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Alcohol misuse
  1. W JOAN ROBSON, Consultant in Paediatric A&E Medicine (now retired)
  1. Royal Liverpool Children's Hospital, Alder Hey
  2. Eaton Road, Liverpool L12 2AP, UK
  3. wjrobson{at}hotmail.com

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    Every society has a socially acceptable drug. In Europe this is alcohol.1 In 1994–96 a Health Survey for England2 found that 29.2% of the adult male population and 14.5% of the adult female population drank alcohol over the recommended limits. For many this pattern will have started in adolescence, which is a time for experimentation with high risk behaviours. From the age of 5 years children in England and Wales can legally drink alcohol. The misuse of alcohol in children must be considered in this context.

    Definitions

    The definition of the age range ofchildren varies. The Children Act of 1989 relates to children and young persons up to the age of 18 years. This is the age after which alcohol may be purchased in all circumstances in the UK, therefore the age limit for children referred to in this annotation is 18 years.

    The Health Advisory Service review of services for young people in Britain3 acknowledged the difficult distinction between use and misuse of drugs, including alcohol. The authors suggesteddrug use referred to experimentation.Misuse was defined as use that is “harmful”, in line with the World Health Organisation definition4: dependent use or use of substances that is part of a wider spectrum of problematic behaviour. In the USA and in some other countries the term use has been superseded by abuse, reflecting the ideological view that any use constitutes abuse. Harrison et al argue that although this may reflect public disapproval of the use of alcohol and other drugs, it blurs the distinctions necessary for clinicians and researchers.5 DSM-IV6 is used for operational definitions and severity criteria for diagnoses of alcohol related problems in adults; however, concern has been expressed about its clinical validity in children.7

    A unit of alcohol is 8 g of alcohol. The percentage of alcohol in any drink is the number of grams of alcohol in 100 ml (one pint is 568 ml).

    For adults, recommended limits of alcohol consumption are defined as 14 units each week for women and 21 units each week for men. No one has defined limits for children.

    Prevalence and trends in use and misuse of alcohol

    A Health Related Behaviour Questionnaire by the University of Exeter has been used nationally.8 For the age group 12–13 years the percentage of children who admitted to drinking alcohol in the past week in 1995 was 29% of boys and 26% of girls. By 1999 this had risen to 38% of boys and 30% of girls. The same questionnaire revealed that in 1998 in the 14–15 years age group, 55% of boys and 53% of girls had drunk alcohol in the past week.

    Young people are drinking larger amounts of alcohol.9 The average consumption among 11–15 year olds in England increased from 0.8 units a week in 1990 to 1.8 units in 1996. If non-drinkers are excluded from this calculation the increase is from 5.4 units a week in 1990 to 8.4 units a week in 1996.

    In 1995 Miller and Plant10 examined the prevalence of self reported alcohol use in the UK among a large representative sample of people born in 1979. Almost all of these 15 and 16 year olds (n = 7722) had drunk alcohol in the previous month. Only 5.8% had never drunk alcohol, mainly for religious reasons. Most (77.9%) reported having at some time experienced intoxication, 48.3% in the previous 30 days.

    Between 1985 and 1996 the number of children attending the Royal Liverpool Children's Hospital (RLCH) Alder Hey with an overdose of alcohol increased from 20 to approximately 200.11Gilvarry12 summarises many prevalence studies in children which conclude that alcohol use and misuse is much more widely reported than that of illicit drugs.

    HOSPITAL ADMISSIONS

    In the early 1980s hospital admissions for alcohol poisoning in children were calculated at about 1000 per year.13Unfortunately these statistics are not collected routinely.

    In 1998/99, 30 children up to the age of 16 years were admitted to the RLCH Alder Hey with alcohol related diagnoses, at a cost of £26 370.14 This does not include those who were nursed in the observation area of the accident and emergency department for up to four hours, then discharged home to the care of their families, nor those who were admitted with overdoses of a combination of alcohol and other drugs for deliberate self harm.

    DEATHS

    Fortunately deaths directly caused by alcohol are rare in children. They are more likely to die indirectly as a result of the effects of injuries which occur secondary to the intoxication. One recent local example was a teenager who fell off a railway platform into the path of a train when he was drunk, and died from his injuries.

    Reasons for children drinking alcohol

    Young people give many reasons for drinking alcohol. A study from the University of Strathclyde15 found that these changed with age. Children aged 12 and 13 years used alcohol to experience the adult world and to satisfy their curiosity. It also enabled many of them to socialise and to say that they had tried drinking. Those aged 14 and 15 were testing out their own limits and having fun. They enjoyed losing control every once in a while. They preferred their drinks to be relatively strong, cheap, and pleasant tasting. For them drinking to get drunk was important as was sharing the experience with others. Those aged 16 and 17 were anxious to show their maturity and experience with alcohol, drinking more like adults.

