Abuse of alcohol frequently causes neurological damage, and early use of alcohol significantly increases both structural and functional brain changes. Because of this impact, youth alcohol abuse needs to be considered in patients presenting with a range of neurological and psychiatric problems, including brain trauma, epilepsy, stroke, and neuropathies as well as psychiatric problems such as depression and anxiety. Early onset alcohol use has long-term detrimental effects on adult behaviour, health, and mood. This paper reviews empirical research on alcohol use in youth, what the key risks are, and what the major protective factors appear to be. This review also assesses when to intervene, where to intervene, who to target, what interventions have been proposed, and what may be the most effective. The conclusion is that youth abuse of alcohol is frequently overlooked by neurologists and other physicians. The best way to reduce such abuse is to provide universal interventions prior to development of significant alcohol use and abuse, ideally during the 12-14 year age period. While the most effective methods for prevention are not yet clear, they are likely to involve internet-based systems, and some already exist. Physicians and neurologists need to recognize how important prevention is to mitigate the major neurological and psychiatric impacts of alcohol abuse in youth, and actively support such preventative measures if there is any realistic possibility of reducing the toll that alcohol abuse causes on developing brains.