Alcoholism, or alcohol dependence, is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as "A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress."
That maladaptive pattern is manifested, according to the DSM-IV , by the following behaviors occurring any time within one 12-month period:
- tolerance for alcohol
- withdrawal from alcohol
- alcohol taken in larger amounts and over a longer period of time than was intended
- persistent desire or unsuccessful efforts to cut down or control alcohol use
- much time spent in activities necessary to obtaining alcohol
- various important activities, for example, in socializing or at work, are given up or reduced because of alcohol use
- alcohol use continued regardless of the pattern of physical or psychological problems that it causes or worsens
Alcohol abuse has the same definition but is manifested by one (or more) of the following behaviors occurring within the same 12-month period:
- repeated alcohol use leading to failure to fulfill major role obligations at work, school, or home
- repeated alcohol use in situations in which it is physically hazardous
- repeated alcohol-related legal problems
- persistent alcohol use despite its causing social and interpersonal problems or exacerbating them
This definition and the criteria established by DSMIV apply to both adults and children. The American Academy of Pediatrics (AAP) states that the pattern of use and abuse of alcohol in children and adolescents is not observably different from what is manifested in young people using marijuana or cocaine.
The AAP divides the progression into childhood alcoholism into three stages:
- Stage 1: Experimentation with alcohol. Normally there is no change noted in physical status or behavior, and the drinking usually occurs only on weekends during social occasions with peers, making it the least detectable of the three. Peer pressure to use alcohol "just for fun."
- Stage 2: Actively trying to obtain alcohol. Alcohol use happens during the week to provide relief when stress is felt or to "feel good" when depressed.
- Stage 3: Preoccupation with alcohol. The child or adolescent has nearly lost the capacity for controlling alcohol use. Setting limits results in withdrawal symptoms, including depression, moodiness, or irritability. Severe withdrawal can result in serious medical problems, including delirium tremens.
Prevalence and severity of the problem
Based on findings mostly coming from the 1990s, the National Council on Alcohol and Drug Dependence (NCAAD) cites the following in its fact sheet Youth, Alcohol and Other Drugs :
- Approximately 10.4 million Americans ages 12 to 20 have at least one drink per month. One fifth of these (2.1 million) are heavy drinkers who have five or more drinks on a minimum of five different occasions. More than half of these (6.8 million) are considered binge drinkers who have five or more drinks on a single occasion.
- Eighty percent of all high school seniors have tried alcohol.
- Eight percent of eighth graders, 24 percent of tenth graders, and 32 percent of high school seniors have been intoxicated from alcohol in the past month.
- Children who begin smoking tobacco before the age of 13 are significantly more at risk for alcohol problems.
- Among high school seniors, alcohol use is more prevalent among Caucasian and Hispanic students than among African American students.
- Junior, middle, and senior high school students consume 35 percent of all wine coolers sold in the United States as well as 1.1 billion cans of beer.
- A Southern Illinois University study showed that students with overall grades of D or F drank on average three times as much alcohol as students with overall grades of A.
- A United States Department of Justice survey showed that nearly one third of children below the age of 18 incarcerated in juvenile institutions are under the influence of alcohol at the time of their arrest.
- More than half (56%) of children and teens in grades five through 12 report that alcohol advertising encourages them to drink.
- Thirty percent of children in grades four through six state that they have received pressure from peers to drink beer.
- Two thirds of teenagers who drink report that they are able to make their own alcohol purchases.
- The total cost of alcohol use by young people, including automobile crashes, violent crime, alcohol poisoning, burns , drowning, suicide attempts, and fetal alcohol syndrome is more than 58 billion dollars each year.
- Eighty percent of teenagers do not know that a 12-ounce can of beer has the same amount of alcohol as a shot of whiskey or a five-ounce glass of wine.
Causes and symptoms
In their article "Early Identification and Intervention for Adolescent Alcohol Use," Mark Werner and Hoover Adjer Jr., both fellows at the American Academy of Pediatrics (AAP), state that attitudes regarding alcohol use are developed quite early in life, usually by the age of eight. Parental attitudes regarding alcohol and behaviors related to alcohol use have a major impact on how children and young adults view drinking alcohol. Not every child or teen who experiments with alcohol becomes an alcoholic, but NCADD studies have shown that children who drink before the age of 15 are four times more likely to become alcoholic than those who begin drinking after the age of 21. Some evidence supports a genetic component to this disease. Parents who are themselves alcoholic or problem drinkers are more likely to have children who develop alcohol dependence. Statistically, one in five children who have an alcoholic parent becomes an alcoholic, too.
