IACAPAP Textbook of Child and Adolescent Mental Health

Section G
SUBSTANCE USE DISORDERS

Photo: kallerna , Wikimedia Commons

IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

G.1

SUBSTANCE USE DISORDERS

ALCOHOL MISUSE
Joseph M Rey

Joseph M Rey MD, PhD,FRANZCP

Professor of Psychiatry, Notre
Dame University Medical
School Sydney; Honorary
Professor, University of Sydney
Medical School, Sydney,
Australia.
Conflict of interest: nonereported.

The Triumph of Bacchus or The Drunks (c.1629). Diego Velázquez, Museo del Prado, Madrid.

Acknowledgements: Drs
Jennifer Bergen and Yvonne
Bonomo (Australia) commented
on earlier drafts.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Rey JM. Alcohol misuse. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Alcohol misuse G.1

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IACAPAP Textbook of Child and Adolescent Mental HealthEthanol (ethyl alcohol), a natural product of the fermentation of foodstuffs
rich in carbohydrates, has been part of human culture from the dawnof civilization, prized for its relaxing properties and facilitation of social
intercourse; it may have also had survival value. Alcoholic beverages are legallyavailable in most countries (exceptions are: Afghanistan, Brunei, Iran, Kuwait,
Libya, Saudi Arabia, Sudan and Yemen). The majority of people use alcohol ina responsible manner most of the time. Yet, excessive consumption has large
damaging social and health consequences. This chapter deals with the harmful
effects of ethanol consumption in young people, henceforth referred to as alcohol.
The terms alcohol use disorder (AUD), alcohol dependence, and alcoholism will be
used interchangeably.
Alcoholic beverages can be classified as fermented and distilled. Fermented
beverages are the product of fermentation of sugary foods. For example, beers are
made from cereals, wines from grape juice and sake from rice; there are many otherfermented beverages around the world from other foodstuffs. Distilled drinks(spirits) are produced by concentrating the ethanol in fermented products. For
example, whiskeys are distilled from fermented cereals, brandies from fruit juices
and rum from molasses. Vodka can be distilled from any fermented food − mostly
grain or potatoes. Vodka and similar spirits are distilled so thoroughly that no taste
from their particular starting foodstuff remains (Wikipedia).

“A secure supply of alcohol
appears to have been partof the human community’s
basic requirements muchearlier than was long
believed. As early as around
9,000 years ago, long
before the invention of thewheel, inhabitants of the
Neolithic village of Jiahu in
China were brewing a typeof mead with an alcohol
content of 10%” (Thadeusz,2009).

The ethanol content of a drink is typically measured as millilitres of alcoholper 100 millilitres of the beverage expressed as a per cent − alcohol by volume(ABV). For example, a beer with 6% alcohol contains 6mL of alcohol per 100mL.
Fermented beverages have a maximum of 18%; the alcohol content of spirits ismuch higher (e.g., 40%-50% for whiskey and vodka).

BURDEN OF ALCOHOL USE
Worldwide, alcohol is one of the main risk factors for incident disabilityadjusted life-years (DALYs) in 10–24-year-olds, representing 7% of all DALYs(compared with 4% for unsafe sex, 3% for iron deficiency and 2% for illicit druguse) (Gore et al, 2011). Overall, about 4% of deaths worldwide are attributable toalcohol. Males (with a 6% mortality rate attributable to alcohol), poorer people
and lower-income countries suffer a relatively greater burden than wealthier ones.
Impact, in particular fatal injuries, is greater in the young of both sexes.

Per head consumption
Alcohol consumption and problems related to alcohol vary widelyaround the globe. Worldwide consumption in 2005 was equal
to 6 L of pure alcohol per person aged 15 years or older. A large
portion of this consumption – 29% (approximately 2 L per person)– was homemade, illegally produced or sold outside normal
government controls. Eastern European countries have the highest
consumption, riskiest patterns of drinking, and alcohol-related deaths and disabilities. One inevery five deaths is due to harmful drinking in the Commonwealth of Independent States (CIS)(Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan,
Turkmenistan, Uzbekistan and Ukraine). About 12% of drinkers show heavy episodic drinking.
The proportion of people drinking alcohol to intoxication is lowest in western European
countries and highest in CIS countries. Outside the CIS, risky patterns of drinking and rates
of disease and disability attributable to alcohol are also high in Mexico and in most SouthAmerican countries. Abstention rates are low in high-income, high consumption countries (e.g.,
Europe, North America), and high in North African and South Asian countries with large Muslim
population, female abstention rates being very high in these regions (WHO, 2011). Click on the
picture to access the WHO’s Global Status Report on Alcohol and Health 2011.

Alcohol misuse G.1“Across England, half amillion children between
the ages of 11 and 15 will
have been drunk in thepast four weeks, and young
people under 18 will haveconsumed the equivalentof 2 million bottles of winein the past week alone […]since 1990 the amount of
alcohol consumed by 11 to
15 year olds who drink has
doubled” (Donaldson, 2009).
Click on the figure to accessthis document.

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IACAPAP Textbook of Child and Adolescent Mental Health

Alcohol is a causal factor in 60 types of diseases and injuries and acomponent cause in 200 others (WHO, 2011), including:
•
•
•
•
•
•
•
•
•
•

Accidents, injuries and harm to both drinkers and the people around them (family,
friends, bystanders)
Reduced school, college and work performance, absenteeism
Family disharmony, violence, abuse
Suicide, homicide, crime
Injury and death from motor vehicle and work accidents
Risky sexual behaviour, sexually transmitted diseases, HIV infection
Teratogenesis, with a range of negative outcomes to the foetus including low birthweight, cognitive deficits, and foetal alcohol spectrum disorders
Neurotoxicity and inhibition of brain maturation, especially frontal lobe development
Acquired brain damage in later years
Cancer (oesophagus, liver, bowel, breast etc.) and other diseases (e.g., cirrhosis of theliver).

Alcohol-attributable costs amount to more than 1% of GDP in mostnations, the United States of America (US) having the largest (2.7%) of the highincome countries and South Korea the highest (3.3%) among middle-income
nations. The total annual cost of alcohol use to the US economy was estimated in1998 to be $184 billion, and £20 billion in the United Kingdom (UK) in 2001
(Saunders et al. 2011).

Wet and dry patternsof drinking
A wet pattern of drinking ischaracterised by frequentconsumption of small
amounts of alcohol, mostly
wine, at meal times or familycelebrations; it is common
in Southern European
countries.
A dry pattern is typified byirregular heavy drinking,often to intoxication, atless family-oriented social
events. This pattern ismore common in Central
and Northern European
countries.
There is an overlap between
wet and wine-drinking
countries, dry and beer- andspirit-drinking societies.
However, this distinction
is weakening, particularly
among the young.

