Adolescents' spirituality and alcohol use.

Alcohol abuse is a significant public health problem in this country. Excessive alcohol consumption is the third leading cause of death in the US; more than 75,000 deaths annually are attributed to alcohol consumption. Unhealthy alcohol use has been found in 7 to 20% of adult outpatients, 30 to 40% of emergency room patients and 50% of trauma patients. (1) Data from the National Longitudinal Alcohol Epidemiologic Survey indicate that 12.5% of adults met DSM-IV alcohol dependence criteria, 19.9% of people who had ever drank met dependence criteria and 8% of adults met dependence criteria before age 25 years. (2) Adults who began drinking before 14 years of age were more likely to experience alcohol dependence at some point in their lives (in most cases within 10 year of the onset of their drinking) than adults who began drinking at age 21 years or older. (3) Not only is adolescent onset of alcohol consumption associated with adult alcohol abuse, but early age of onset of alcohol use is associated with increased alcohol use and other health risk behaviors as adolescents move from early adolescence to middle adolescence. (4)

Because of these troubling statistics, Knight et al's (5) study published in this issue of the Southern Medical Journal makes an important contribution to our understanding of what factors may be protective against adolescent alcohol use, and may potentially be used in the treatment of adolescent alcohol abusers. In a cross sectional sample of adolescents from three clinics in Boston, MA, Knight et al (5) found that alcohol use one or more times during the previous three months was associated with four indicators of spirituality during bivariate analyses: forgiveness, positive religious/spiritual coping, daily spiritual experiences and a belief "that God watches over me." In multivariate analyses, only forgiveness, broken down into three subscales of "I have forgiven myself," "I have forgiven others," and "God forgives me," were associated with a lower risk of previous three-month alcohol use. When the analyses were conducted only on adolescents who had attended an organized religious event, such as a church service, within the past year, only the belief that "God forgives me" was associated with not using alcohol. In the accompanying editorial, Dr. Peteet (6) provides a thorough discussion of the possible mechanisms of the relationship between feelings of forgiveness and alcohol use. Interestingly, Knight et al (5) did not find significant relationships between indicators of religiousness and past alcohol use in this sample of adolescents. Previous research among adolescents and young adults has consistently found weak, but significant, inverse relationships between measures of religiousness and alcohol and substance use. (7) Specifically, less substance use by adolescents has been associated with frequent attendance at religious services, importance of religion in their lives, and belonging to a church denomination that prohibits or discourages alcohol and drug use. It has been hypothesized that positive peer associations and support following traditional modes of socialization and subsequent higher psychological well-being are the primary mechanisms for this relationship between increased religiousness and lower alcohol and other substance use by adolescents.

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Recently, Cotton et al (8) have proposed a theoretical framework explaining the relationships between indicators of spirituality and religiousness and health outcomes among adolescents. Distal domains, consisting of indicators of religiousness, such as service attendance, frequency of prayer and meditation, and self-rated feelings of religiousness, are directly associated with proximal domains consisting of factors that include both indicators of spirituality and religious feelings. These include feelings of meaning and peace, positive and negative coping, and positive and negative church support. Proximal domains are then directly associated with health outcomes. In this model, Knight et al's (5) finding of a relationship between feelings of forgiveness and lower alcohol use would be considered a proximal domain, as it has a direct effect on the adolescent's health outcome. We assume that the indicators of religiousness, distal domains, are associated with the indicators of spirituality in this sample, thus having an indirect influence on alcohol use. Unfortunately, the correlations between indicators of religiousness and spirituality are not provided and the cross-sectional sample precludes us from drawing lines of causality; we can only assume covariation among these variables.

Although this is an extremely important study, the findings need to be interpreted in light of at least two weaknesses. First, alcohol use in this sample of youth appears to be different from national representative samples of high school age adolescents. (9) However, comparisons are problematic because Knight et al (5) measured alcohol use during the preceding three months and the traditional manner in which alcohol use has been measured among middle and high school students is within the last 30 days, last year, and lifetime. (9) In this study, past 90-day alcohol use was 30.1% for blacks, 30.9% for Hispanics and 57.8% for the small number of whites. (5) The 2005 CDC Youth Risk Behavior Survey (9) found that past 30-day alcohol use was 31.2% for blacks, 46.8% for Hispanics and 46.4% for whites. Assuming that the past 30-day use is lower than the past 90-day use, this clinic-based sample of adolescents does not mirror national statistics. Secondly, we do not know how stable the relationships between spirituality and alcohol are in adolescents. While Knight et al (5) should be commended for providing psychometric data on the internal reliability of the spirituality and religiousness scales, we do not have long-term test-retest data on these scales. Because of the rapid cognitive, psychological, and social developmental processes that are occurring during adolescence, it is safe to assume that the spirituality of adolescents may evolve rapidly as well. (10) This influences the clinical applicability of data drawn from cross-sectional studies for the inclusion of spirituality in both prevention and treatment. Longitudinal studies of representative samples are needed to replicate the important findings reported in this study. Apart from these weaknesses, Knight et al (5) have further increased our understanding of the relationship between spirituality and health outcomes among adolescents.

References

1. Centers for Disease Control and Prevention (CDC). Alcohol-attributable deaths and years of potential life lost-United States, 2001. MMWR Morb Mortal Wkly Rep 2004;53:866-870.

2. Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: results from the National Longitudinal Alcohol Epidemiologic Survey. J Subst Abuse 1997;9:103-110.

3. Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med 2006;160:739-746.

4. DuRant RH, Smith JA, Kreiter SR, et al. The relationship between early age of onset of initial substance use and engaging in multiple health risk behaviors among young adolescents. Arch Pediatr Adolesc Med 1999;153:286-291.

5. Knight JR, Sherritt L, Harris SM, et al. Alcohol use and religiousness/spirituality among adolescent. South Med J 2007;100:349-355.

6. Peteet JR. Should clinicians prescribe forgiveness? South Med J 2007;100:339-340.

7. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. Oxford, Oxford University Press, 2001.

8. Cotton S, Zebracki K, Rosenthal SL, et al. Religion/spirituality and adolescent health outcomes: a review. J Adolesc Health 2006;38:472-480.

9. Eaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance-United States, 2005. MMWR Surveill Summ 2006;55:1-108.

10. DuRant RH. Religiosity and spirituality and substance use and abuse: epidemiology, identification, and treatment. Paper presented to the Spirituality/Medicine Interface Conference. Southern Medical Association. Atlanta, GA, September 16, 2006.

Still--in a way--nobody sees a flower--really. It is so small--we
haven't time--and to see takes time, like to have a friend takes time.
--Georgia O'Keefe

Robert H. DuRant, PhD

From the Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC.

Reprint requests to Robert H. DuRant, PhD, Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1081. Email: [e-mail]

Accepted January 5, 2007.