Every clinician employed in a university or college counseling center or student health center in the United States is dealing with the complex issue of high-risk underage alcohol consumption. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), stated: Alcohol is the most widely used substance of abuse among youth in the United States, and drinking by young people possess enormous health and safety risks [1]. Young people are drinking alcohol in very large amounts, and most high schools, colleges, and universities are trying to find effective ways to combat this public health epidemic. In 2013, 59.4 percent of full-time college students’ ages 18-22 drank alcohol in the past month compared with 50.6 percent of other persons of the same age [2]. According to the Centers for Disease Control and Prevention (CDC) “Drinking by individuals under the age of 21 is illegal in all 50 states; however, people aged 12 to 20 drink 11% of all alcohol utilized in the country [2]. These researchers also found on “Average, underage drinkers consume more drinks per drinking occasion than adult drinkers”. Not only are underage individuals consuming a lot of alcohol they are doing so in larger numbers than legal age adults. This behavior can result in a variety of consequences. Ehrlich, Haque, Swisher-McClure, and Helmkamp found college students are very likely to have alcohol-related problems [3].

Underage high-risk drinking can have implications ranging from occurrences that cause damage to the drink to second-hand effects that affect others. Many researchers on the subject matter cite the following risks: binge drinking, alcohol poisoning, physical injury of self or others, aggression, suicide ideation, symptoms of alcohol use disorder, and death. Perkins also included the following “Potential negative consequences of college student drinking “Academic impairment, blackouts, short and longer term physical illnesses, unintended and unprotected sexual activity, sexual coercion/rape, impaired driving, legal repercussions, and reduced athletic performance” [4]. College Drinking found “about 1 in 4 college students report academic consequences from drinking, including missing class, falling behind in class, doing poorly on exams or papers, and receiving lower grades overall [5]. All of the risks above are first-hand effects of underage alcohol consumption.

Underage high-risk drinking also includes second-hand effects that are overlooked and affect more than just the college drinker. Second-hand effects of college drinking cost colleges and universities a substantial amount of money can. Some costs include: Campus property damage; loss of tuition from students not retained; cost of substance misuse prevention, education, and treatment personnel; college counseling centers; security staff; administrative hearings on academic and dispensary cases; and legal expenses from suits against institutions found liable [4]. Due to the many consequences associated with high-risk college drinking, many higher education administrators actively try to solve this problem.

Universities and colleges have reviewed many ways in which to prevent, educate, screen, and briefly treat college students who misuse alcohol. Many colleges and universities hire psychologists, social workers, and counselors as the clinicians to combat the issue of highrisk underage drinking. Clinicians in higher education should use the College Systems Model to prevent, educate, assess, and treat high-risk underage drinking. Giving particular attention to both the students drinking motives and mental health systems which both can encourage dangerous levels of alcohol consumption amounts underage drinkers. There has not been a significant amount of research published on student health and counseling center staff members using the College Systems Model as a part of their clinical practice. Practitioners on the front lines of dealing with the problem of underage drinking should use the College Systems Model “Comprehensive, integrated approach to reducing alcohol-related problems on college campuses” [6]. More research should address social workers, counselors, psychologists, and other on-campus mental health providers using the College Systems Model to combat the problem of underage drinking.

Searches for journal articles and dissertations were conducted using Pro Quest and Google Scholar databases. Search terms included: underage drinking, high-risk drinking, social work systems theory, drinking motives, college alcohol systems, and mental health. Articles had to be written in English and published in a peer-reviewed journal to meet the criteria for being part of this review. Dissertations written in English were also included. A review of titles, abstracts, and keywords determined inclusion.

Collectively, more than 121,141 articles were produced. Any materials lacking empirical results or involving information on underage college alcohol consumption, College Alcohol Systems, drinking motives, or mental health were excluded. Articles appearing on multiple databases were also eliminated. Nine articles initially met inclusion criteria and were selected for this literature review. The reference section of each article was scanned for additional relevant citations. No additional articles were identified or added to the literature review. A total of nine peer-reviewed journal articles are included in this literature review.

Life stressors and maladaptive coping skills can encourage college students to engage in high-risk drinking behaviors. Other researchers feel high-risk drinking occurs to do student’s drinking motives, impulsivity, difficulty adjusting to college life and mental health disorders such as depression, trauma, and social anxiety.