EPIDEMIOLOGY
There is wide variation in adolescents’ drinking and attitudes to alcohol
around the world, which are influenced by family, peers, schools, religious beliefs,
and national and cultural mores. Drinking alcohol has become in many culturesa rite of passage into adulthood. In these cultures, drinking is but one aspect of
teenage risk-taking behaviour (e.g., smoking, risky sex, illicit drug use) associatedwith rebelliousness and challenging of rules.
In recent decades there has been a worldwide increase in alcohol consumption
due to:• Industrialization of the developing world• Globalization• Growing wealth• Increased availability of high alcohol pre-prepared drinks (e.g., alcopops)• Lower relative prices of alcoholic beverages• Increased publicity and marketing
Young men drink more than women but there is growing evidence thatwomen are increasingly following men’s patterns of consumption. This may be due
to women becoming emancipated from traditional female roles and increasingly
equal to men in terms of their aspirations and achievements.

THE PATHOPHYSIOLOGY OF ALCOHOL USE
Alcohol is rapidly absorbed and distributed throughout the body. Alcohol isa brain depressant causing disinhibition, impaired memory and decision making,and incoordination. With further doses this may progress to stupor, coma anddeath from respiratory depression. Other biological effects of alcohol include
nausea, vomiting (with the risk of aspiration of vomit leading to asphyxiation),
hangover, amnesic episodes (blackouts), and diseases such as acute gastritis. The

Alcohol misuse G.1“I drank an ‘Irish car bomb’
and a beer and two shotsof Smirnoff vodka. I was
perfectly fine. Then it hitme all at once (I think I
drank too fast). I was told
the following day that I tried
to kiss people at the party
including a girl, her sisterand another boy (I'm a girlby the way). I woke to thorns
in my feet, dirt in my shoes,
my cell phone was in thewoods, my keys in anotherperson's custody, and my
car rearranged. I woke nothaving to pee, so I hope I
didn't just decide to pee infront of everybody. Oh god, I
think I would die of shame!”(Anonymous).

3IACAPAP Textbook of Child and Adolescent Mental Health

Table G.1.1. Alcohol intoxication: symptoms observed at various
blood alcohol concentrations (BAC)
BAC range* (g/100
mL of blood) and[alcohol consumed −approximate standard
drinks**]Observable effects

0.01-0.05[1-3]

Normal behaviour on observation, subjective
feelings of relaxation, talkative, more confident.

0.05-0.08[3-5]

Euphoria: increased self-confidence,talkativeness, disinhibition, loss of concentration,
impaired psychomotor coordination.

0.09-0.15[5-9]

Excitement: Slurring of speech, unsteadybalance, emotional instability, loss of judgement.

0.16-0.25[9-16]

Confusion: disorientation, confusion, nausea,
vomiting, memory impairment, staggering gait,
apathy, incoordination, loss of bladder control.

Above 0.25[>16]

Stupor, coma: unconsciousness, breathing is
suppressed, gag and cough reflexes diminishedand possibly paralyzed, breathing slows, becomesincreasingly irregular and may cease completely(death may occur at BAC above 0.45).

*This is a rough guide; BAC varies according to gender, weight and age; with regular alcohol
consumption tolerance to alcohol and neuro-adaptation develops over time. Therefore this should not betaken as a guide to consumption. **In the previous 3 hours.

effects of various blood alcohol concentrations (BAC) are summarised in Table
G.1.1.
Blackouts. Alcohol interferes with the formation of new memories. A
common by-product of inebriation is memory loss for events that occurred while
the person was intoxicated — blackout, a form of anterograde amnesia. Blackouts
do not involve loss of consciousness, just loss of memory. The typical blackout
lasts 2 to 6 hours, corresponding to the peak BAC. Blackouts are more likely whenpeople drink large amounts of alcohol in a short time (i.e., with a rapid rise in
BAC).

Monitoring the Futureand ESPAD
The Monitoring the Future
project began in 1975 tosurvey substance use
behaviours, attitudes andvalues of US secondary
school students, college
students and young adults.
About 50,000 8th, 10th and12th grade students are
surveyed each year. Dataand reports are available at
the website.

The European School

Survey Project on Alcoholand Other Drugs (ESPAD)

began in 1995 and currently
surveys more than 100,000
school students aged 16
years from 35 European
countries. The 2007 survey
is the last reported (Hibell etal., 2009).
Click on the respective picture
to acess the Monitoring the
Future and ESPAD websites.

Hangovers develop when BAC returns from a high level to zero and maylast longer than 24 hours. They are characterised by symptoms such as misery,
drowsiness, concentration problems, dry mouth, dizziness, gastro-intestinal
complaints, sweating, nausea, hyper-excitability, and anxiety. It is not known why
symptoms can persist after alcohol and its metabolites have been eliminated fromthe body. Surprisingly, the causes of alcohol hangover are not known. A multitudeof physiological changes take place after excessive drinking (e.g., dehydration,
endocrine changes, metabolic acidosis) and all may contribute to hangover. It has
also been hypothesized more recently that hangovers may be related to immune
system activation or neurotransmitter imbalance. Adolescents seem to be lessprone to experiencing hangovers.

Metabolism
A person’s BAC will generally increase by 10-20 mg/100 ml for each 10gof alcohol consumed (about one standard drink) although it varies according togender, weight, age, individual characteristics and previous drinking history (e.g.,tolerance to alcohol). Alcohol is chiefly metabolized in the liver by oxidation to
Alcohol misuse G.1

Watch video by clicking on the
picture4

IACAPAP Textbook of Child and Adolescent Mental Healthacetaldehyde via the enzymes alcohol dehydrogenase and aldehyde dehydrogenase.
Acetaldehyde undergoes further conversions to form carbon dioxide and water.
The metabolic breakdown of alcohol takes place at a constant rate of 7 g to 10 g perhour; this speed is not influenced by the amount of alcohol consumed.

Alcohol and the Developing Brain
The developing brain is likely to be exposed to alcohol during the foetal
period via maternal drinking and during the rapid brain transformations ofadolescence through the initiation of alcohol use (Spear, 2011). Alcohol during
pregnancy is teratogenic; about 1% of all births in western countries are estimatedto exhibit alcohol-induced deficits, collectively known as foetal alcohol spectrum
disorders (FASD). A small group of these children show the foetal alcohol syndrome(FAS). FASD is likely when pregnant women binge-drink or repeatedly use alcohol.
Timing is critical; the typical facial features of FAS are the result of exposure toalcohol during the third week − before women realize they are pregnant (seeChapter B.1).
Studies in humans and in laboratory animals suggest that the effects ofalcohol on the adolescent brain may be slightly different from those in adults. For
example, adolescents appear to be more resistant than adults to the intoxicating
and aversive effects of alcohol (e.g., nausea, vomiting, anxiety, slurred speech)
often cues to stop drinking − but more sensitive to the social facilitation effects.
These differences may result in a relatively higher tolerance and intake of alcohol
during adolescence (Spear, 2011).