Physical symptoms seen in adult alcoholics, such as gastritis, pancreatitis, hepatitis, or even cirrhosis, usually are absent in childhood alcoholics. Such physical damage normally takes longer to develop and is more typical of long-term adult alcoholics. More often in potential childhood alcoholics, behavioral symptoms provide the most significant clues.
These behavioral warning signs, according to the AAP, typically include the following:
- decline in school functioning, decreased attendance, poorer grades, and/or general deterioration in social functioning in school
- increased isolation outside school; rejection of usual long-term friendships in favor of new or different friends
- frequent arguments or less communication with family members; being more secretive
- marked changes in grooming and clothing styles
- noticeable increase in unexplained injuries and fights
- running away from home
- depressive symptoms such as weight loss, sleep problems, lethargy, feelings of hopelessness, mood swings, suicidal feelings, or suicide attempts
- evidence of the presence of risk-taking behaviors such as either driving while under the influence of alcohol or driving with others who are intoxicated, engaging in violent behaviors such as fights, or participating in unsafe sex
When to call the doctor
It is worth noting that these behavioral warning flags can appear in non-alcoholic children or teens and also are usually not observed before the second or third stage of childhood alcoholism. Parents observing some or all of these warning signs need professional help to both clarify diagnosis and plan treatment. Individual and family denial is considered a large portion of any alcohol problem. Parents need objectivity and open and honest communication with their children in order to deal effectively with childhood alcoholism and to know when to seek help.
As noted, behavioral symptoms help to determine the diagnosis, but not usually until the second and third stage of the disease. There are assessments available that can provide both earlier identification and intervention for childhood alcoholism.
Diagnostic assessments for alcoholism, according to the APA, include:
- CAGE, a mnemonic that points to four key questions by highlighting key words: "Cut down," "Annoyed," "Guilty," and "Early" (see below)
- Alcohol Use Disorders Inventory Test (AUDIT)
- Personal Experience Screening Questionnaire (PESQ)
- Problem Oriented Screening Instrument for Teenagers (POSIT)
CAGE is an assessment guide containing the following four questions:
- C: Have you ever felt the need to cut down on your drinking?
- A: Do you get annoyed at criticism by others about your drinking?
- G: Have you ever felt guilty about your drinking or something you have done while drinking?
- E: Have you ever felt the need for a drink early in the morning?
Once assessment has led to a diagnosed problem with alcohol, its severity determines the treatment needed. In "Early Identification and Intervention for Adolescent Alcohol Use," Werner and Adjer divide problem teen drinkers into three groups:
- The first category includes those teens who are using alcohol occasionally but still doing well emotionally and developmentally and who are not drinking and driving. The treatment objectives for this group are to encourage abstinence and re-enforce safety by fostering the continuation of not driving while drinking and not driving with others who are drinking.
- The second category includes those teens who are more at-risk because while they are maintaining stability in physical, developmental, and emotional status, they are also drinking and driving. Professionals dealing with members of this group may not be able to maintain confidentiality, and people in this group may benefit from an introduction to organizations such as Students Against Drunk Driving (SADD).
- The third category includes those showing serious signs of impairment, including inability to follow through on obligations at school or on a job, alcohol-related encounters with police or the justice system, and mental health problems such as anxiety , depression, or oppositional-defiant behavior. These children may experience frequent acute intoxication or withdrawal symptoms, medical complications, or an inability to stop or reduce their alcohol intake. Werner and Adjer suggest that professionals dealing with members of this group probably need to set aside confidentiality in order to involve parents in the treatment process. Treatment may include detoxification in an in-patient facility and/or rehabilitation in a youth-centered substance abuse program.
