Since the beginning of recorded history, people have consumed alcoholic beverages for purposes of religious ceremony, celebration, medicinal therapy, pleasure, and recreation.

Problem drinking in all age groups has also been recognized and reported for thousands of years. [1] Research continues to evaluate the wide range of alcohol use--from its hazardous use in pregnancy to its possible beneficial use for adult physical or psychological health. There is debate as to whether youths should postpone the use of alcohol until the legal drinking age or be encouraged to develop safe, responsible drinking patterns through progressive, controlled exposure in family or religious settings. The debate is complex because although alcohol is a legal drug, its purchase, possession, and use by minors are illegal.

Further confusion exists because of negative adult attitudes and poor adult role modeling regarding alcohol use that are observed by our youth.

Although pediatricians witness the consequences of alcohol use in their patients and families, physician training about substance abuse is deficient,[2] and efforts to improve physician knowledge are clearly indicated.

ALCOHOL USE AND ABUSE AMONG YOUTH

The annual "Monitoring The Future Study" of alcohol and drug use by American students has shown consistently that alcohol is the drug most often used and abused by children and adolescents.[3] In 1992, 88% of American high school seniors had tried alcohol at least once, compared with 82% of 10th graders and 69% of 8th graders. With regard to recent use of alcohol, 51% of 12th graders, 40% of 10th graders, and 26% of 8th graders had at least one drink in the previous month. In the 2 weeks before being surveyed, 28, 21, and 13% of the students, respectively, admitted to binge drinking (five or more drinks in a row on one occasion). Currently, 1 in 30 high school seniors drink daily.[3] Alcohol use by school dropouts or chronically truant students is suspected to be significantly higher.

The initial use of alcohol frequently occurs before or during early adolescence. A retrospective report among students who have used alcohol indicated that 11% had their first drink by 6th grade, 38% by 8th grade, and 60% by 9th grade. Between 4% and 9% of 8th, 10th, and 12th graders admit to having been drunk by the 6th grade.[3]

In the last decade the small decrease in alcohol use compared with the twofold to threefold decrease in the use of marijuana and cocaine has resulted from the perceived greater risks attributed to the use of the latter substances. A survey of college students 1 to 4 years beyond high school shows even smaller decreases in alcohol use, with almost no change in the frequency of binge drinking.[3]

Most studies of teen drug use have surveyed large-scale populations in schools or selected populations such as in clinics or treatment centers; few reports originate from pediatric practices. One survey, using an anonymous questionnaire, completed by 203 adolescents seen in an upper middle class practice in San Diego showed that female adolescents apparently began experimenting with alcohol and other drugs at an earlier age than did their male counterparts.[4] A 1992 study comparing suburban and urban pediatric practices with distinct ethnic and parental marital and educational status differences disclosed white suburban youth drank more alcohol more often than black urban youth. Marijuana and cocaine use was not significantly different for the two groups. Although both groups experienced predictable negative consequences of drug use, suburban youth reported more problems with blackouts, family conflict, school absence, suicidal thoughts, and loss of peer relationships.[5]

HAZARDS OF ALCOHOL USE

Unintentional injuries, suicides, and homicides account for 80% to 90% of deaths in adolescents. The leading cause of death among Americans 15 to 24 years of age is alcohol-related motor vehicle injuries. Even though the number of accidents has declined from 1982 to 1989, approximately 7000 such fatalities occur per year.[6] In addition, thousands of seriously and often permanently injured passengers and drivers survive injuries. After the legal drinking age was changed in all states, the number of motor vehicle fatalities in the under-21 age group significantly decreased.[6]

Alcohol has been implicated in a majority of other causes of unintentional deaths including drownings and fatal falls.[7,8] Elevated blood alcohol levels have been reported in many suicide and homicide victims. Also, a history of suicide attempts is more prevalent among adolescents who are in drug and alcohol treatment facilities.[9]

In a 1991 survey of 21 metropolitan areas, more than 48000 emergency department visits by 6- to 17-year-olds were caused by the intentional ingestion of drugs. Of these visits, 5300 were related to alcohol in combination with other drugs. The motive for drug use in 20% of these patients was recreational or other mood-altering effects. Suicide was the motive for 68% of the patients, although the fatality rate was less than 0.05%.[10]

The use of alcohol is common before the use of illegal substances. Most adolescents use tobacco and drink beer or wine before they begin drinking liquor. Some adolescents then use marijuana, with a smaller number progressing to other illicit drug use. Rarely does drug use begin with marijuana.[11] Alcohol is often used in combination with other drugs, which may potentiate their side effects.