Gary Reinbach, a 22
year old Englishman from
Dagenham, Essex, died in
hospital after he was refuseda liver transplant because
he could not prove he had
not drank alcohol for atleast six months — one of
the requirements for livertransplant in the UK. Mr
Reinbach had been admitted
to hospital 10 weeks earlier
with cirrhosis of the liver. His
family said he had started
drinking at 11 years of age
and drank heavily after theage of 13 (Rouse, 2009).

Early Onset of Drinking
The earlier the onset of alcohol use the more likely the adverse outcomes.
Onset of drinking before 14 years of age is an indicator of high risk for future
Table G.1.2. Factors that increase the risk of alcohol use
disorders.
Factor
Genetic

Comments•••

Adoption, twin and extended family studies show moderate to strong
genetic components to the liability to use alcohol and to develop
AUDs
The genetic causation of early onset drinking and subsequent
dependence is less clear
Genetic factors leading to alcohol use, drug use, and behaviouraldisorders may overlap.

Individual••

Psychiatric disorder such as ADHD, conduct disorder, anxiety
Poor school performance.

Family•••Parental or sibling use of alcohol or drugs
Permissive parental attitudes to drinking
Poor parental supervision.

Social••••Having friends who use alcohol, tobacco or other substances
Easy availability (e.g., cheap alcohol)Less strict laws about minimum drinking age, marketing and publicity
Culture of the country or social group (e.g., military settings, college,fraternity)
Being an indigenous minority group (e.g., American Indian, Canadian
Inuit, Aboriginal Australian).

•

Alcohol misuse G.1

Alcohol use significantly
increases the risk of suicide. To
watch video click on the picture.

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure G.1.1 Australian standard drinks. Source: Australian Government, NHMRC.

Standard drink
Within a given country, astandard drink is a drinkthat contains a specificamount of pure alcohol.
One standard drink always
contains the same amountof alcohol regardless ofcontainer size or type ofalcoholic beverage (seeFigure G.1.1).
Although the standard
drink is used to quantify
alcohol intake, there is nointernational agreement(standard) on what
constitutes a standard drink,varying substantially fromcountry to country — from
6 g of alcohol in Austria to
19 g in Japan (1.2 mL ofethanol equals 1 g). For
example, a standard drink
is 8 g of alcohol in the UK,
10 g in Australia, 12 g inFrance, and 14 g in Canada
and the US. As a result, 500
mL of beer with an ABV of
5% represents 1 standard
drink in Japan, 1.4 in theUS, 1.6 in Denmark, Finlandand France, 2.0 in Australia,
Ireland and Poland, and 3.2
in Austria. This is confusing.

Alcohol misuse G.1

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IACAPAP Textbook of Child and Adolescent Mental Health

Table G.1.3. Issues that need to be clarified during assessment.
Age at initiation

The age at which more than a sip of alcohol was consumed

Frequency of
consumption

Daily, weekly, irregularly?

Amount and type

Ask about the last drinking occasion and to recall the numberof each type of drink consumed according to brand and in
the adolescent’s words (“I drank an ‘Irish car bomb’ [cocktail
of Guinness stout, Bailey’s Irish cream, and Jameson Irish
whiskey] and a beer and two shots of Smirnoff vodka”) − it isoften easier for adolescents to remember this than the type ofalcohol (beer, wine or spirits)

Pattern

Drinking patterns change over time, thus it is useful to ask
about (1) recent drinking (e.g., past week or last drinking
occasion) and (2) the heaviest drinking period

Context

−
−
−
−
−
−
−
−

Intoxication−

Alcohol-related consequences

−
−
−
−

Are there particular triggers for use, such asboredom, sadness, anger, anxiety?
Do you drink alone, with friends or both?
What are your friends’ attitudes to alcohol?
What benefits do you get out of drinking?
Is alcohol available at home?
What do your parents think about drinking?
How do you pay for it?
Do you use other drugs?
Have you ever been drunk? If so, how manytimes?
Some young people deliberately plan to get
drunk…do you?
Have you ever had blackouts (when you
cannot remember the next day what happened
the night before)?
Have you been involved in fights when under
the influence of alcohol?
Have you been caught drink-driving?

Hangover−−Have you ever had a hangover?
Does a hangover happen often when you
drink?

Accidents−

Have you been involved in a car accident after
drinking?

Risk-taking−

Have you had unprotected sex or sexualintercourse after having been drinking?
Did you regret that later?
Have you ever driven a car while intoxicated?

−−
Impairment

Click on the picture to access
AUDIT, the Alcohol Use
Disorders Identification
Test: Guidelines for Use inPrimary Care

Whether alcohol use causes impairment in other areas of
psychosocial functioning

A two-question screen
Newton and colleagues (2011) recommend two questions to screen for possible alcohol misuse in emergency departments.
Youth who answer yes to at least one of these questions have an eightfold risk of having an AUD and should be referred forassessment:• In the past year, have you sometimes been under the influence of alcohol in situations where you
could have caused an accident or gotten hurt?
• Have there often been times when you had a lot more to drink than you intended to have?

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IACAPAP Textbook of Child and Adolescent Mental Health

AUD and is associated with a more rapid progression to and longer duration of
alcoholism and greater difficulty achieving abstinence (Skidmore et al, 2011).
Conduct disorder, anxiety, depression, ADHD, shyness, being abused, family
conflict, poor parenting, inadequate monitoring, poverty, parental modelling of
drinking, and peer influences have all been noted in the research literature as risk
factors for early-onset drinking (Skidmore et al, 2011).

ETIOLOGY
The aetiology of AUDs is multifactorial. Some of the best known aetiologicalfactors are summarized in Table G.1.2.

CLINICAL ASSESSMENT
Building rapport with the adolescent is the key aspect of a successful
assessment. Many clinicians find that a non-judgemental approach using
motivational interviewing techniques achieves the best results. Optimally,assessment requires information from multiple sources and is usually conducted
as part of a wider substance use evaluation – several substances are often involved.
School reports can be helpful by highlighting inconsistencies, repeated absences
and other relevant behaviours. Issues that need to be clarified during assessment
are summarised in Table G.1.3.

Confidentiality
Like in most psychiatric assessments of young persons, confidentiality andits limits are best dealt with at the beginning of the clinical interview. Check thatthe young person understands what is meant by confidentiality. The concept ofadolescence varies between cultures with regard to the adolescent’s independence
and capacity to make decisions, and the role of the family. As a result, laws andexpectations about confidentiality differ making it difficult to give unambiguous
guidance that can be universally applied. Nonetheless professionals need to keep
in mind that confidentiality, particularly if children are older than 14 years, is a key
issue when assessing alcohol use: if adolescents are unsure about the confidentialityof their disclosures they are less likely to give accurate information. Parents alsoneed to be made aware that respecting confidentiality is standard practice inadolescent health care (see Chapter A.1). It is often helpful to explain to parents
that the purpose of confidentiality is not to exclude them but to facilitate theyoung person’s personal development (Bonomo, 2011).

