Divergent Pathways Taken in Adolescence Predict Embracing or Resisting Moderate-to-Heavy Drinking in Young Adulthood

BACKGROUND: Heavy alcohol drinking during adolescence is a major public health concern and a primary risk factor for developing alcohol use disorder (AUD) in adulthood. Identifying robust, modifiable predictors that distinguish adolescents who initiate heavy drinking from those who maintain low consumption can guide targeted prevention strategies. METHODS: We analyzed longitudinal data from 285 participants (141 female and 144 male) of the NCANDA (National Consortium on Alcohol and Neurodevelopment in Adolescence) study. All participants were no-to-low drinkers at age 15 years, remained in the study within a year of turning 21, and were followed annually, making this neuroimaging study the largest of its kind. Each visit consisted of 240 measurements (spanning cognitive, environmental, neuroimaging, and psychosocial domains), which were used to train a deep learning model to predict drinking levels and learn an embedding space capturing key risk factors. Individual developmental profiles were then clustered into distinct pathways across ages 15 to 21. RESULTS: Six unique drinking pathways were identified. Two pathways leading to heavy drinking were characterized by early exposure to peer drinking, positive alcohol expectancies, and higher sensation seeking, predominantly among males. Three moderate-drinking pathways showed gradual increases in consumption while maintaining lower peer drinking exposure. One pathway maintained no-to-low drinking, marked by negative expectancies toward alcohol and low social reinforcement. CONCLUSIONS: Distinct developmental pathways highlight socially driven motivators as key modifiable risk factors underlying adolescent drinking. Targeting peer influence and alcohol-related expectancies could help divert youth from trajectories leading to heavy drinking and reduce the future burden of AUD.