Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
Commentary

Alcohol Use Disorder: A Pediatric-Onset Condition Needing Early Detection and Intervention

Scott E. Hadland, John R. Knight and Sion K. Harris
Pediatrics March 2019, 143 (3) e20183654; DOI: https://doi.org/10.1542/peds.2018-3654
Scott E. Hadland
aDepartment of Pediatrics and Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts;
bDivision of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
John R. Knight
cDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts;
dDepartments of Medicine and Psychiatry, Boston Children's Hospital, Boston, Massachusetts
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sion K. Harris
cDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts;
eDivision of Adolescent and Young Adult Medicine,
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • Comments
Loading
Download PDF
  • Abbreviations:
    AUD —
    alcohol use disorder
    CRAFFT —
    car, relax, alone, forget, friends, trouble
    NIAAA —
    National Institute on Alcohol Abuse and Alcoholism
  • Despite the enormous attention currently paid to drug overdose mortality in the United States, it is humbling that in 2016, deaths caused by alcohol were more than double those involving opioids.1,2 Alcohol contributes to up to one-half of all deaths among the 3 leading causes of adolescent and young adult mortality: unintentional injury (the majority of which are motor vehicle crash fatalities), homicide, and suicide.1,3 Heavy alcohol use also contributes to liver disease, cancer, and stroke among numerous other fatal chronic illnesses arising during adulthood.3

    Alcohol use disorder (AUD) is a pediatric-onset condition. AUD is defined as recurrent alcohol consumption coupled with physiologic dependence, risky use, loss of control, and/or impaired social functioning.4 Nearly 4 in 5 people in treatment for AUD report that they first began drinking during adolescence.5 It is therefore incumbent on pediatricians and other providers caring for adolescents to detect and intervene in AUD as early as possible in the life course.

    In this issue of Pediatrics, Linakis et al6 report a large, pediatric emergency department–based study of screening for alcohol use. Using a validated 2-question screen from the National Institute on Alcohol Abuse and Alcoholism (NIAAA),7 the authors follow >1300 adolescents aged 12 to 17 years and determine the extent to which baseline screening results are associated with a future diagnosis of AUD at 1, 2, and 3 years follow-up. The NIAAA screen asks adolescents to quantify the number of days of any alcohol use they have had during the past year. The authors found that sensitivity and specificity for identifying adolescents who go on to develop future AUD at any of the follow-up time points were maximized using a cutoff of any days of drinking in the past year; sensitivity and specificity of any past-year drinking were 86% and 78%, respectively, at 1 year of follow-up. As might be expected, the predictive validity of the baseline screen waned at 2 and 3 years follow-up, pointing to the need for recurrent (eg, greater than or equal to annual) screening over time.

    Long-term predictive validity may also be improved by identifying adolescents who do not use alcohol but who report having peers who drink and are therefore at risk for initiation; the second question in the NIAAA 2-item screen pertains to peer drinking. Following the NIAAA items with a brief screen for problematic use, such as the 6-item CRAFFT (car, relax, alone, forget, friends, trouble) screening tool (crafft.org), could also help improve specificity.8 Additionally, the CRAFFT includes an important safety-risk screen; the first item in the CRAFFT asks about riding with a driver who is under the influence or driving under the influence, both of which are central contributors to motor vehicle crash mortality.1 The NIAAA recommends the CRAFFT screen as a follow-up in those who screen positive for alcohol use only.7 However, nearly one-third of adolescent primary care patients report riding with an impaired driver, and >40% of these have no past-year substance use.9 The risk could be even more prevalent in the emergency department setting.

    The findings of Linakis et al6 beg the question: should emergency departments screen all adolescents for alcohol use? The American Academy of Pediatrics recommends universal substance use screening, brief intervention, and referral to treatment for adolescents presenting to primary care,10 and increasingly, schools are also adopting screening, brief intervention, and referral to treatment.11,12 Conducting universal screening in emergency departments would offer an additional setting in which to identify high-risk adolescents, including the highest-risk individuals who might not seek primary care or attend school. Although the NIAAA 2-item screen is somewhat complicated for clinicians because its questions and screen-positive cutoffs are based on age, studies increasingly suggest that screening can be conducted electronically to improve fidelity.13 Fortunately, Linakis et al6 found that the NIAAA screen for predicting future AUD may work best when using a simple cutoff (any days of past-year alcohol use) and thus facilitating clinical use.

    As is the case for all screening tests, the utility of the NIAAA screen hinges entirely on the availability and implementation of evidence-based interventions for adolescents who screen positive. Widespread screening should only be adopted if the health system can intervene to prevent future alcohol-related harm, including AUD. Clinicians will need to provide an immediate, age-appropriate, brief intervention to adolescents who drink. Computer-based, brief interventions have been developed for high-risk adolescents and are effective in emergency department settings14 but have not yet been widely implemented.