Screening
Except in countries in which alcohol consumption is not allowed andthis is enforced, clinicians need to assume that most adolescents presenting withmental health problems consume alcohol unless there is evidence to the contrary.
Therefore, they should be screened for alcohol use.

Validity of selfreports
Much of the information
described in researchstudies has been obtained
from the adolescentsthemselves (e.g., using
self-report questionnaires)but there is some concern
about its validity. Overall,
information given byadolescents is more valid
than that obtained fromother sources. Parents
often do not know theextent of their children’s
alcohol (or substance) use
and tend to under-reportthese problems. Computerassisted questionnaires
may improve validity

Adolescents’ alcohol (or drug) consumption is a sensitive topic which ought
to be tackled similarly to suicide risk assessment. For example, questioning fromthe general to the specific and, when appropriate, using a third person approach (Dostudents at your school drink alcohol? What about your friends…? Do you ever drink?
Alternatively: Does your family drink alcohol during meals? Do you also drink?).
Once it is established that the teenager drinks, the age of onset of drinking, patternof alcohol consumption and alcohol-related consequences need to be clarified.
Careful questioning about the frequency, amount, types of alcohol consumed
and circumstances associated with drinking is essential; this can be established

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IACAPAP Textbook of Child and Adolescent Mental Healthconversationally or using questionnaires or rating scales. Such a discussion will also
provide opportunities for education, for example to explain non-judgementallywhat a standard drink is, the effects of different levels of alcohol in the bloodand other relevant matters. Using standard drinks allows a quantification of
consumption (g/day).

The assessment interview
The clinical interview of adolescents with a suspected alcohol problem
should broadly follow the structure of a psychiatric assessment (see Chapter A.5)
rather than focussing exclusively on alcohol use, and adjusting the interview
style to the developmental stage and age of the adolescent. Psychiatric disorders(ADHD, conduct disorder, depression etc.) are often present in adolescents who
misuse alcohol.
Enough information should be collected to answer the following questions(Goldstein 2010):
•
•
•
•
•

What factors predispose the adolescent to use alcohol?
What precipitates alcohol use and what were the triggers for this episode?
Are there perpetuating factors that make it difficult for the adolescent toabstain?
Does a family member (parent, sibling) misuse alcohol? What about peers?
Are there protective factors that can be used in treatment?

Instruments
Among the many screening instruments one of the most widely used is
the WHO’s Alcohol Use Disorders Identification Test (AUDIT). The AUDIT wasdeveloped to screen for excessive drinking and to assist in brief assessment andmanagement. Using AUDIT scores, four levels of risk have been defined (Baboret al, 2001):••••

Low-risk drinking or abstinence (score lower than 8): no intervention
required.
Alcohol use in excess of low-risk recommendations (score 8 to 15): provide
brief intervention using education and advice
Harmful or hazardous drinking (score 16 to 19): combination of education,
advice, brief counselling and continued monitoring, with further diagnostic
evaluation or specific treatment if there is no improvement
High risk or dependence (score above 19): these individuals require specificdiagnostic evaluation and possible treatment for alcohol dependence.

Many measures have been published: questionnaire- or interview-based,short or comprehensive. They often assess not only alcohol but also other substanceuse (Teeson et al, 2011). Reliability and validity of these instruments when applied
to adolescents is not well known.

Biomarkers
A biomarker is a biological characteristic that can be used to measure theprogress of a disease (in this case AUD) or the effects of treatment. There are twomain types of biomarkers: state and trait. State biomarkers provide information
about drinking activity while trait biomarkers give indications of a person’s genetic
predisposition to alcoholism (Peterson 2004/2005)
Biomarkers contribute to diagnosis (for example, elevated gammaglutamyltransferase [GGT] without obvious explanation would raise suspicions),

Alcohol misuse G.1

Biomarkers
Of recent alcohol use:•

BAC (usually measured
with a breathalyser)
Of chronic alcohol use(e.g., 5 or more drinks
per day, most days of theweek). All have relatively
low sensitivity and specificity
and should be interpretedwith caution:•
Increase in GGT•Increase in aspartate
aminotransferace (AST)•
Increase in alanine
aminotransferace (ALT)•
Increase in mean
corpuscular volume(MCV)

Binge drinking andextreme drinking
The traditional view ofan alcoholic binge wasan extended period of
consumption to the pointof being incapable ofperforming the usual
activities or until losing
consciousness. However,the definition of a bingeis contentious. It has
been redefined in the
research literature as theconsumption in a drinking
session of five standard
drinks for men and fourstandard drinks for women(on the grounds that this
could lead to a significantly
increased risk of harm).
Please note the provisos
highlighted in the standard
drink section.
Extreme drinking is a
growing phenomenon
among young people
in many countries. It is
exemplified by prolonged,
excessive drinking over ashort period with the aim ofgetting drunk. While in thepast being inebriated wasfrowned upon, disapproval
has lessened in the current
youth culture.

9IACAPAP Textbook of Child and Adolescent Mental Health

Table G.1.4. Diagnosing alcohol use disorder and alcohol withdrawal.
Alcohol use disorder•

Continued use of alcohol in spite of it causing:

Alcohol withdrawal•

Autonomic hyperactivity (e.g., sweating, pulse rate
greater than 100)•

Increased hand tremor•

Insomnia•

impairment of functioning•

risk to themselves or others (e.g., driving under
the influence)•social or interpersonal problems•

Nausea or vomiting•

physical health problems•

Transient visual, tactile, or auditory hallucinations•

Tolerance•

Psychomotor agitation•

Withdrawal symptoms•

Anxiety•

Craving•Grand mal seizures•

Desire or unsuccessful efforts to reduce alcohol use•

Spending much time in activities to obtain, consume or
recover from the effects of alcohol

Make a diagnosis if two or more symptoms are present. If
more than four symptoms, the problem is severe.

Make a diagnosis if two (or more) of these symptoms
develop within hours or a few days of ceasing or reducing
heavy or prolonged alcohol intake

to evaluate harm (e.g., liver damage) and to monitor abstinence but should always
be interpreted with caution and taken in context clinically. There are no clinicallyuseful trait biomarkers available yet.

DIAGNOSIS
Alcohol intoxication, AUD (also known as alcohol dependence, addiction, or
alcoholism) and alcohol withdrawal are the clinical diagnoses relevant to adolescentalcohol misuse. The traditional classifications distinguish between alcohol abuse
and alcohol dependence. However, research has failed to provide convincing
evidence of the validity and clinical usefulness of this distinction. The recent trend(e.g., DSM-V) is for a single diagnosis of AUD with several levels of severity.