Addiction to alcohol is underdiagnosed in the young. 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."[12]

Alcoholism should be suspected in youths who are frequently intoxicated or experience withdrawal symptoms from chronic or recurrent alcohol use; tolerate large quantities of alcohol; attempt unsuccessfully at cutting down or stopping alcohol use; experience blackouts due to drinking; or continue drinking despite adverse social, occupational (educational), physical, or psychological consequences and/or alcohol-related injuries.[13]

Alcohol abuse progresses from experimentation to more regular use in the adolescent substance use/abuse continuum.[14,15] By definition this includes individuals who continue a pattern of alcohol use over a period of 1 month or longer despite persistent or recurrent negative consequences or in situations where such use is physically dangerous.[13] The negative consequences of alcohol use include impaired relationships with family, peers, or teachers; problems with school performance; problems with authorities; and high-risk behavior, such as driving or swimming while drinking. Alcohol use or abuse also increases the likelihood of other risk-taking behaviors such as unprotected or unplanned intercourse that may lead to adolescent pregnancy.[16] Additional associated risks include acquiring a sexually transmitted disease and increased risk of physical or sexual abuse, often by an acquaintance of the same age.

Adolescents who use alcohol while pregnant increase the risk of complications associated with pregnancy as well as giving birth to infants with fetal alcohol syndrome.[17,18] Some teenagers may be unaware they are pregnant, or deny the possibility they are pregnant, delaying prenatal care while continuing to drink. In one study, 17% of pregnant adolescents in a comprehensive teen pregnancy program tested positive for alcohol or other drug use.[19] Another study showed continued but decreased drug use after pregnancy was confirmed.[20]

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, hyperactivity, psychosomatic complaints, and problem drinking or alcoholism as adults.[21] Additional research is required to validate the clinical impression that describes interpersonal problems encountered by children of alcoholics.[22]

FACTORS CONTRIBUTING TO ALCOHOL USE/ABUSE

Genetic and Family Factors
A family history of alcoholism predisposes children to problem drinking, especially if one or both parents are heavy drinkers.[23] Sons of alcoholic men have a 25% risk of becoming alcoholics themselves.[24,25] 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.[26]

Parental attitudes and behavior regarding alcohol use play important roles in how children and adolescents view its use. Evidence exists that a family history of antisocial behavior and poor parenting skills increases the risk of having children who use alcohol and other drugs.[27] The home is the primary source of alcohol for the young adolescent; 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 male adults, 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.[28]

Peer Influence
During adolescence, drinking behavior, which often begins within the family, may be reinforced by peers. Because vulnerable adolescents generally seek out peer groups with similar attitudes and behaviors, pressure from this group can stimulate 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. Teenagers, like adults, may use alcohol to reduce social inhibitions and to accompany sexual activity.[29]

Society
Alcohol use permeates Western society. It is advertised widely and is frequently seen by teenagers on television. Drinking alcohol is portrayed by advertisers as being sophisticated and a natural part of life. Beer continues to account for the majority of all alcohol consumed by the young; wine coolers (sweetened and/or carbonated beverages) are popular in some geographic areas, especially among female adolescents. A conflictual 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 media message to youth is clear: alcoholic beverages are essential to social acceptance, of minimal harm to health, and a reward at the end of a normal day's work, a school exam, a sports victory, or for any relaxing moment.[30,31] The risk for excessive alcohol use is never stated or even implied.

