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= Underage drinking = Underage drinking is the consumption of alcohol at an age that is below the legal drinking age of a country. The prevalence of underage drinking differs between cultures, with the highest percentage of teenage alcohol consumption being in Europe and Australia, and the lowest in Central Asia, East Asia and the Middle East and North Africa, possibly due to the strong islamic presence which forbids the drinking of alcohol. Multiple factors are seen as triggers for high underage drinking such as peer pressure and the influence of the family. As Bandura’s Social Learning Theory states, learning occurs through the observation and imitation of models, so naturally if drinking and heavy intoxication are regularly presented by models in the family, it desensitizes children to the consumption and presence of alcohol. This can have a severe effect on children’s lives as underage drinking can lead to health risks such as impaired brain development,  liver damage, disrupted growth and puberty, and weight loss. Possible strategies to avoid the occurrence of underage drinking is to have a good parent-child relationship, and to limit the premature exposure of children to alcohol.

Peer pressure
It is widely known that peers play a crucial role in teenage drinking. The negative influence of peers can increase the risk of alcohol consumption in adolescents. In a study where the Resistance to Peer Influence Scale was used, findings suggested that the resistance to peer pressure grew as age increased. In addition to that, the same study found that during the mid-adolescent period girls are generally more resistant towards peer influence than boys, as well as the resistance occurs earlier than in boys. Besides that, the quality of a parent-child relationship can influence peer affiliation on adolescent substance use and deviant behaviour by buffering the effects. So that adolescent girls, that experienced parenting behaviour such as social support and consistency of discipline, were less likely to be influenced by alcohol drinking peers. A study of McIntosh and colleagues explored that the focus of teenage drug users shifts from risk taking and experimentation with drugs, to a regular use for enjoyment, which includes that they are much less likely to seek to involve others in the activity.

Family influence
According to Foxcroft & Lowe, proper family socialisation can benefit an adolescent to have normal drinking behaviour. This indicates a responsible and controlled alcoholic consumption. In Western societies an occasional alcoholic beverage in an appropriate environment, is considered to be a normal part growing up from a child to an adult. Family socialisation can be divided into parental support and control. Excessive or insufficient support and control from caretakers leads to less confidence, less autonomy and poorer social skills. Inadequate levels of these factors have been associated with excessive underaged drinking.

A variety of certain family situations have a heightened risk of developing unusual drinking behaviour. For example, children growing up in a single-parent family or in a family with one birth parent and one step-parent are more vulnerable towards developing excessive drinking behaviour than children growing up with both birth parents. Similarly, children from divorced parents have more emotional distress and are therefore more vulnerable. In addition, the more one is exposed to intoxicated family members, the greater the negative influence on later drinking behaviour can be. Modelling of drinking behaviour can result in familiarization of alcoholic beverages and higher expectation with regard to the reinforcing effects of alcohol.

Other non-alcohol-specific influences include family history of psychopathology and socioeconomic status. Many parents who have alcoholic issues suffer from psychiatric disorders; Thus there is a low probability of their children learning the necessary self control towards alcohol. In most cases a combination of alcoholic and non-alcoholic risk factors leads to disturbed alcohol consumption in adolescents.

It should be noted that family is a crucial factor in preventing later alcohol abuse. Evidence suggests that individuals living in a disadvantaged neighbourhood with poor parents and an environment in which peers promote drinking, one is able to behave responsibly if one has desirable parental conditions. The most beneficial parental condition is when there is a balance between family support and control in the manner that the parents are not too strict or too tolerant. Importantly, family has a major influence on how threatening the mentioned risk factors are.

Statistics
According to the World Health Organization 2016, underage drinking between 15-19 years is common in most countries of the world with an overall alcohol consumption ranging from 10% to over 30% amongst the teenage population. Heavy episodic drinking amongst teenagers is most prevalent with over 30% in Europe, Australia, Congo and Gabon, followed by the United States, Canada, Russia and parts of South America with 20-29,9%. Less alcohol consumption can be found in Central- and South America and East- and South Asia with 10-19,9%. The only significant difference in Alcohol consumption of teenagers and amongst the population in general are in Central Asia, Southeast Asia, Middle East and North Africa with less than 5% which might be due to the dominant Islamic population in these countries.

In relation to the last years there are studies from the United States and Europe which show an annual decrease in teenage drinking. The 2018 Monitoring the Future Survey reported a proportional decrease of 67% among eighth graders, 57% among tenth grade students and 44% among twelfth grade students from 1991 to 2018 in the US. A similar trend can be found in Europe where the EU-average of teenagers between 11-15 years who reported drinking at least once a week has decreased about 32% from 2006 to 2014.