Alcohol intoxication
Intoxication is the most common alcohol-related problem found inadolescents − when severe, also called alcohol poisoning. A diagnosis of intoxication
can be made after excluding other causes (such as haed injury or encephalitis)
if individuals display at least one sign of intoxication (e.g., slurred speech,
Figure G.1.2 In the US
in 2002, only 16% of
the 1.4 million youth
aged 12 to 17 estimatedto have alcohol use
disorders reported
receiving any typeof service for these
problems.
Source: National Institute on
Alcohol Abuse and Alcoholism(NIAAA)

Alcohol misuse G.1

A 17-year-old German man
was taken to emergency
because of vomiting anddizziness after having run
two 100 m races at school.
He was hyperventilating,slightly tachycardic andtired but could be awaken.
He subsequently revealed
having drunk 3 L of anenergy drink and 1 Lof vodka (equivalent to4600 mg of taurine, 780
mg of caffeine and 380
g of alcohol). Combining
energy drinks with alcohol
is becoming increasingly
popular among youth. The
combination, particularly
in large amounts, posesconsiderable risk. (Schöffl
et al, 2011).

10IACAPAP Textbook of Child and Adolescent Mental Healthincoordination, unsteady gait, nystagmus, attention or memory impairment,
stupor, coma) after ingesting alcohol and are significantly impaired in theirfunctioning as a result. When compared with adults, adolescents are much more
likely to use alcohol episodically and heavily (binges), making drinking moredangerous. Rapid drinking of large amounts, often related to a bet or dare, isparticularly hazardous.

Alcohol use disorder (AUD)
Repeated excessive consumption of alcohol leads over time to AUD –alcohol dependence (addiction) or alcoholism. AUD is a clinical syndrome inwhich alcohol is consumed irrespective of the person’s circumstances and despite its
harmful consequences. The person’s life becomes increasing focused on obtaining
alcohol (craving), consuming it, experiencing and recovering from its effects, andtends to be self-perpetuating (Saunders, 2011). The traditional symptoms ofdependence are tolerance (need to consume increasing amounts) and withdrawal(physical symptoms upon cessation of consumption). Diagnostic criteria for AUD
are summarised in Table G.1.4.

Alcohol withdrawal
The diagnosis of alcohol withdrawal is summarized in Table G.1.4.
Withdrawal symptoms reflect an overactivity of the autonomic nervous system andtypically appear between 6 and 48 hours after ceasing consumption. They rarely
last longer than 48 hours. Withdrawal symptoms are infrequent in adolescents.

TREATMENT

Although young persons
may have stopped
consuming alcoholsome time before theirpresentation to theemergency department,
BAC may continue to risethrough the initial medical
assessment, resuscitation,and treatment phases.

Only a very small minority of people with AUDs receive treatment – about
10% in the US, with the initial treatment episode typically occurring 8-10 years
after the onset of the disorder (see Figure G.1.2). Most individuals who develop
AUD started drinking during their adolescent years. Thus, the focus in this age
group should be prevention and early intervention − i.e., delaying the onset of
drinking, reducing the amount of alcohol consumed, reducing binge drinking,minimising the risks, and detecting misuse early. If alcohol misuse is left untreated
it often progresses to alcoholism.

ALCOHOL INTOXICATION
Alcohol intoxication is a common occurrence among adolescents, typically
identified and handled informally by peers, teachers, relatives, or police; only asmall proportion comes to the attention of health practitioners. Nevertheless,severe intoxication (alcohol poisoning) is an acute illness that requires immediate
attention, particularly if ingestion of other substances has occurred also. An
adolescent that initially appears mildly intoxicated may easily go unnoticed to
become unresponsive and risk dying. Severely intoxicated adolescents can become
hypothermic, develop arrhythmias, compromised heart function and breathing.
Lack of gag or cough reflexes can lead to acute respiratory obstruction should theyouth vomit (Vaca and Sayegh, 2011).
The key aspect of management is aggressive respiratory and cardiovascularsupportive care. If the patient is intoxicated but awake and with a secure airway, aphysical examination should be performed to exclude traumatic injuries (e.g., head
injury) that may mimic the symptoms of intoxication or co-exist with it. Once
intoxication is treated it is essential to follow up the adolescent and deliver a shortintervention or treatment if necessary.

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IACAPAP Textbook of Child and Adolescent Mental Health

ALCOHOL WITHDAWAL
Once it is found that no significant comorbid physical illnesses are present,adolescents who show alcohol withdrawal symptoms can − and should − be treatedon an ambulatory basis, if at all possible involving the family. Supportive care(reassurance and encouragement in a peaceful environment without criticism andwith limited interpersonal interactions, plenty of fluids and good nutrition, andadministration of thiamine and multivitamins) is enough to manage withdrawal in
the majority of cases in which symptoms are not severe.
In severe cases, particularly if the risk of seizures is high (e.g., history ofprevious seizures, abnormal electrolytes, concomitant benzodiazepine abuse), thecurrent treatment of choice is benzodiazepines, usually diazepam, following similar
protocols to those in adults. This can be done either on a fixed schedule (doses
are given at specified amounts and intervals) or, preferably, following a symptomtriggered regime (benzodiazepines are administered if the score in an alcohol
withdrawal rating scale is above a specified cut-off). If there is severe agitation or
hallucinations, the addition of haloperidol to diazepam may be helpful. Following
successful withdrawal, it is essential to offer treatment for their alcoholism.

ALCOHOL USE DISORDER (AUD)
Alcoholic adolescents present specific challenges for therapists: they rarely
seek treatment for alcohol misuse on their own accord but are brought by parents,
or compelled by the school or the courts. In some countries, adolescents who
violate alcohol policies (e.g., driving under the influence of alcohol, intoxication at
school) are often ordered by the court or school authorities to undergo treatment.
These individuals, often referred to as mandated patients, are at high risk foralcohol-related harm. There is evidence that mandated young people benefit frominterventions as much as non-mandated individuals. Whether improvement is dueto the intervention or to having been caught is unclear although both may play arole.
Teenagers are difficult to engage, usually don’t want to stop drinking anddon’t see anything wrong with it. Building rapport, getting them to understand therisks of alcohol misuse and building motivation to change are essential first steps.
Rather than a therapy, motivational interviewing is a widely accepted techniquethat can be used across most of the treatments mentioned to foster rapport andunderstanding of the risks of alcohol misuse; it seeks to enhance motivation tochange by providing education and feedback and by exploring and resolving
ambivalence. Family involvement in treatment results in better outcomes.
One of the advantages of treating AUDs is that one is able to objectively
monitor consumption, i.e., abstinence. According to some treatment guidelines
this “should be a routine part of the formal evaluation and ongoing assessmentof substance use both during and after treatment” (Bukstein et al, 2005). Rather
than having to rely on adolescents’ reports, the advent of affordable breathalysersthat can be used at home makes monitoring easier but their usefulness is limited
to a few hours after alcohol is consumed and the adolescent should agree to themonitoring.
Goals of treatment vary according to country, therapy, therapist and patient.
In some countries (e.g., US) treatment mostly seeks to achieve abstinence; othercountries (e.g., some European countries) favour a harm minimization or harm
reduction approach. Abstinence is the only effective option for many patients;
however some who do not accept abstinence can achieve sensible drinking. The goalin AA is abstinence; the aim of other treatments can be abstinence or responsibleuse. Tailoring the treatment to the specific needs, personality and beliefs of theindividual adolescent increases the likelihood of success.

