Clinical Handbook of Adolescent Addiction

Richard Rosner

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470972342
• eBook ISBN: 9781118340875
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Since 1960, the burden of adolescent illness has shifted from the traditional causes of disease to the more behavior-related problems, such as drinking, smoking and drug abuse (nearly half of American adolescents have used an illicit drug sometime during their life). Instilling in adolescents the knowledge, skills, and values that foster physical and mental health will require substantial changes in the way health professionals work and the way they connect with families, schools, and community organizations. At the same time, the major textbooks on addiction medicine and addiction psychiatry devote relatively little attention to the special problems of diagnosing and treating adolescent addicts. Similarly, the major textbooks on general and child and adolescent psychiatry direct relatively little attention to the issues surrounding adolescent addiction.

The Clinical Handbook of Adolescent Addiction is one response to the challenge of meeting the mental health needs and behavior-related problems of addicted teenagers. The work has been edited as an independent project by members of the American Society for Adolescent Psychiatry, the oldest professional organization of psychiatrists devoted solely to the mental health care and treatment of teenagers in the USA. The forensic psychiatry perspective permeates the entire book. It will help to produce health providers with a deep and sensitive understanding of the developmental needs and behavior-related problems of adolescents.

The Clinical Handbook of Adolescent Addiction is a practical tool for all those who help adolescents: practitioners of family medicine, general psychiatrists, child/adolescent psychiatrists, adolescent psychiatrists, addiction psychiatrists, non-psychiatric physicians specializing in addiction medicine, forensic psychiatrists, psychologists, clinical social workers, mental health administrators, Court/Probation/ Parole/Correctional health workers.

The book is organized in a user-friendly format so that readers can easily locate the chapters that provide the information that is required. In some instances, topics of special importance deliberately have been addressed in more than one chapter, to illuminate the topics from a variety of vantage points. One aim of the editors is to move the topic from being a specialist area to a generalist one by providing tools for generalist to use.

Section Four

Clinical Conditions

Edited by Charles Scott

18

Adolescent Alcohol Use

Karen Miotto, Andia Heydari, Molly Tartter, Ellen Chang, Patrick S. Thomas and Lara A. Ray

Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA

Introduction and Epidemiology

Experimentation with substance use is common during the adolescent years, predominantly with substances that are easily accessible. In 2008, the Monitoring the Future Study found that 39% of 8th-graders, 62% of 10th-graders, and 72% of 12th-graders reported having tried alcohol, with 92% of 12th-graders feeling that “it is or would be fairly easy or very easy to get alcohol” [1]. Most young people report that they obtain alcohol from their family or friends. Some parents permit underage drinking, while the majority of parents are an unwitting source of alcohol. For example, data from the National Survey on Drug Use from 2006 to 2009 indicates that 93.4% of adolescents who drank in the past month obtained their alcohol for free, and 44.8% of these adolescents obtained it from family members or from their own homes [2]. For this reason, family involvement is especially important to consider when looking at this prevalent problem. The sources of alcohol and patterns of early use often have prognostic importance: the younger the onset of alcohol use, the greater the risk of developing addiction. Data from a longitudinal study have shown that adolescents with an age of drinking onset (not counting sips or small tastes) of 12 years or younger were found to have a 40% prevalence of lifetime alcohol dependence. Individuals who initiated alcohol use at 18 years of age were found to have a 16.6% prevalence of lifetime alcohol dependence, whereas those who delayed drinking until 21 years of age have a lifetime prevalence of 10.6% [3].

Adolescent binge drinking constitutes a public health concern. Binge drinking is defined as four or more standard drinks for a female and five or more standard drinks for a male within a 1-hour period [4]. The Monitoring the Future Survey found that 10% of 8th-graders, 22% of 10th-graders, 26% of 12th-graders, and 40% of college students reported binge drinking within 2 weeks prior to the date of the questionnaires [1]. Drinking peaks during college years, with more than 30% of college students meeting a Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnosis of alcohol abuse or alcohol dependence [5]. It is commonly assumed that young people will outgrow college drinking patterns. However, Jackson et al. found that binge-drinking college students had a correlation with heavy drinking at age 29–30 (r = 0.29), alcohol consequences (r = 0.35), as well as symptoms of alcohol dependence (r = 0.38) [6].

Distinguishing between normal and abnormal adolescent alcohol experimentation requires information from a biopsychosocial assessment. In contrast to adults, where a pattern of use such as "needing an eye opener" in the morning is often predictive of alcoholism, information on a confluence of risk factors is necessary in order to assess the level of severity of alcohol use in youth. These risk factors include individual factors (such as depression and anxiety symptoms, poor self-control, and high sensation seeking), family factors (such as family addiction, permissive parents, or disruptive family relationships), school factors (such as lack of academic success), and peer factors. These different types of factors have been shown to increase the likelihood of crossing over from normative adolescent alcohol use to more serious alcohol-related problems. Fortunately, the majority of adolescents who experiment with alcohol do not develop later life addiction. Alcohol experimentation is consistent with other age-appropriate behaviors, including challenging authority, experimenting with adult behaviors, and risk taking. Early motivations for drinking include social facilitation, peer influence, and novelty seeking.