Even if there is a decline in underage drinking it is still a sensitive topic with many factors that can lead to a negative influence for the later development.

Health risks
Since the consumption of alcohol is becoming more frequent among teenagers, it is crucial to know the health risks connected to it.

The main health risks of underage drinking are:


 * Alcohol poisoning
 * Accidents and injuries
 * Sexual risk-taking
 * Disturbed sleep
 * Weight loss
 * Headaches
 * Disturbances in brain development
 * Disruption of growth and puberty
 * Liver damage
 * Damage to brain cells

Exposing the brain to alcohol during such a young age may interrupt key processes of brain development, possibly leading to mild cognitive impairments as well as to a continuous addictive drinking behaviour.

In a study by Brown and colleagues, memory problems were most common among adolescents in treatment, who had experienced alcohol withdrawal symptoms. The emergence of withdrawal symptoms generally indicates an established pattern of heavy drinking. Their appearance at a young age underscores the need for early intervention to prevent and treat underage drinking.

Underage drinking is also highly correlated with mental health problems. In fact, 43% of young people who drink alcohol have reported that it is their form of a coping mechanism to deal with other problems in their life:

It has been shown that chronic alcohol consumption in adolescence is linked to several mental disorders. 60% of juveniles which are engaged in substance abuse are diagnosed with a co-morbid psychiatric disorder. One of them is depression, as there is evidence that chronic drinking may increase depression level due to decreasing serotonin levels. A higher suicide risk is also associated with increased alcohol consumption. Researchers described that the positive correlation of depression and alcohol abuse also result in an increase of suicide among adolescents. There is conflicting evidence about the relationship between alcohol misuse and anxiety levels. Researchers differentiated between two “types” of drinkers. There is some evidence that adolescents who drink out of a sensation-seeking drive are less associated with long-term negative consequences than those who drink to reduce stress and anxiety. Alcohol consumption in adolescents seems to be linked to aggression as well. Researchers argued that alcohol consumption can facilitate certain psychological processes that lead to the expression of aggressive behavior. Still, this relationship remains complex.

Brain development
Drinking during teenage years can have major influences on the developing brain. Hereby applies, that the earlier the person starts drinking, the more severe will the risks be of changing the development of the brain. Two areas in the brain are especially at risk of being affected by early drinking:

The Hippocampus
The hippocampus is a small brain part, located in the medial temporal lobe and part of the limbic systems. It plays an important role in learning and memory consolidation. There is proof that heavy and extended alcohol use in adolescents is associated with a 10% reduction in the size of the hippocampus. It is supposed that neurons in the hippocampus are uniquely sensitive to alcohol, as they it is unusual poisonous to them and can lead to cell damage or death.

The prefrontal cortex
The prefrontal cortex is the part of the brain that covers the frontal part of the frontal lobe. It is associated with planning, decision making, organization and personality expression. It undergoes major changes during teenage years, and researchers have found that adolescents who are heavy drinkers significantly smaller prefrontal lobes than teenagers with normal drinking behavior. Convenient to that, there are studies that show that adolescent’s alcohol use can lead to impairment of problem solving and other cognitive functions.

In general, these impairments and changes of brain development in adolescents with heavy drinking attitudes increase the risk of alcohol-related problems in later life.

Prevention
Early exposure to alcohol consumption is highly correlated to subsequent alcoholism in during adulthood, which is why it is so important for preventive measures to start during early adolescence.

Peer pressure and social influence play a large role in the amount of alcohol being consumed by adolescent drinkers. It is more likely for adolescents to become heavy drinkers if they are within a social group that consists of numerous excessive drinkers. Possible intervention strategies against this include educating and improving the drink-refusal skills of adolescents, so that they have the means and know-how to reject offers of alcohol from peers. Furthermore, it is generally more likely for children with alcoholic parents or siblings to have premature exposure to alcohol. Preventive measures against alcoholism for adults (especially parents) will therefore, also make a difference in reducing underage drinking. Further efforts of prevention include engagement of school and parents to inform children of the dangers of alcohol consumption as well as involving them in extracurricular activities, such as sports, recreation, camps and drop-in centres, which have shown to decrease the likelihood of adolescents involving themselves in risk behaviour such as drug use. Community mobilization to prevent alcohol misuse has also proven to be useful. This includes communities making an effort to address underage drinking as a problem and in turn to enforce a change in norms or policies where needed. The quality of parent-child relationships are a good indicator of the likelihood of underage drinking, especially between ages 10 to 15. Parent-bonding, effective disciplining and involvement of the parents in the child’s activities have shown to decrease aggressive behaviour and enhance their social and cognitive competence, which in turn reduces the risk of a child turning to alcohol as a means of escaping depression or anxiety.