Alcohol misuse G.1

Mandated patients
Individuals who haveviolated alcohol policies orlaws and are ordered by
the appropriate authority or
court to undergo treatment
for their alcohol misuse.

Stages of change
The stages of change
model allows clinicians tounderstand the process
whereby people movethrough different phases ofreadiness to change. Theseare:•

Pre-contemplation:

not acknowledging that
there is a problem thatneeds to be changed•

Contemplation:•

Preparation/
determination: getting

acknowledging that
there is a problem
but not yet wanting to
make a change•

ready to change − i.e.,
accepting treatment
Action: changing
behaviour − i.e.,undergoing treatment•

Maintenance:•

maintaining the
behaviour change− i.e., continuing withtreatment/abstinence
Relapse: return toformer behaviours
and abandoning thechanges achieved

Responsible alcoholuse
Drinking in a way that is
unlikely to cause significant
risk of harm to the individual
or to others.

12IACAPAP Textbook of Child and Adolescent Mental Health

Table G.1.5. Summary of psychosocial treatments for alcohol use disorders and theireffectiveness.
Treatment

Description

Evidence

Motivational
enhancement therapy

Assumes that responsibility and capacity forchange lie within the patient. The therapist
provides individualized feedback about the effectsof the patient's drinking. Working closely together,
therapist and patient explore the benefits ofabstinence, review treatment options, and designa plan to implement treatment goals.

The motivational interviewing
technique — a key component ofmotivational enhancement therapy— was shown in adults to overcome
patients' reluctance to enter treatment
more effectively than did otherconventional approaches.

Brief interventions

Up to 4 sessions, typically follows CBT principles
and incorporates education, motivational
interviewing, and individualised feedback. Oftendelivered opportunistically (e.g., following an
alcohol-related motor vehicle crash).

Lump together a variety ofinterventions. Good evidence ofeffectiveness in adults, particularly in
milder cases, but limited evidence inadolescents. There is concern aboutmaintenance of gains over time.

Internet & cellular
phone-based
interventions

Much research interest and activity in this area.
Mostly used to deliver brief interventions or
to complement other treatments (e.g., face-toface). The better ones include education andindividualised feedback.

Evidence beginning to emergethat they can be effective as partof a multimodal approach and if
individualised feedback is provided.
Cellular phone reminders appear to beeffective in quitting smoking.

Family therapy

Assumes that the adolescent’s behaviour
is shaped (caused or reinforced) by familyinteractions. Therapies follow a variety of models.

The most widely practised and studied
set of treatments in this age groupbut evidence of effectiveness is still
limited.

Multy-systemic
therapy

Delivered in adolescents’ social environment(family, school, neighbourhood…) it provides
intensive support seven days a week, 24 hours
a day, and the treatments required (family,
individual, pharmacological). Costly andresource-intensive.

There is evidence of effectivenessin complex cases with significant
comorbidity (e.g., delinquency,
conduct problems).

Contingency
management

It follows operant conditioning principles by
rewarding initiating treatment and maintaining
abstinence. A key aspect is the availability ofan objective measure of abstinence such as anegative breath test.

An attractive approach that empowers
parents. The few studies available arepromising but definite evidence is stilllacking.

Cognitive behaviour
therapy (CBT)

Individually or in conjunction with family therapy

CBT combined with family therapy
obtains better results than CBT alone

Alcoholics Anonyms(AA)“A fellowship of men and women who share theirexperience, strength and hope with each otherthat they may solve their common problem andhelp others to recover from alcoholism”. The
only requirement for membership is a desire tostop drinking (i.e., the goal is abstinence). AA
follows a 12-steps program. Few AA groups foradolescents. AA attendance is often encouraged
in multimodal treatments.

Some evidence of effectiveness inadults but limited research available inadolescents.

Multi-modal
treatments

Treatment in practice is often multimodal, forexample including family therapy, contingency
management and AA attendance.

Multimodal treatments usuallymore effective than their unimodal
counterparts.

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IACAPAP Textbook of Child and Adolescent Mental HealthContingency management
Following Stanger et al (2009), a program of this kind would involve: (1) assessment of the problem; (2) adolescent and parents
formally agreeing to undertake the program under the supervision of the clinician; (3) a detailed schedule of incremental voucherbased monetary or other rewards for consecutive negative breathalyser readings (parents would be expected to purchase orborrow a personal breathalyser) for the length of the treatment (e.g., 3 months). Because poor parental support and participationin treatment can become a barrier, parents may be rewarded also for their participation.
Because adolescent drinking takes place mostly during unsupervised time outside school, the breathalyser is used twice weekly
at the parent’s discretion when the adolescent arrives home from situations in which drinking might have taken place. The firstnegative breathalyser reading is rewarded, for example, with a $2 voucher, with $2 increments for each consecutive negative
breath test. There is also a $10 bonus for each three consecutive negative tests. Vouchers are reset back to their initial value
if results are positive, from which they can escalate again after an agreed number of consecutive negative results (e.g., three).
Example: 1st negative test: $2; 2nd negative test: $4; 3rd negative test: $6 + $10 (bonus for three consecutive negative tests); 4thtest positive: $0, reward schedule is reset; 5th test negative: $0; 6th test negative: $0; 7th test negative: $0; 8th test negative: $2;
9th test negative: $4 etc. Voucher earnings can be redeemed for goods selected by the adolescent (e.g., movie passes, hobby
equipment, items of clothing) but not for cash.

Psychosocial treatments
Psychosocial treatments for AUD and their effectiveness are summarised inTable G.1.5. Brief interventions are popular because of their short duration (from a
few minutes to a few sessions) and appropriate in adolescents − in whom alcohol
use is often not severe or entrenched. Short interventions are recommended inprimary care settings or hospital emergency departments for individuals whose
presenting complaint is not primarily an alcohol problem, although it may be
alcohol-related such as a car accident (opportunistic intervention).

