Alcohol Use and Abuse: A Pediatric Concern

ATTITUDES, PERCEPTIONS, AND INFLUENCE

The use of alcohol commonly begins before the use of other mood altering substances. Most adolescents drink beer or wine before they begin drinking distilled spirits yet are unaware that a 12-oz can of beer or 5-oz glass of wine has the same amount of alcohol as a 1.5-oz shot of distilled spirits.¹⁰ Alcohol is often used in combination with other drugs, which may potentiate their effects.

Addiction to alcohol is underdiagnosed in adolescents. By definition, alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol with adverse consequences, and distortion in thinking, most notably denial.²⁰

Alcoholism should be suspected in young people who are often intoxicated or experience withdrawal symptoms from chronic or recurrent alcohol use; those who tolerate large quantities of alcohol; those who attempt unsuccessfully to cut down or stop alcohol use; those who experience blackouts attributable to drinking; or those who continue drinking despite adverse social, educational, occupational, physical, or psychological consequences or alcohol-related injuries.²¹ In the adolescent substance use and abuse continuum, alcohol abuse may progress from experimentation to more regular use.^22,,23 Regular users are those individuals who continue a pattern of alcohol use throughout a period of 1 month or longer despite persistent or recurrent negative consequences or in situations in which such use is physically dangerous.²¹

Genetic and Family Factors

A family history of alcoholism predisposes children to problem drinking, especially if 1 or both parents are heavy drinkers.²⁴ Sons of alcoholic men have a 1 in 4 risk of becoming alcoholics.^25,,26 Daughters of alcoholics are also at increased risk for alcoholism and are more likely to marry alcoholic men, thereby continuing the cycle of family problems with alcohol.²⁷

In the United States, 7 million children younger than 18 years have alcoholic parents. Adult alcohol abuse contributes to 50% of reported instances of marital violence and 35% to 70% of child abuse cases. Children of alcohol abusers are at increased risk for delinquent behavior, learning disorders, attention-deficit/hyperactivity disorder, psychosomatic complaints, and problem drinking or alcoholism as adults.²⁸ Additional research is required to validate the clinical impression that describes interpersonal problems encountered by children of alcoholics.²⁸

Parental attitudes and behavior regarding alcohol use play important roles in how children and adolescents view its use and whether they will drink. A family history of antisocial behavior and poor parenting skills increases the risk of having children who use alcohol and other drugs.²⁸ The home is the primary source of alcohol for adolescents; however, drinking customs and patterns differ among ethnic groups. In some families, children are introduced to alcohol as a beverage at an early age, but these families do not drink excessively, do not tolerate or condone excessive drinking in others, and experience low levels of problem drinking. Other families, however, may accept and encourage excessive drinking, especially among males of any age, reinforcing the image of alcohol use as an indicator of maturity, bravado, and masculinity. Older siblings often influence their younger brothers or sisters to initiate using alcohol or other drugs.²⁹

Adolescent Development

Drinking by adolescents is often perceived as normal behavior. Some adolescents report that they drink for enjoyment, for peer acceptance, to forget problems, or to reduce stress and anxiety in their lives. Not all drinking by adolescents results in observable negative consequences, and a significant number of individuals do not continue to use alcohol after their initial experience. Because of their limited experience with alcohol and smaller body size, however, adolescents may become intoxicated with less alcohol intake than adults. In addition, in susceptible adolescents, the time frame of progression to alcohol dependence is much shorter, compared with that for adults.²³ They are less able to recognize and compensate for the neuropsychiatric effects of alcohol use because of biological, cognitive, and psychological immaturity and may experience psychological arrest of development with continued abuse.³⁰ Those with early antisocial behavior, poor self-esteem, school failure, attention-deficit/hyperactivity disorder, learning disabilities, or drug-using friends and those who are alienated from their peers or families are at increased risk. Depressed adolescents or those who have been physically or sexually abused may use alcohol to attempt to cope with their psychological distress and have a higher incidence of alcohol or other drug addiction.^31,,32

