American Psychologist, 44, 242–248.
O’Malley, P. M., Johnston, L. D., & Bachman, J. G. (1998). Alcohol use among adolescents. Alcohol Heath & Research World, 22, 85–93.
Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of adolescent substance use: Organizing pieces of the puzzle. Psychological Bulletin, 117, 67–86.
Pollock, N. K., & Martin, C. S. (1999). Diagnostic orphans: Adolescents with alcohol symptoms but no DSM-IV diagnosis. American Journal of Psychiatry, 156, 897–901.
Shedler, J., & Block, J. (1990). Adolescent drug use and psychological health: A longitudinal inquiry. American Psychologist, 45, 612–630.
Swadi, H. (1999). Individual risk factors for adolescent substance use. Drug and Alcohol Dependence, 55, 209–224. Tarter, R. E., & Vanyukov, M. (1994). Alcoholism: a developmental disorder. Journal of Consulting and Clinical Psychology, 62, 1096–1107.
Wagner, E. F. (2004). Developmentally and contextually congruent approaches to treating alcohol and other drug use problems among adolescents. Talk given at University of Wisconsin-Oshkosh, Oshkosh, Wisconsin. Windle, M. (1996). An alcohol involvement typology for adolescents: Convergent validity and longitudinal stability. Journal of Studies on Alcohol, 57, 627–637.
Winters, K. C. (2001). Assessing adolescent substance use problems and other areas of functioning: State of the art. In P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 80–108). New York: Guilford Press.
Winters, K. C., Latimer, W., & Stinchfield, R. D. (1999). The DSM-IV criteria for adolescent alcohol and cannabis use disorders. Journal of Studies on Alcohol, 60, 337–344.
The conceptual development of this taxonomy parallels recent empirical work to establish a more valid diagnostic understanding of alcohol-involved adolescents. Research to establish diagnostic thresholds for adolescent AUDs on the symptom-level should be considered within the context of clinical utility for practitioners in the field. Use of this taxonomy has potential to increase clinical utility by linking Zones with type of services and by informing treatment planning or intervention strategies. This taxonomy could also be utilized with existing instruments that screen or assess alcohol-involved adolescents.
Acknowledgements
This paper was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (AA03510 and U10-AA08401). We thank Dr Pamela Bean for her helpful comments on an earlier draft.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders, 4th edition. Washington, DC: APA.
Bray, J. H., Adams, G. J., Getz, G., & Baer, P. E. (2001). Developmental, family, and ethnic influences on adolescent alcohol usage: A growth curve approach. Journal of Family Psychology, 15, 301–314.
Bukstein, O., & Kaminer, Y. (1994). The nosology of adolescent substance abuse. American Journal of Addiction, 3, 1–13.
Center for Substance Abuse Treatment (CSAT) (1999) Screening and assessing adolescents for substance use disorders (Treatment Improvement Protocol Series, No.31). Rockville: Substance Abuse and Mental Health Services Administration.
Chung, T., & Martin, C. S. (2001). Classification and course of alcohol problems among adolescents in addictions treatment. Alcoholism: Clinical and Experimental Research, 25, 1734–1742.
Chung, T., & Martin, C. S. (2005). What were they thinking? Adolescents’ interpretations of DSM-IV alcohol dependence symptom queries and implications for diagnostic validity. Drug and Alcohol Dependence, 80, 191–200.
Chung, T., Martin, C. S., Armstrong, T. D., & Labouvie, E. W. (2002). Prevalence of DSM-IV alcohol diagnoses and symptoms in adolescent community and clinical samples. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 546–554.
Clark, D. B. (2004). The natural history of adolescent alcohol use disorders. Addiction, 99(Suppl 2), 5–22. Clark, D. B., & Bukstein, O. (1998). Psychopathology in adolescent alcohol abuse and dependence. Alcohol Heath & Research World, 22, 117–122.
Darkes, J., & Goldman, M. S. (1993). Expectancy challenge and drinking: Experimental evidence for a mediational process. Journal of Consulting and Clinical Psychology, 61, 344–353.
Deas, D., Riggs, P., Langenbucher, J., Goldman, M., & Brown, S. (2000). Adolescents are not adults: Developmental considerations in alcohol users. Alcoholism: Clinical and Experimental Research, 24, 232–237.
Goldberg, J. H., Halpern-Felsher, B. L., & Millstein, S. G. (2002). Beyond invulnerability: The importance of benefits in adolescents’ decision to drink alcohol. Health Psychology, 21, 477–484.
Guo, J., Hawkins, J. D., Hill, K. G., & Abbott, R. D. (2001). Childhood and adolescent predictors of alcohol abuse and dependence in young adulthood. Journal of Studies on Alcohol, 62, 754–762.
Harford, T. C., Grant, B. F., Yi, H., & Chen, C. M. (2005). Patterns of DSM-IV alcohol abuse and dependence criteria among adolescents and adults: Results from the 2001 National Household Survey on Drug Abuse.
Alcoholism: Clinical and Experimental Research, 29, 810–828.
Harrison, P. A., Fulkerson, J. A., & Beebe, T. J. (1998). DSM-IV substance use disorder criteria for adolescents: A critical examination based on a statewide survey. American Journal of Psychiatry, 155, 486–492.
Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64–105.
Ivey, A. E., & Ivey, M. B. (1998). Reframing DSM-IV: Positive strategies from developmental counseling and therapy. Journal of Counseling and Development, 76, 334–350.
Johnson, L. D., O’Malley, P. M., Bachman, J. D., & Schulenberg, J. E. (2004, December). Overall teen drug use
continues gradual decline; but use of inhalants rises. Ann Arbor: University of Michigan News and Information Services. Available at: www.monitoringthefuture.org (accessed on September 12, 2005).
Kilpatrick, D. G., Acierno, R., Saunders, S., Resnick, H. S., Best, C., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68, 19–30.
Leccese, M., & Waldron, H. B. (1994). Assessing adolescent substance use: A critique of current measurement instruments. Journal of Substance Abuse Treatment, 6, 553–563.
Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1996). Alcohol consumption in high school adolescents: Frequency of use and dimensional structure of associated problems. Addiction, 91, 375–390.
Martin, C. S., Kaczynski, N. A., Maisto, S. A., Bukstein, O. M., & Moss, H. B. (1995). Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. Journal of Studies on Alcohol, 56, 672–680. Martin, C. S., & Winters, K. C. (1998). Diagnosis and assessment of alcohol use disorders among adolescents. Alcohol Health & Research World, 22, 95–105.
Mee-Lee D., G. D. Shulman, M. Fishman, D. R. Gastfriend, & J. H. Griffith (Eds.). (2001). ASAM placement
criteria for the treatment of substance-related disorders, second edition-revised. Chevy Chase: American Society of
Addiction, Inc.
Meyers, K., Hagan, T. A., Zanis, D., Webb, A., Frantz, J., Ring-Kurtz, S., Rutherford, M., & McLellan, A. T. (1999). Critical issues in adolescent substance use assessment. Drug and Alcohol Dependence, 55, 235–246. Milgram, G. G. (2002). Youthful drinking. Alcoholism Treatment Quarterly, 20, 143–146.
Miller, E. T., Turner, A. P., & Marlatt, G. A. (2001). The harm reduction approach to the secondary prevention of alcohol problems in adolescents and young adults: Considerations across a developmental spectrum. In: P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 58–79). New York: Guilford Press.
Newcomb, M. D., & Bentler, P. M. (1989). Substance use and abuse among children and teenagers. American Psychologist, 44, 242–248.
O’Malley, P. M., Johnston, L. D., & Bachman, J. G. (1998). Alcohol use among adolescents. Alcohol Heath & Research World, 22, 85–93.
Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of adolescent substance use: Organizing pieces of the puzzle. Psychological Bulletin, 117, 67–86.
Pollock, N. K., & Martin, C. S. (1999). Diagnostic orphans: Adolescents with alcohol symptoms but no DSM-IV diagnosis. American Journal of Psychiatry, 156, 897–901.
Shedler, J., & Block, J. (1990). Adolescent drug use and psychological health: A longitudinal inquiry. American Psychologist, 45, 612–630.
Swadi, H. (1999). Individual risk factors for adolescent substance use. Drug and Alcohol Dependence, 55, 209–224. Tarter, R. E., & Vanyukov, M. (1994). Alcoholism: a developmental disorder. Journal of Consulting and Clinical Psychology, 62, 1096–1107.
Wagner, E. F. (2004). Developmentally and contextually congruent approaches to treating alcohol and other drug use problems among adolescents. Talk given at University of Wisconsin-Oshkosh, Oshkosh, Wisconsin. Windle, M. (1996). An alcohol involvement typology for adolescents: Convergent validity and longitudinal stability. Journal of Studies on Alcohol, 57, 627–637.
Winters, K. C. (2001). Assessing adolescent substance use problems and other areas of functioning: State of the art. In P. M. Monti, S. M. Colby, & T. A. O’Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp. 80–108). New York: Guilford Press.
Winters, K. C., Latimer, W., & Stinchfield, R. D. (1999). The DSM-IV criteria for adolescent alcohol and cannabis use disorders. Journal of Studies on Alcohol, 60, 337–344.
2009, Vol. 14, No. 1 , Pages 49-60 (doi:10.1080/14659890802211796)
M. A. Felgus, S. B. Caldwell, and V. HesselbrockDepartment of Psychiatry, University of Wisconsin Medical School, Wisconsin, , USA
Adolescent Alcohol/Drug Assessment Intervention Program, University of Wisconsin Hospital & Clinics, WisconsinUSA
Department of Psychiatry, University of Connecticut School of Medicine, ConnecticutUSA
660 West Washington Avenue, Suite 307, Madison, WI 53703, USA mafelgus@wisc.edu
M. A. Felgus, S. B. Caldwell, and V. HesselbrockDepartment of Psychiatry, University of Wisconsin Medical School, Wisconsin, , USA
Adolescent Alcohol/Drug Assessment Intervention Program, University of Wisconsin Hospital & Clinics, WisconsinUSA
Department of Psychiatry, University of Connecticut School of Medicine, ConnecticutUSA
660 West Washington Avenue, Suite 307, Madison, WI 53703, USA mafelgus@wisc.edu