Adolescent Development
Drinking by youth is perceived by society as normal experimental behavior. Teenagers 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 is hazardous, and a significant number of individuals do not continue to use alcohol after their initial experience. Adolescents, however, may be at increased risk of becoming intoxicated while drinking less than adults because of their limited experience with alcohol and smaller body size. In addition, in susceptible adolescents the time frame of progression to alcohol dependence is much shorter compared with adults.[15] They are less able to recognize and compensate for the neuropsychiatric effects of alcohol use due to biologic, cognitive, and psychological immaturity, and may experience psychological arrest of development with continued abuse.[32] Those with early antisocial behavior, poor self-esteem, school failure, attention deficit disorder, learning disabilities, drug-using friends, and 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 in an attempt to cope with their psychological distress and have a higher incidence of alcohol or other drug addiction.[33,34]

RECOMMENDATIONS

1. Pediatricians should condemn the nontherapeutic use of all psychoactive drugs, including alcohol and nicotine by children and adolescents.

    

2. The AAP encourages all providers of adolescent health care to discuss the hazards of alcohol and other drug use with their patients as a routine part of risk behavior assessment, to take the opportunity to reinforce nonuse behaviors and assess current use with a nonjudgmental approach. Special attention should be paid to the discussion of this issue when risk factors for problem drinking, such as a family history of alcoholism, are present.

    

3. Pediatric residency training programs should develop and implement substance abuse education curricula for medical students and residents.

    

4. Prenatal visits and preventive child health care provide an opportunity to inquire about a family history of alcoholism and parental attitudes about alcohol use. Parents can be urged to use alcohol safely and in moderation, to restrict children from family alcohol supplies (or remove them), and recognize the influence their own drinking patterns can have on their children and their parenting. The practice of giving alcohol to young children should be discouraged, though appropriately supervised use in a religious ceremony is acceptable to many.

    

5. Pediatricians should encourage their patients to avoid attending parties where alcohol is served, at least until the adolescent is mature enough and is able to use appropriate refusal techniques to avoid the pressure to drink. Pediatricians should discourage parents from allowing their children to attend such parties and should not allow alcohol to be served to minors at parties in their own homes.

    

6. Pediatricians are encouraged to assist families, churches, community agencies, and school personnel in developing alcohol education programs and alcohol-free activities. The medical complications and physiologic effects of alcohol use can be taught and information shared about the developmental aspects of childhood and adolescence that increase the risk of problem drinking and adverse consequences from alcohol use.

    

7. Pediatricians are encouraged to support a "zero tolerance" policy in local schools against alcohol, tobacco, and other drug use not only at school, but also at all school-sponsored and sanctioned activities that applies equally to students and staff. Penalties for noncompliance should be clear and enforced.

    

8. The Academy supports a ban on the advertising of alcohol similar to that of cigarettes. As an initial alternative, there should be equal time from television networks for public service announcements about the hazards of alcohol use. Pediatricians should work with other professionals and concerned parents to persuade the media to eliminate or substantially modify the current glamorous portrayal of alcohol use, both in regular programming and commercials. Controlled, responsible alcohol use by adults should be conveyed by the media, including the option of not drinking alcohol in social settings, especially when children are present.

    

9. Continued legal efforts should be supported in states where "zero tolerance" laws have not yet been enacted. The AAP recommends a standard blood alcohol level of no more than 0.02% for those under the legal drinking age who are operating a motor vehicle and supports the automatic suspension or delay of conferral of drivers' licenses for minors convicted of alcohol or drug law violations. Research is encouraged on the effects of these laws in reducing the number of fatal traffic crashes and on the overall downward trend in motor vehicle fatalities in the under-21 age group.

    

10. Pediatricians need to be able to recognize early signs of alcohol and other drug abuse or dependency so patients can be properly managed and/or referred for assessment and initiation of treatment. In addition, parents need guidance and support in assessing their children's use of alcohol and in setting appropriate limits and consequences for continued use. Parents also need to know where to get help when they, the school, or the pediatrician believe the child's alcohol use is a problem.