    Given the low positive predictive value of the NIAAA screen (only 7% of adolescents who screening positive developed AUD 1 year later), emergency departments would need any brief intervention to be time efficient because the majority of adolescents reporting drinking will not ultimately develop AUD. Tailoring brief interventions to the risk level of adolescents (which can be determined by using the NIAAA screen) is likely to improve outcomes and efficiency. Adolescents who are already demonstrating signs of AUD will need referrals to alcohol-use treatment services, which are limited in many geographical regions, particularly rural areas.15 Even when referrals to treatment are made, adolescents and their families are likely to require substantial support in navigating the complex addiction-treatment landscape, where substantial barriers (eg, limited insurance coverage, waiting lists, and stigma surrounding treatment) impede the receipt of care and where quality varies widely.16,17

    Intervening as early as possible in the trajectory of developing AUD offers great promise to prevent a lifetime of potential harm and avert early death. The work of Linakis et al6 elucidates the critical first step in addressing AUD by demonstrating how to identify adolescents who are at risk. Next, the pediatric workforce needs to ensure that adolescents who are identified receive effective, evidence-based interventions to reduce morbidity and mortality from AUD, which is a childhood-onset condition.

    Footnotes

      • Accepted December 13, 2018.
    • Address correspondence to Scott E. Hadland, MD, MPH, MS, Department of Pediatrics and Grayken Center for Addiction, Boston Medical Center, Vose Hall 322, 88 E. Newton St, Boston, MA 02118. E-mail: scott.hadland@bmc.org
    • Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Dr Hadland was supported by the National Institutes of Health National Institute on Drug Abuse (K23DA045085), and the remaining authors received no funding. Funded by the National Institutes of Health (NIH).

    • POTENTIAL CONFLICT OF INTEREST: Dr Knight holds the copyright to the CRAFFT (car, relax, alone, forget, friends, trouble) screening tool; and Drs Hadland and Harris have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2001.

    References

    1. ↵
      1. Xu J,
      2. Murphy SL,
      3. Kochanek KD,
      4. Bastian B,
      5. Arias E
      . Deaths: final data for 2016. Natl Vital Stat Rep. 2018;67(5):1–76pmid:30248015
      OpenUrlPubMed
    2. ↵
      1. Seth P,
      2. Scholl L,
      3. Rudd RA,
      4. Bacon S
      . Overdose deaths involving opioids, cocaine, and psychostimulants - United States, 2015-2016. MMWR Morb Mortal Wkly Rep. 2018;67(12):349–358pmid:29596405
      OpenUrlCrossRefPubMed
    3. ↵
      1. Gonzales K,
      2. Roeber J,
      3. Kanny D, et al; Centers for Disease Control and Prevention (CDC)
      . Alcohol-attributable deaths and years of potential life lost–11 states, 2006-2010. MMWR Morb Mortal Wkly Rep. 2014;63(10):213–216pmid:24622285
      OpenUrlPubMed
    4. ↵
      1. American Psychiatric Association
      . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013
    5. ↵
      1. Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality
      . Treatment Episode Data Set (TEDS): 2005-2015. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-91, HHS Publication No. (SMA) 17-5037. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2017
    6. ↵
      1. Linakis JG,
      2. Bromberg JR,
      3. Casper TC, et al; Pediatric Emergency Care Applied Research Network
      . Predictive validity of a 2-question alcohol screen at 1-, 2- and 3-year follow-up. Pediatrics. 2019;143(3):e20182001
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. National Institute on Alcohol Abuse and Alcoholism
      . Alcohol screening and brief intervention for youth: a practitioner’s guide. 2015. Available at: https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf. Accessed November 10, 2018
    8. ↵
      1. Knight JR,
      2. Sherritt L,
      3. Shrier LA,
      4. Harris SK,
      5. Chang G
      . Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607–614pmid:12038895
      OpenUrlCrossRefPubMed
    9. ↵
      1. Knight JR,
      2. Csemy L,
      3. Sherritt L, et al
      . Screening and brief advice to reduce adolescents’ risk of riding with substance-using drivers. J Stud Alcohol Drugs. 2018;79(4):611–616pmid:30079877
      OpenUrlPubMed
    10. ↵
      1. Levy SJ,
      2. Williams JF; Committee on Substance Use and Prevention
      . Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211pmid:27325634
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Mitchell SG,
      2. Gryczynski J,
      3. Gonzales A, et al
      . Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program: services and outcomes. Am J Addict. 2012;21(suppl 1):S5–S13pmid:23786511
      OpenUrlPubMed
    12. ↵
      1. Maslowsky J,
      2. Whelan Capell J,
      3. Moberg DP,
      4. Brown RL
      . Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: process and feasibility. Subst Abuse. 2017;11:1178221817746668pmid:29317825
      OpenUrlPubMed
    13. ↵
      1. Harris SK,
      2. Csémy L,
      3. Sherritt L, et al
      . Computer-facilitated substance use screening and brief advice for teens in primary care: an international trial. Pediatrics. 2012;129(6):1072–1082pmid:22566420
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Cunningham RM,
      2. Chermack ST,
      3. Ehrlich PF, et al
      . Alcohol interventions among underage drinkers in the ED: a randomized controlled trial. Pediatrics. 2015;136(4). Available at: www.pediatrics.org/cgi/content/full/136/4/e783pmid:26347440
      OpenUrlAbstract/FREE Full Text
    15. ↵
      1. Substance Abuse and Mental Health Services Administration
      . SAMHSA behavioral health treatment services locator. Available at: https://findtreatment.samhsa.gov. Accessed November 10, 2018
    16. ↵
      1. Mark TL,
      2. O’Brien J,
      3. Mendell G,
      4. McLellan AT,
      5. Arsenault S
      . Improving addiction treatment with consumer report cards. Health Affairs Blog. January 5, 2018. Available at: https://www.healthaffairs.org/do/10.1377/hblog20180102.514756/full/. Accessed November 10, 2018
    17. ↵
      1. Ashford RD,
      2. Brown AM,
      3. Curtis B
      . Systemic barriers in substance use disorder treatment: a prospective qualitative study of professionals in the field. Drug Alcohol Depend. 2018;189:62–69pmid:29883870
      OpenUrlPubMed
    • Copyright © 2019 by the American Academy of Pediatrics
    PreviousNext
    Back to top