The following key issues should be considered in determining which treatment option is appropriate:
- severity of the problem and evidence to suggest other mental health problems (e.g. depression, suicide attempts)
- staff credentials of those treating the child or teen, and what forms of therapy (e.g., family, group, medications) are to be used
- nature of family involvement
- how education is to be continued during treatment
- if an in-patient program is necessary, what length it should be
- what aftercare is to be provided following discharge
- what portion of treatment is to be covered by health insurance and what needs to be paid out of pocket
Since its inception in the 1930s, Alcoholics Anonymous (AA) has been an important non-medical means of treating alcoholism with millions of members worldwide, many of whom are teenagers. It is a spiritual but non-religious program that fosters abstinence from alcohol based upon a belief that the person suffering from alcoholism is "powerless" over their addiction . AA suggests that people can stay free of alcohol by using an attitude that focuses on "one day at a time" and that consciously seeks spiritual support from "a power greater than themselves." AA is generally a part of most in-patient treatment and rehabilitation programs.
Prevention provides the best possible prognosis for alcohol abuse and dependence. The National Council on Alcoholism and Drug Dependence estimates that parents who talk with their children regularly about the danger from drugs (including alcohol) have children who are 42 percent less likely to use these substances. Once alcoholism is present, abstinence is the only known completely successful treatment. Children suffering from alcohol dependence continue for the rest of their lives to be at risk for problems with alcohol if they again drink. The prognosis is excellent for young alcoholics who remain alcohol-free and who do not substitute other drugs for alcohol, sometimes called "chewing their booze" in AA.
Alcohol use and abuse has been a feature of Western culture for centuries, a facet of American life since Europeans arrived in North America, literally arriving with the pilgrims on the Mayflower. It is typically part of U.S. celebrations and even some American-observed religious rites. Because alcohol overuse and abuse has been so much a part of Western experience, there is clearly a tremendous need–among children and adults—for better education about both alcohol consumption and alcoholism. The statistics indicate that parents, teachers, and healthcare professionals need to begin educating children as early as possible regarding the risks involved in alcohol use. Parents who provide the example of limiting their own alcohol and other drug use can help their children inestimably. It should never be inferred that difficult situations can be better coped with by having a drink or that getting drunk is either helpful or amusing. Moreover, parents and other adults need to set the example by not driving a car or operating machinery while they are drinking or under the influence of alcohol.
The APA suggests the following as the most effective ways that parents can aid their children in resisting drinking:
- Provide children with self-confidence by building self-esteem and not engaging in constant criticism. Good self-esteem is the best defense against peer pressure to drink.
- Listen to children. Parents who listen attentively and provide support during difficult times give their children invaluable aid in coping with pressures.
- Get to know the children's friends.
- Provide supervision and discourage teens from attending parties where alcohol is served or parents are absent, and band together with other parents to arrange alcohol-free social events for children.
- Be available and encourage children and teens to call home for a ride rather than drive with someone who has been drinking; assure children there will be no recrimination, as SADD recommends.
- Teach therapeutic coping mechanisms by modeling how to handle stress, pain , or tension in healthy ways, by exercising, using yoga and meditation, and talking about feelings.
- Understand the tremendous importance of child and adolescent issues, including alcohol and other drug use and acceptance by peers; be ready and able to discuss these subjects with children.
- Encourage and participate in enjoyable, worthwhile activities with children; be reassuring that there is time enough for both work and fun.
- Be willing to learn about alcohol abuse; attend, along with their children, programs offered by schools, churches, and other groups providing information about the prevention of alcohol abuse.
- Maintain healthy lines of communication with children; remember the saying, "You are only as sick as the secrets you keep."
Most childhood alcoholics do not reach the serious state of malnutrition that chronic adult alcoholics can reach. However, severe cases of alcohol abuse and dependence may result in a child or teen not eating normally, resulting in weight loss and vitamin deficiencies (B-vitamins particularly). Resumption of normal eating habits and possible addition of vitamin supplements can help in regaining normal nutrition .
Parents of alcoholic children often encounter persistent and highly traumatic worries regarding serious physical, emotional, social, and legal problems for the affected child as well as the terrifying possibility of that child's death or serious injury. Clearly, these concerns can take a huge toll in a family. The denial mentioned earlier is often a complicating factor. The notion of "Not my son or daughter!" can actually hinder treatment and recovery for a child. Parents are also often embarrassed by their child's alcohol abuse and may believe that it is somehow their fault. It is not uncommon for parents to feel isolated and to feel as if they are the only ones with this problem. High school programs such as the earlier-described SADD can address some of the fear regarding drunk driving. Parental support groups such as Tough Love programs and twelve-step groups such as Al Anon can help parents to better understand the problem they facing and can help make them aware that they not alone and that they have options.