    Family influences—The attitudes and behaviours of children are initially shaped by families. Parents are powerful role models for children, as the family is the primary source for socialisation. A sensible drinking example set by parents seems to be particularly important in protection of children against alcohol misuse, as both abstainers and heavy drinkers are more likely to have heavy drinking children.16 17 The balance between environmental and genetic factors has been studied by many researchers as reported by Gilvarry.12

    Peer influences are strong in older children. Fergusson et al reported that association/affiliation with substance using peers at age 15 years independently predicted abusive or hazardous alcohol consumption at age 16 years.18

    Marketing and advertising of alcohol is unlikely to influence younger children. They look for drinks that are strong and cheap “to get drunk as quickly as possible”.19 There was concern that “alcopops” would encourage teenage drinking. A study in Edinburgh20 found that the main consumers were females aged 20–31 years. Atkin reported21 “The preponderance of the evidence indicates that alcohol advertising stimulates favourable dispositions, higher consumption, and greater problem drinking by young people. Nevertheless, the evidence clearly does not support the interpretation that advertising exerts a powerful, uniform, direct influence; it seems that advertising is a contributing factor that increases drinking and related problems to a modest degree rather than a major determinant.”

    Sources of alcohol

    Much alcohol consumed by children is from their own homes or purchased by persons over the age of 18 years. In 1996 about 10% of 12–13 year olds, 16% of 13–14 year olds, and 25% of 14–15 year olds claimed to have bought alcohol recently.22 Off licences were the most commonly used outlets.

    Types of alcohol

    The children attending RLCH Alder Hey in 1996 with overdoses of alcohol mostly had drunk strong cider, cider, or vodka.10Few had drunk alcopops. National statistics8 for all alcohol consumed by children aged 11–15 in the same year showed:

    • Beer, lager, cider 57%

    • Alcopops 17%

    • Spirits 14%

    • Wine 8%

    • Fortified wine 2%

    • Shandy 2%.

    Effects of misuse

    Acute intoxication in children gives the same symptoms and signs as in adults. Hypoglycaemia is more common.

    The long term effects of frequent/excessive ingestion of alcohol on young people are difficult to predict. Little research has been done on the effects of alcohol on the developing human after birth. The features of the fetal alcohol syndrome in babies born to mothers who misuse alcohol are well documented.23

    Potential secondary risks are:

    • Alcohol related crime, including sexual assaults

    • Accidents

    • Fires/burns

    • Glass injuries

    • Homelessness.

    Comorbidity

    In the psychiatric literature comorbidity is defined as “the presence of more than one disorder in a person in a defined period of time”. Children with certain disorders are more likely to harm themselves with alcohol. These conditions include:

    • Suicide

    • Attention deficit hyperactivity disorder

    • Conduct disorder

    • Depression.10

    They may also have comorbidities resulting from accidental injuries or assaults which occur while they are intoxicated.

    Management

    ASSESSMENT

    A history of alcohol consumption should be taken in the personal history of all children over the age of 11 years of age. Pointers to potential alcohol dependence should be sought24:

    • Drinking more than 10 units daily (equivalent for prepubertal children is unknown)

    • Tolerance to alcohol: blood alcohol >150 mg/100 ml without drunkenness

    • Repeated withdrawal symptoms; morning shakes relieved by alcohol

    • Repertoire narrowed by drink, e.g. truancy

    • Compulsion to drink in spite of problems

    • Abnormal laboratory tests.

    TREATMENT

    In acute alcohol poisoning the initial management is a primary survey with resuscitation as required. Remember that hypoglycaemia and hypothermia are common complications. Children who attend RLCH Alder Hey are put into one of three categories for subsequent management:

    (I)   One attendance with an overdose of alcohol or an injury related to intoxication

    (II)   One attendance with an overdose of alcohol plus another drug

    (III)  Recurrent attendances with overdoses of alcohol.

    Most in category (I) are discharged after a few hours of observation without follow up. Those in categories (II) and (III) are admitted for full assessment as many have comorbidities.

    If chronic alcohol problems are suspected in any consultation, specialist advice needs to be sought. As with adults, the person has to accept that an alcohol related problem exists and must have a will for change before any treatment programme can be agreed. The options are outpatient day programmes, inpatient hospital programmes, and residential units. Unfortunately in the UK these services are fragmentary, ad hoc, and poorly evaluated.2 Some are tagged onto adult services without addressing the unique needs of children.

    Education and prevention

    School based prevention programmes have a modest degree of success.25 Increased attention has been given to parent directed or family directed interventions to delay the onset of use of alcohol and to prevent misuse.26

    Conclusion

    While alcohol is such a socially accepted drug in the UK, children will mimic adults in their use and misuse of it. Any education programmes to increase the age of onset of drinking or to advocate “sensible” drinking in the later teens must start at primary school age.

    Research is needed to establish a clinically valid diagnostic classification of alcohol misuse in children. This classification could then be used to develop a national perspective.

    In the future all paediatricians should have training in the assessment of children for potential misuse of alcohol, as many children now start drinking alcohol regularly as soon as they are in secondary schools. Health professionals must learn to recognise when experimentation by children has changed to harmful misuse of alcohol, which may go on into adult life.

    References

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