    Advertising Disclaimer »

    In this issue

    Pediatrics
    Vol. 143, Issue 3
    1 Mar 2019
    • Table of Contents
    • Index by author
    View this article with LENS
    PreviousNext
    Email Article

    Thank you for your interest in spreading the word on American Academy of Pediatrics.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Alcohol Use Disorder: A Pediatric-Onset Condition Needing Early Detection and Intervention
    (Your Name) has sent you a message from American Academy of Pediatrics
    (Your Name) thought you would like to see the American Academy of Pediatrics web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Request Permissions
    Article Alerts
    Log in
    You will be redirected to aap.org to login or to create your account.
    Or Sign In to Email Alerts with your Email Address
    Citation Tools
    Alcohol Use Disorder: A Pediatric-Onset Condition Needing Early Detection and Intervention
    Scott E. Hadland, John R. Knight, Sion K. Harris
    Pediatrics Mar 2019, 143 (3) e20183654; DOI: 10.1542/peds.2018-3654

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Share
    Alcohol Use Disorder: A Pediatric-Onset Condition Needing Early Detection and Intervention
    Scott E. Hadland, John R. Knight, Sion K. Harris
    Pediatrics Mar 2019, 143 (3) e20183654; DOI: 10.1542/peds.2018-3654
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    Print
    Download PDF
    Insight Alerts
    • Table of Contents

    Jump to section

    • Article
      • Footnotes
      • References
    • Info & Metrics
    • Comments

    Related Articles

    • No related articles found.
    • PubMed
    • Google Scholar

    Cited By...

    • Predictive Validity of the CRAFFT for Substance Use Disorder
    • Google Scholar

    More in this TOC Section

    • Artificial Intelligence for ROP Screening and to Assess Quality of Care: Progress and Challenges
    • Children’s Hospitals: We Get What We Pay For
    • Breastfeeding: A Key Investment in Human Capital
    Show more Commentary

    Similar Articles

    Subjects

    • Substance Use
      • Substance Use
    • Adolescent Health/Medicine
      • Adolescent Health/Medicine
    • Journal Info
    • Editorial Board
    • Editorial Policies
    • Overview
    • Licensing Information
    • Authors/Reviewers
    • Author Guidelines
    • Submit My Manuscript
    • Open Access
    • Reviewer Guidelines
    • Librarians
    • Institutional Subscriptions
    • Usage Stats
    • Support
    • Contact Us
    • Subscribe
    • Resources
    • Media Kit
    • About
    • International Access
    • Terms of Use
    • Privacy Statement
    • FAQ
    • AAP.org
    • shopAAP
    • Follow American Academy of Pediatrics on Instagram
    • Visit American Academy of Pediatrics on Facebook
    • Follow American Academy of Pediatrics on Twitter
    • Follow American Academy of Pediatrics on Youtube
    • RSS
    American Academy of Pediatrics

    © 2021 American Academy of Pediatrics