Youth and AA

There is particular interest and growing research on electronic options forthe delivery of treatment for AUD. Internet and cellular phone-based treatments
have features highly valued by teenagers (convenience, privacy, minimise stigma,
use a medium in which young people feel comfortable) and governments (cheaper
than face-to-face or group treatments, can reach many people); the issue is whether
they are effective. Although evidence is still limited, it would appear that programs
that among other features provide individualised feedback are effective in reducing
excessive drinking and alcohol-related problems. That is, individualised feedback
is a key element in effective programs.
According to Deas and Clark (2011), contingency management therapies,
which are based on operant conditioning principles, may be a useful intervention.
Contingency management provides incentives for initiating treatment andmaintaining abstinence with vouchers for monetary and other rewards (appropriate
to the socioeconomic conditions of the country and family but attractive enoughto generate significant motivation in most adolescents); optimally, it requires theactive involvement of the family. A key ingredient is an easy to use, reliable andobjective measure of abstinence such as a negative breathalyser result.
AA initially attracted severely impaired middle-aged and older individuals.
More recently, AA has begun to attract increasing numbers of young people andhas begun to publish youth-specific literature. Younger patients with SUD differ
from adults in that they are often less motivated for treatment, less likely to seek
abstinence, and have less severe alcohol use, which makes their engagement with
12-step programs more difficult. However, adolescents do attend AA and positive
outcomes appear to be associated with attendance (Kelly & Yeterian, 2011).

Pharmacological treatments
Psychosocial interventions are the mainstay of AUD treatment in young
people. The persistence of long-term craving in alcoholics, even after prolonged
abstinence, often triggers a relapse. Craving is thought to be maintained byneuronal changes in addicted individuals, these changes may be amenable to

Alcohol misuse G.1

Is naltrexone effective foralcoholism?
Click on picture to watch David
Sack MD discuss this issue.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table G.1.6. Pharmacological agents used to treat AUD.
Medication (dose*)

Comments

Disulfiram

An alcohol-sensitizing drug that has been available for a long time and may be adeterrent for drinking in patients willing to take it. If patients drink alcohol, the drug
produces an unpleasant reaction.

(start with 125mg/day,
gradually increase to a
maximum of 500mg/day)
Naltrexone(start at 25 mg/day for two days
and increase to 50 mg per day)

Helps to prevent relapse among abstinent alcohol dependent individuals who are
simultaneously undergoing psychosocial therapy. Naltrexone is only effective if taken ona regular basis. There is an extended-release preparation available in some countries
requiring one monthly injection (watch for reaction at the injection site). Conduct liverfunction tests before prescribing as naltrexone can impair liver function tests; if liverfunction results are more than five times normal limits, proceed cautiously. Opioids should
not be consumed while taking naltrexone.

(666 mg three times daily)

In one study, more than twice as many alcohol dependent individuals receiving
acamprosate remained abstinent up to 1 year compared with participants receiving
psychosocial treatment alone. Side effects include diarrhoea, dizziness, flatulence, loss ofappetite, nausea, and trouble sleeping.

Other

Other promising agents currently being researched include topiramate, ondansetron,
baclofen, and the SSRIs.

Acamprosate*These are the recommended doses for adults.

pharmacological intervention and have become a focus of intense research. So
far, there is very limited data on adolescents, results being extrapolated fromadult populations with all the limitations this entails. For example, there is little
information about optimal dosage in adolescents.
The first proviso in the pharmacological management is that medication iseffective only if administered as part of a comprehensive, multimodal treatment
package and once the patient has stopped drinking. The second is that many factors
need to be taken into consideration when prescribing for adolescents, weighing
the potential risks and benefits of medication in a developing brain against thehazards of continuous alcohol use. Finally, medication is indicated only in addictedindividuals, typically those who show craving, tolerance or withdrawal symptoms.
Pharmacological agents used to treat AUD are summarised in Table G.1.6.
Disulfiram has been around for a long time and can be helpful especially when
there is supervised dosing and the person is motivated. It is an aversive treatmentthat produces an unpleasant reaction if the individual taking it consumes alcohol.
Disulfiram blocks the enzyme acetaldehyde dehydrogenase resulting in highconcentrations of acetaldehyde in the blood. The person experiences flushing of theface, headache, low blood pressure, palpitations, dizziness, nausea and vomiting.
All the other medications listed seek to reduce craving. Medications are effective
only if taken regularly, so that patients’ adherence and cooperation are essential.
For more information see Johnson (2011).

Click on the picture toaccess a variety of resourcesfrom the NIAAA’s Helping
Patients Who Drink Too
Much: A Clinician's Guide
and Related Professional
Support Resources site

(some are also available in
Spanish).

PREVENTION
The amount of alcohol-related harm in a society and the proportion ofpeople who consume hazardous levels of alcohol are closely related to the overallor per capita consumption. However, most alcohol-related harm takes place notin the heaviest drinkers but in those whose consumption is at lesser levels. Though
the evidence in favour of universal preventative measures that reduce overall

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IACAPAP Textbook of Child and Adolescent Mental Health

Drink driving

A car crash on Jagtvej in Copenhagen, Denmark. Source: Wikimedia Commons

There is considerable
evidence that drink-driving
accidents and fatalities canbe reduced by:•
Lowering the legal
concentration of
alcohol in the blood
while driving•
Systematic random
breath-testing (whenpolice regularly stop
drivers to check BAC
through breath testing)•
For repeat drink
drivers, mandatory
treatment and the useof an ignition interlock(mechanical device that
does not allow a car to
be driven by a driver
who is over the legal
alcohol limit).
(Source: Anderson et al, 2009)

alcohol consumption is compelling, whether it is better to concentrate on universal
interventions or to target specific groups at high risk of harm (targeted prevention)
remains contentious. The two approaches can and should be combined. Legislative
measures illustrate the former while preventive programs in schools illustrate thelatter.

LEGISLATIVE MEASURES
Most societies seek to manage or prevent the harm resulting from alcohol
use through a variety of policies that range from total prohibition to a range ofrestrictions. Legislative strategies include laws that regulate minimum drinking
age, driving under the influence of alcohol (drink driving), price of alcoholic
beverages, availability of alcohol (alcohol outlets, their concentration, days andhours of sale), and marketing and advertising.

Minimum drinking age laws
Minimum drinking age laws stipulate who can purchase or consume
alcoholic beverages. The legal drinking age usually refers to the minimum age at
which alcohol can be consumed in licensed premises (bars, restaurants), which may
be the same or different from the minimum age at which alcohol can be purchased.
These laws do not usually apply to consumption at home. The minimum drinking
age in most countries is 18 years (21 in the US). A few countries do not haveminimum drinking age laws (e.g., Albania, Armenia, Azerbaijan, Fiji, Ghana,
Jamaica, Kyrgyzstan, Morocco, Togo, Tonga, Vietnam).