Peer Influence

Thirty percent of children in grades 4 through 6 report that they have received a lot of pressure from their classmates to drink beer.³³ During adolescence, drinking behavior, which often begins in a family setting, may continue with and be reinforced by peers. Because vulnerable adolescents generally seek out peer groups with similar attitudes and behaviors, pressure from this group can encourage alcohol and other drug use and other high-risk activities. Excessive drinking is more likely to occur outside the home with peers than within the family setting. Adolescents, like adults, may use alcohol to reduce social inhibitions and to accompany sexual activity.³⁴

Media Influence

Alcohol use permeates western society. Alcohol is advertised widely and is often seen by adolescents on television and in movies. Content analyses of alcohol advertisements on television show that the ads link drinking with highly valued personal attributes, such as sociability, elegance, and physical attractiveness, and with desirable outcomes, such as success, relaxation, romance, and adventure.³⁵ Fifty-six percent of students in grades 5 through 12 say that alcohol advertising encourages them to drink.³⁶ Studies show that with greater exposure to beer advertising, children have higher recall of brands or brand characters, are more likely to expect to drink as adults, and hold more positive beliefs about the social and ritual uses of beer.³⁵Econometric studies to date suggest that new restrictions on alcohol advertising or more counteradvertising could help reduce levels of alcohol abuse.³⁷

A recent study of more than 300 Web sites found that 25 major alcoholic beverage companies are using the Internet to advertise, promote, and sell their products through a variety of marketing techniques that capitalize on the Internet's strong attraction of young people. Such techniques include sponsorship of musical and sporting events, interactive games and contests, and chat and message boards. Overall, there are now hundreds of Web sites that promote alcohol, drinking, and specific products.³⁸

Community Attitudes

Alcoholic beverages are repeatedly seen as a reward at the end of a normal day's work or a sports victory or for any relaxing moment.^39,,40 A conflicting message about the hazards of drinking and driving is clearly present with the emergence of the mini-market, where beer, recreational items, and gasoline are sold at the same site. The risk of excessive alcohol use is never stated or even implied.

RECOMMENDATIONS

1. Pediatricians should strongly advise against the use of alcohol and illicit drugs as well as the nontherapeutic use of approved psychoactive drugs by children and adolescents.

2. Pediatricians should discuss the hazards of alcohol and other drug use with their patients as a routine part of risk behavior assessment, with special attention when there are risk factors for problem drinking, such as a family history of alcoholism.

3. Pediatricians should assess their patients' current use of alcohol and other drugs using a nonjudgmental approach.

4. Pediatricians should be able to recognize early signs and symptoms of alcohol abuse so they can properly evaluate, manage, and refer patients for further assessment and treatment as indicated.

5. Pediatricians should use prenatal and preventive child health care visits as an ideal opportunity to explore the family history and attitudes regarding alcohol use and discuss with parents the effects of positive and negative role modeling on their children.

6. Pediatricians should discuss the issue of adolescent parties with alcohol and discourage parents from allowing underage drinking at home or other locations.

7. A comprehensive substance abuse education curriculum should be an integral and integrated part of every training program for medical students and pediatric residents.

8. Pediatricians are encouraged to participate in school, community, and state efforts to promote alcohol-abuse prevention programs.

9. Alcohol consumption should be modeled responsibly in all media, with particular attention to its impact on youth.

10. There should be continued legislative efforts at the federal and state level to mandate a maximum legal blood alcohol level of 0.02% for those under 21 with appropriate penalties for those convicted of exceeding the legal level.

11. Pediatricians are encouraged to become familiar with the use of the Internet as a source of valuable information for themselves (see “Internet Resources”) as well as a potential source of misinformation for, and advertising aimed at, their patients.

Committee on Substance Abuse, 2000–2001

Edward A. Jacobs, MD, Chairperson

Alain Joffe, MD, MPH

John R. Knight, MD

John Kulig, MD, MPH

Peter D. Rogers, MD, MPH

Liaisons

Gayle M. Boyd, PhD

National Institute of Alcohol Abuse and Alcoholism

Dorynne Czechowicz, MD

National Institute on Drug Abuse

Deborah Simkin, MD

American Academy of Child and Adolescent Psychiatry

Staff

Karen Smith