Adolescence is a critical time during which unique cognitive, physical, genetic, social, and academic influences integrate. Early onset of alcohol use can disrupt this integration and change a person's life trajectory by contributing to a host of problems [7]. A few examples of the perils of alcohol experimentation include personal injury, accidents involving others, unsafe or unwanted sexual activities, legal charges, and incarceration. Adolescents lack the experience and cognitive ability to accurately estimate the probability of harmful alcohol-related consequences, thereby increasing the risk of accidents or even fatality.

Influences on Adolescent Alcohol Use

Social Determinants

The constant endorsement of alcohol by the media influences young people's beliefs and behaviors regarding drinking. In the United States, alcohol use is promoted through radio, television, billboards, and the internet [8]. A study by Primack et al. found that one out of every three of the most popular songs contains either social, sexual, financial, or emotional endorsements for alcohol [9]. Aggressive marketing of flavored beverages that mask the taste of alcohol targets an increasingly younger population. For example, the American Medical Association released a report on the marketing of “alcopops” – fruit-flavored malt beverages. The article cites a rise in adolescent girls' drinking, with the average age on having the first drink now 13 years. Teenage girls report more exposure to advertisements for these drinks than women over 21, and were found to drink alcopops more often than women over 21, despite the alcohol industry's claim that they market only to legal age drinkers [10, 11].

The types of drinks geared toward young consumers are predominantly sweet, fizzy, “ready to drink,” or premixed alcoholic beverages such as alcopops. Alcopops are a potential risk for the inexperienced drinker because the sweet flavor hides the taste of alcohol, making it easier to become intoxicated. Furthermore, young people have been shown to perceive alcopops as being less harmful than other types of alcohol [12], suggesting that they may be comfortable with drinking more of them, resulting in greater and/or quicker intoxication.

Popular caffeinated alcoholic drinks are also currently being investigated as a source of danger for the young alcohol consumer. The caffeine can counteract the sedating effects, which would normally protect the consumer against overdrinking. Caffeinated drinks are sold as premixed products, or can be made by mixing energy drinks with various forms of alcohol. The Centers for Disease Control and Prevention report that drinkers who mix alcohol and energy drinks are three times more likely to binge drink than those who do not [13]. In addition, those who consume caffeinated alcoholic drinks are three times more likely to leave an event highly intoxicated (breath alcohol level ≥0.08 g/210 L) and are four times more likely to intend to drive upon leaving compared to drinkers who did not consume caffeine with their alcoholic drinks [14]. Sweet and caffeinated alcohol drinks in trendy packaging are designed to attract young people; such consumers often lack the knowledge or experience to anticipate the hazards that can occur at various levels of intoxication.

School-Based Substance Abuse Prevention Programs

School-based substance abuse prevention programs provide young people with information that seeks to counter the marketing devices and glamorization of alcohol in the media. Thirty-nine US states require, and all states recommend, that schools provide students with substance use prevention programs [15]. Designing and evaluating programs that prevent substance use is complex and costly; a review of the different school-based programs can be found on the National Institute of Drug Abuse website [16]. Most of the programs advocate that providing information about the more immediate short-term health risks in conjunction with other prevention approaches is more effective than focusing on long-term risk factors. Examples of other prevention approaches include social resistance skills training, normative education about alcohol use, as well as competence enhancement skills training. Social resistance training seeks to increase teens' awareness about the advertising techniques used to sell alcohol and tobacco products and to resist the allure of media pressures in addition to offers of alcohol or drugs from peers. Teens learn how to identify and avoid situations where there is likely to be pressure to drink, and practice realistic and effective ways of communicating refusal to peers. In normative education, adolescents learn about the prevalence of alcohol and drug use. Many adolescents may drink alcohol as a result of the unfounded belief that most of their peers and all those around them are drinking. Normative education is an important technique to correct misperceptions by emphasizing that there are large numbers of young people who drink modestly or do not drink at all. Competence enhancement involves teaching adolescents social skills, such as decision-making and self-control, and enables them to apply these general skills when confronted with an alcohol- or drug-related situation. Teens with poorly developed social and coping skills often turn to drugs or alcohol as a method of facilitating social interaction [17, 18]. An active area of research is computer-delivered school-based prevention programs in keeping with the increased utilization of technology. One study found that a series of computer-delivered secondary prevention programs reduced alcohol use for teens transitioning to college [19]. Clinicians will recognize many of these prevention strategies because they are based on common therapeutic interventions used with young people, aimed at helping them develop social-cultural awareness, social skills, and problem-solving capabilities.

Family Influences

Another part of the continuum of factors that contribute to a young person's desire to drink is the influence of their family. Popular federal and state prevention campaigns often read, “Teens that eat dinner with their family are less likely to drink alcohol.” Indeed, greater parental involvement in an adolescent's life acts as a form of preventive intervention for substance use. Parental attitudes about substance use have a significant im...

Table of contents

• Cover
• Title Page
• Copyright
• Section Editors
• List of Contributors
• Preface
• Foreword
• Section One: The Scourge of Adolescent Addiction
• Section Two: Assessment of the Substance-Abusing Adolescent
• Section Three: Risk and Prevention
• Section Four: Clinical Conditions
• Section Five: Treatment
• Section Six: Special Issues in Adolescent Addiction
• Section Seven: Forensic Considerations
• Index