Drink driving laws
In 1936, Norway passed the world’s first law making an offense to drivewith more than a specified amount of alcohol in the blood. Nowadays almost
all countries outlaw driving a motor vehicle with BAC above specified levels,
which vary according to country (e.g., 0.08/100ml in the US, Canada and the

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IACAPAP Textbook of Child and Adolescent Mental Health

UK; 0.05/100ml in Australia, France and Germany; 0.04/100ml in Lithuania;
0.03/100ml in Russia; 0.02/100ml in China, Norway and Sweden; 0.0/100ml in
Brazil, Iran and Saudi Arabia).
All the measures that reduce alcohol consumption contribute to a greater or
lesser extent to reduce alcohol-related road traffic accidents, particularly in young
people. The risk of being involved in a crash is greater for the young at all BAC
levels. Among US drivers with a BAC level of 0.08% or higher involved in fatal
crashes in 2008, more than one third were between 21 and 24 years of age.
Designated driver programs seek to reduce alcohol-related accidents byproviding a safe transportation for those who have been drinking. It is still unclear
whether they lead to a reduction in drink driving or AUDs

Pricing policies
Minimum pricing means that alcoholic beverages cannot be sold for lessthan a set amount per unit of alcohol contained. Young people who drink andthose who drink harmful amounts tend to choose cheaper beverages when prices
increase. Establishing a minimum price per unit of alcohol would limit the abilityof these groups to trade down to cheaper products.
A rise in alcohol price leads to less alcohol consumption and less alcoholrelated harm, and vice versa. Young drinkers are very sensitive to price increases.
Price rises:• Delay the age when young people start drinking• Reduce the number of drinking bouts• Reduce the amount of alcohol consumed on each occasion• Slow progression towards drinking larger amounts.

Availability of alcohol
There is good evidence that legislation to control the number of alcohol
outlets, their concentration, and days and hours of sale influence alcohol related
problems.

Marketing and advertisingMarketing and advertising of alcoholic beverages has become increasingly
sophisticated and is globally worth many billions of dollars annually. It often targets
young people through linking alcohol brands to sports and cultural activities,
sponsorships and product placement. Restrictions placed on alcohol marketing
and advertising reduce this effect, and data suggest that children and young
people should be protected as much as possible. Thus restrictions are placed on,
for example, sport sponsorship, and bans on television advertising at times whenchildren and young people are more likely to watch or during children’s programs.

PREVENTON PROGRAMS
Exposure to alcohol during early adolescence is associated with poorer
outcomes in adulthood. However, many of the adolescents who use alcohol early
also have a history of other problems (e.g., behaviour problems), which raises thequestion of whether early exposure to alcohol leads by itself to poorer outcomes orwhether this only happens in adolescents who are already at risk through their preexisting difficulties. Research evidence shows that early consumption of alcohol

Alcohol misuse G.1

Supervised drinking
There is a widespread
belief particularly in wet
countries that allowing
adolescents to drink under
adult supervision at family
gatherings is a way ofteaching them responsible
drinking. Research has
shown this not to be thecase: adult-supervised
drinking results in higher
levels of harmful alcohol
use in adolescents(McMorris et al, 2011).
The later adolescents startdrinking alcohol the better.
Certainly they should notstart before the age of 15
years.

ESPAD (Hibell et al, 2009)
reports that among 16 year
old European students,
binge drinking is mostprevalent (60%) in Denmarkand the Isle of Man. Malta,
Portugal, Estonia, Latvia
and the UK also display
high rates (around 55%). On
average, binge drinking ismore frequent among boys
than girls (47% versus 39%)
but in Iceland and Norway
more girls than boys reportbinge drinking. ESPAD
shows a clear increase(9%) in binge drinking from1995 to 2007, mostly due toincreasing rates among girls.
In the US, binge drinking
among 12th graders peakedin 1979 (at about thesame time as overall illicit
drug use). Subsequently,
it remained steady for a
few years before declining
substantially (from 41%
in 1983 to a low of 28%
in 1992). In 2010, 28%
reported having been
drunk in the past 30 days.
Disapproval of binge
drinking has also increased(Johnston et al. 2011).

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IACAPAP Textbook of Child and Adolescent Mental Healthby itself leads to worse adult outcomes (Boden & Fergusson, 2011; Odgers etal, 2008). Thus, interventions that delay the age of onset of drinking, reduce theamount of alcohol consumed and risky drinking patterns (e.g., binge drinking),
will lessen the harm of alcohol.
School-age alcohol use is widespread in most western countries. So, it is not
surprising that governments and communities seek to prevent or reduce alcohol
consumption among students. Also, schools are optimal settings for the deliveryof alcohol prevention programs because: (a) most individuals begin using alcohol
during their school years; (b) schools provide an efficient way of reaching almost
all young people; and (c) schools can implement a broad range of educational anddisciplinary measures (Rey & Saltz, 2011).
Prevention programs can be specific (i.e., focus on alcohol) or generic (dealwith a variety of behaviours and substances such as tobacco, alcohol, cannabis etc.).
According to a recent review (Foxcroft & Tsertsvadze, 2011), generic programs
based on psychosocial or developmental approaches are more likely to report
longer term benefits than other interventions. Thus generic programs should be
preferred over alcohol-specific ones. Those with better evidence of effectivenessare currently the Unplugged program (Caria et al, 2011), and the Good Behaviour
Game. All require training.
To be successful schools need to adopt a sophisticated approach toprevention that includes universal, selective and indicated approaches (see Chapter
A.8). Prevention programs, apart from being tailored to the circumstances of thespecific age group, need to:• Increase knowledge of the harm alcohol use can cause, physically, mentallyand socially (including legal consequences)• Provide opportunities to explore attitudes to and perceptions of alcohol use• Help students develop decision-making, assertiveness, coping and expressive
skills• Increase awareness of how the media, marketing, role models as well as theviews of parents, peers and society can influence alcohol use• Provide personalized feedback.
A whole school approach (i.e., involving staff, parents and pupils) to alcohol
is likely to be the most successful. In addition, schools should offer parents
information about where they can get help to develop their parenting skills.

Good Samaritan laws
seek to protect from liability
individuals who help
others who are injured orill, to reduce bystanders'
hesitation to assist. In thiscontext, they are policies
protecting students fromdisciplinary action regarding
alcohol and drug use if
they seek medical help
(also known as Medical
Amnesty Policies).

Schools also need to have in place mechanisms to identify students who aredrinking or drinking excessively, to offer them brief, individual, evidencebased interventions by appropriately trained personnel or referral to external
services. Violations of school alcohol policies may result in attending mandatory
education or treatment programs. Medical amnesty (Good Samaritan) policies
may lessen the risk of harm in case of alcohol poisoning.

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