Al Anon is a twelve-step program (that is, a program based on the twelve steps employed by Alcoholics Anonymous) that provides support and spiritual recovery for the families and loved ones of alcoholics. This program was begun in the early 1940s by the wives of some of AA's earliest members and founders, including Lois Wilson, wife of AA founder Bill Wilson. Twelve-step programs have spun off over the years to meet the needs of specific populations, including adult children of alcoholics and teens who are alcoholics.
Because parents of alcoholic children often believe they are responsible for their child's drinking, the Three C's that Al Anon offers its participants may be particularly helpful. These Three C's state:
- "I didn't cause anyone else's alcoholism."
- "I can't control anyone else's alcoholism."
- "I can't cure anyone else's alcoholism."
Tough Love , a program begun by Phyllis and David York, co-authors of a book by the same title, is designed to help families and especially parents cope with a variety of problems, including alcoholism and drug abuse, that often affect children and ultimately the whole family. Tough Love 's approach is different from that of Al Anon. The ten beliefs listed below form the basis for this program and show clearly the difference in philosophy:
- Parents are people too.
- Parents' material and emotional resources are limited.
- Parents and kids are not equal.
- Blaming keeps people helpless.
- Kids' behavior affects parents. Parents' behavior affects kids.
- Taking a stand precipitates a crisis.
- From a controlled crisis comes the possibility of positive change.
- Families need to give and get support in their own community in order to change.
- The essence of family life is cooperation, not togetherness.
Al Anon and Tough Love are offered in a variety of formats to the families of alcoholic children through treatment centers, churches, and other community services. It is clear that there are dramatic differences between these two philosophies. But perhaps the best way for parents to decide which approach makes sense to them is to take the advice Al Anon offers all newcomers: "Take what you like and leave the rest."
Alcohol Use Disorders Inventory Test (AUDIT) —A test for alcohol use developed by the World Health Organization (WHO). Its ten questions address three specific areas of drinking over a 12-month period: the amount and frequency of drinking, dependence upon alcohol, and problems that have been encountered due to drinking alcohol.
Binge drinking —Consumption of five or more alcoholic drinks in a row on a single occasion.
CAGE —A four-question assessment for the presence of alcoholism in both adults and children.
Delirium tremens —A complication that may accompany alcohol withdrawal. The symptoms include body shaking (tremulousness), insomnia, agitation, confusion, hearing voices or seeing images that are not really there (hallucinations), seizures, rapid heart beat, profuse sweating, high blood pressure, and fever.
Detoxification —The process of physically eliminating drugs and/or alcohol from the system of a substance-dependent individual.
Personal Experience Screening Questionnaire (PESQ) —A questionnaire for alcoholism.
Problem Oriented Screening Instrument for Teenagers (POSIT) —A questionnaire used specifically for teenagers to assess alcohol and drug use.
Students against Drunk Driving (SADD) —An organization that offers a "Contract for Life" that asks teens to discuss substance use with parents, to call home for a ride if safe transportation is needed, and to wear a seat belt. Parents in turn promise to arrange for that safe transportation home "regardless of the time or circumstances," without discussion of the incident until both teens and parents are calm.
Tolerance —A condition in which an addict needs higher doses of a substance to achieve the same effect previously achieved with a lower dose.
Twelve-step programs —Several programs to assist in breaking addictions, offering either support to addicted people or to friends and loved ones of addicted people. These programs are spiritual but not religious and are based on the twelve steps that are the basis of Alcoholics Anonymous (AA). Programs include AA, Narcotics Anonymous (NA), Al-Anon, Adult Children of Alcoholics (ACOA), Alateen, and Co-Dependence Anonymous (CODA).
Withdrawal —The characteristic withdrawal syndrome for alcohol includes feelings of irritability or anxiety, elevated blood pressure and pulse, tremors, and clammy skin.
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Alcoholics Anonymous. (See white pages of local telephone book for area groups.) Web site: http://www.alcoholicsanonymous.org.
National Council on Alcoholism and Drug Dependence. 20 Exchange Place, Suite 2902, New York, NY 10005. Web site: http://www.ncadd.org.
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Joan Schonbeck, R.N.