Drinking motives are paths to alcohol use that include both individual and ecological impacts. College students drink for positive mood enhancement, to be social and outgoing, and to cope and avoid negative experiences [7]. These researchers also found that social and enhancement motives are considered to be positive reinforcement for drinking and do not have a direct association with alcohol consequences through increased alcohol use [7]. Using alcohol to cope with something is a drinking motive that is considered a negative motive because drinkers consume alcohol to deal with something negative. These behaviors can produce maladaptive coping skills and can lead to symptoms of an alcohol use disorder. The research also stated that college students that drink for social or enhancement reasons often consume alcohol at higher levels [7]. The more college students drink to be social or if alcohol is used to produce a positive mood these students tend to drink more which could lead to harmful drinking consequences. “Coping motives are less frequently endorsed and are more strongly related to negative alcohol-related consequences; however, another study demonstrated the relationship between coping and alcohol-related consequences was mediated by level of alcohol use” [7]. It is important for clinicians to ask about the amount college students drink as well as if they are drinking to improve their mood, be social, or to cope with something.

Impulsivity is one of the main reasons college students engage in high-risk drinking. Impulsivity can be broadly defined as “The predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions” [8]. Being a college student is one of the most impulsive times in a person’s life. Higher levels of impulsive traits distingue early-onset from later onset drinkers and are related to greater student drinking [9]. All impulsive college students do not engage in high-risk drinking; however, “If an impulsive individual does not expect that drinking will likely lead to a positive experience, his or her ability to inhibit drinking will not be challenged by poor impulse control” [9]. However, those students who are both impulsive and believe that their drinking would lead to positive drinking experiences are more likely to engage in high-risk drinking behaviors and also experience negative drinking consequences. Therefore, it is important for clinicians to identify whether or not impulsive student views alcohol consumption as yielding a positive or negative experience.

College is a time of great fun but also a time of severe stress and adjustment. Transitioning to a new city, home, and finding on-campus support can be a daunting task for most college students. “The college environment presents a dramatic lifestyle change for many students. Some students quickly acclimate to this environment while others struggle to adjust” [7]. “Schulenberg and co-authors state a student’s time at college can be stressful and characterize it as a “developmental disturbance” in which the student is presented with a broad range of academic, social, and developmental challenges that must be navigated concomitantly with the sudden increase in autonomy [10]. This time of developmental disturbance can cause high levels of stress for college students who may find it difficult to find ways to cope with all changes. In turn, coping-motivated alcohol use is positively related to psychological maladjustment in college students” [7]. Without the ability to adequately cope with the stressors of the college environment, some college students will turn to alcohol to deal with collegiate adjustment and other life stressors will result in high-risk drinking consequences. It’s important that clinicians explore the collegiate adjustment with students as a possible motivator for high-risk alcohol consumption.

Several mental health disorders have a relationship with high-risk collegiate alcohol consumption: depression, social anxiety, and trauma/ post-traumatic stress disorder. Alcohol use, depression, and suicide ideation/attempts are all significant public health issues where college students are particularly at risk [8]. College students that consume alcohol can also be in danger for symptoms of depression and suicide ideation. According to Dvorak, Lamis, and Malone, it is important to examine underlying mechanisms that may be contributing to an elevated suicide risk among individuals who are using alcohol and experiencing depressive symptoms [8]. There can be times when college students may be drinking to decrease symptoms of depression and end up having suicidal ideation or increased feelings of depression. It is the duty of on-campus to screen, assess, educate, and treat co-occurring depression and alcohol use disorder symptoms in college students.

Many college students experience trauma exposure both on and off their college campuses. These traumatic experiences can increase their alcohol consumption. Trauma exposure among college students is, unfortunately, common [11]. Collegiate traumatic experiences are significant by standard—including but not limited to sexual assault and other interpersonal violence, natural disasters, military trauma, life-threatening illness, and motor vehicle accidents [11]. Not all students who experience trauma meet the criteria for posttraumatic stress disorder. A substantial portion of trauma-exposed individuals do not meet the full criteria for PTSD diagnosis but nonetheless suffer significant trauma associated distress [11]. Many researchers report individuals who experience trauma or have symptoms of PTSD engage in self-medicating through the use of mood altering substances. Some empirical evidence supports the self-medication hypothesis on traumatic stress and substance use [11]. Researchers have found “trauma exposure and PTSD, in particular, heightens the risk of alcohol and other drug consequences during this period of vulnerability [11]. It is paramount that on campus clinicians be able to understand the link between alcohol use disorders and high-risk drinking and trauma and posttraumatic stress disorder symptoms. Also due to the severity of traumatic experiences, social workers should be trained to work specifically with students who experience aspects of trauma. The failure in being trained in trauma based evidenced informed practices may lead to social workers re-traumatizing the student which then may affect how much alcohol they consume.

There is often a correlation between social anxiety and high-risk drinking behaviors amongst college students. Social anxiety may increase the risk of alcohol-related problems in this population [12]. Some researchers found that students with symptoms of social anxiety disorder tend to drink more and have more negative consequences in comparison to the student without a social anxiety disorder. Some researchers suggest that drinking in adverse situations to alleviate negative emotions may account for the positive relationship between social anxiety and adverse drinking consequences [12]. Morris, Stewart, and Ham suggested that social anxiety may provide insight into problem drinking among college students [13]. It is vital that on campus clinicians understand the link between alcohol use disorders and high-risk drinking and anxiety disorder symptoms. Clinicians should be able to screen and treat students with anxiety disorders who may be drinking to alleviate emotional, behavioral, and physical symptoms. The students may also need additional coping mechanisms to identify ways to better cope with their anxiety disorder symptoms.

The College Alcohol Systems Model is a comprehensive tool that addresses high-risk alcohol consumption. This model was introduced to the public by the University of Minnesota’s Alcohol Epidemiology program. The tool was created to assists colleges and universities in being effective when supporting students who have various types of experiences with alcohol. To be effective at reaching the entire contumely of students who may experience alcohol-related problems, campuses must do more than implementing single policy or program. Commented of a comprehensive campus alcohol system include alcohol screening, intervention, treatment, prevention policy, and enforcement [6]. On campus, clinicians must look at ways to actually help students at the micro level directly and individually, at the macro level on campus dealing with policy creators and rule markers, and at the mezzo level to identify the needs of both the campus and surrounding community. Toomey and co-authors stated that while some colleges and universities may implement that single programs and policies that may reduce alcohol use and related problems among students; however, the programs do not address the problem in its entirety [6]. To effectively deal with the complex issue of high-risk and underage drinking colleges must do more than implementing single policies and programs [6]. According to the AEP at the individual level students should gain skills development, mandated intervention, age specific high-quality treatment, and system-wide screening for problematic use and symptoms of alcohol use disorders [6]. At the college level, there should be “awareness of policies, consistent consequences, and accessible websites for resources, system-wide coordination, consistent enforcement, prevention policies, and a change in the campus drinking norms as well as campus drinking culture [6]. And finally, at the community level, there should be “controlling of alcohol at on-campus parties, control of alcohol at rental properties, restricting alcohol availability in the community, regulating the alcohol marketing, and making sure that all alcohol services is responsible [6]. Clinicians should be able to screen the campus community for alcohol consequence signs and symptoms, provide education, treatment, and invention clinical services, as well as work on committees to be a part of prevention policies and join task forces to be a part of the enforcement conversation. Not engaging in this comprehensive model is not only detrimental to college students but also to the college campus and surrounding community. Based on an assessment done by Toomey and co-authors, there is not a University that has “an overall, comprehensive alcohol system, such as the College Alcohol System, to address student alcohol use [6]. These researchers have found the College Alcohol System model complement each other and have a synergistic effect when combating the issue of collegiate drinking [6]. More research is needed on the collegiate use of the College Alcohol Systems model.

The College Alcohol Systems model can be essential in combating the public health issue of high-risk underage alcohol consumption [14]. The model is integrated and comprehensive enough to assist both the students and the campus community. This model will also encourage the counseling center and student health staff members, often on the front line, more support when dealing with this complex issue as well as insight and input on rules, regulations, and policies that affect the campus and surrounding community.

There are a few limitations in this literature review. There is a lack of research on the use of the College Alcohol System Model. There have been studies that have shown success with different aspects of the model but not a study that has demonstrated the effectiveness of this model in its entirety. More colleges and universities as well counseling center and student health providers should incorporate the College Alcohol Systems Model to combat the complex issue of high-risk underage drinking. Such a complex problem should be addressed on the individual, campus, and surrounding community levels.

The major implication of this literature review is that more research is needed on the effectiveness of the College Alcohol Systems Model as it relates to both colleges and universities and those who are working in university counseling centers or student health centers. There is no “one size fits all” approach to treating the complex issue of underage highrisk alcohol consumption. Colleges and universities need programs that are both comprehensive and integrated.