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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Binge Drinking Lorena Siqueira, MD, MSPH, FAAP, Vincent C. Smith, MD, MPH, FAAP, COMMITTEE ON SUBSTANCE

abstract is the substance most frequently abused by children and adolescents in the , and its use is associated with the leading causes of death and serious injury at this age (ie, motor vehicle accidents, homicides, and ). Among youth who drink, the proportion who drink heavily is higher than among adult drinkers, increasing from approximately 50% in those 12 to 14 years of age to 72% among those 18 to 20 years of age. In this clinical report, the definition, , and risk factors for binge drinking; the neurobiology of intoxication, blackouts, and ; genetic considerations; and adverse outcomes are discussed. The report offers guidance for the pediatrician. As with any high-risk behavior, prevention plays a more important role than later intervention and has been shown to be more effective. In the pediatric office setting, it is important to ask every adolescent about alcohol use.

Adolescence is a time of exploration and limit testing; therefore, it is no coincidence that this is the chief period for initiating substance use. Alcohol is the substance most frequently used by children and adolescents in the United States, and its use in youth is associated with the leading

This document is copyrighted and is property of the American causes of death and serious injury at this age (ie, motor vehicle accidents, Academy of Pediatrics and its Board of Directors. All authors have filed homicides, and suicides).1 Drinking levels that may cause little or no fl con ict of interest statements with the American Academy of 2 Pediatrics. Any conflicts have been resolved through a process problem for adults may be dangerous for adolescents. Recent studies approved by the Board of Directors. The American Academy of indicate that alcohol use during this period of growth may interrupt key Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. processes of brain development, possibly leading to cognitive impairment and an elevated risk of developing a chronic alcohol use disorder.3 Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external Twenty-one percent of youth acknowledge having had more than a sip of reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the alcohol before 13 years of age, and most (79%) have done so by 12th organizations or government agencies that they represent. grade.4 Among youth who drink, the proportion who drink heavily is The guidance in this report does not indicate an exclusive course of higher than among adult drinkers, rising from approximately 50% in those treatment or serve as a standard of medical care. Variations, taking 12 to 14 years of age to 72% among those 18 to 20 years of age.5 The into account individual circumstances, may be appropriate. original definition for binge drinking (5 drinks in 2 hours) was based on All clinical reports from the American Academy of Pediatrics fi automatically expire 5 years after publication unless reaffirmed, size and body composition for men. A has been de ned by revised, or retired at or before that time. the National Institute on and (NIAAA) as one fl www.pediatrics.org/cgi/doi/10.1542/peds.2015-2337 that contains 14 g of pure alcohol (about 0.6 uid oz or 1.2 tablespoons), as is found in one 12-oz , one 5-oz glass of , or one 1.5-oz shot of DOI: 10.1542/peds.2015-2337 distilled spirits.6 The NIAAA has defined binge drinking as the pattern PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). of drinking that brings a person’s blood alcohol concentration (BAC) to Copyright © 2015 by the American Academy of Pediatrics 0.08% or greater, which derives from concentrations for for

Downloaded from www.aappublications.org/news by guest on September 29, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 136, number 3, September 2015 those 21 years or older (the legal points to define binge drinking by age respectively), but male respondents intoxication level for adults in all and in youth have been were more likely to report binge 50 states in the United States). A suggested: for girls 9 to 17 years of drinking (15.8% and 12.4%, quantitative definition of drinking age, the cutoff suggested is $3 drinks. respectively).12 makes results comparable across For boys 9 to 13 years of age, the Among high school students, boys studies and is also important from cutoff suggested is $3 drinks; for (24.7%) were more likely than girls a clinical point of view, because binge boys 14 to 15 years of age, the cutoff (15%) to participate in all levels of drinkers are more likely to experience suggested is $4 drinks; and for boys binge drinking.2 alcohol-related problems than 16 to 17 years of age, the cutoff drinkers who do not binge. In adults, suggested is $5 drinks. These cutoffs The trends in binge drinking among binge drinking refers to the in boys reflect their greater muscle youth also vary by race or ethnicity consumption of 5 or more alcoholic mass and total body water content. and geography. Binge drinking was drinks in a row by men and 4 or more However, fewer drinks than far more common among white high drinks in a row by women, over suggested in these cutoffs should not school students (23.8%) than among a 2-hour period.7 On average, women be considered safe. Again, using adult black high school students (7.6%).2 weigh less than men and have lower definitions of binge drinking will Hispanic (22.4%) and non-Hispanic body water percentages; therefore, result in younger children who are at white (21.7%) high school girls had they reach higher BACs than men substantial risk of poor outcomes a higher prevalence of binge drinking with similar quantities of alcohol being missed. than did non-Hispanic black girls consumed.8 The time period used in (10.3%).15 Young men, students from surveys to record past episodes EPIDEMIOLOGY OF BINGE DRINKING more rural areas, and youth of white varies from one or more times in the race or ethnicity had particularly high last 2 weeks to one or more times in Binge drinking is a common problem. rates of extreme binge drinking. Rates the last 30 days. In a 2013 report, 22.9% (60.1 of binge drinking vary within and million) of Americans 12 years or between states in the United States.16 Binge drinkers have been older surveyed reported binge The regions with the highest rates of characterized in studies by the drinking in the 30 days before the underage binge drinking were located frequency of the binge episodes and 12 survey. Among those 12 to 20 years in , New Hampshire, by the quantity consumed above the of age, 14.2% (5.4 million) reported Rhode Island, Vermont, District of 4- to 5-drink limit to better correlate binge drinking. Additional breakdown Columbia, Florida, West Virginia, the drinking pattern with outcomes. by age revealed that 0.8% of 12- to Indiana, North Dakota, Ohio, and Frequent binge drinkers are those 13-year-olds reported binge drinking Wyoming.16 Teens from the Midwest who engage in this behavior 3 or and 4.5% of 14- to 15-year-olds were more likely than those in other more times in the period studied reported binge drinking. geographic regions to report extreme (usually the previous 2 weeks), and binge drinking.17 Socioeconomic occasional binge drinkers are those High school is a time when drinking status was less consistently who drink this way less than 3 times rates increase drastically. Between predictive of binge drinking behavior. in the previous 2 weeks. Frequent 36% and 50% of high school students Youth of higher socioeconomic status binge drinkers are significantly more currently drink alcohol, and 28% to are at greater risk of binge drinking likely to endorse reduced health 60% of them report binge 13,14 but lower risk of extreme binge quality of life and mental distress.9 drinking. Nearly two-thirds of drinking; however, youth of lower They are also more likely to develop these students reported binge socioeconomic status and those from alcohol and substance use drinking on more than one occasion rural areas may be at higher risk of disorders.10 Studies have also defined in the past 30 days. One in 10 high very extreme binge drinking (ie, $15 extreme binge drinkers as those who school seniors report drinking 10 or drinks on one occasion).2 consume dangerously high levels of more drinks in a row, and 5.6% of alcohol on one occasion, with high school seniors report consuming Lesbian, gay, bisexual, and 2 thresholds of $10 drinks and $15 15 or more drinks in a row. transgender (LGBT) youth are at drinks.2 Studies in youth may The rates of alcohol consumption and elevated risk of alcohol misuse, with underestimate the resulting harm, binge drinking in girls and young drinking patterns that significantly because the definitions used for binge women have been increasing but are increase linearly over time, more drinking are not consistent. Because still lower than among boys and rapidly among male compared with youth typically weigh less than adults, young men. In 2013, male and female female LGBT youth.18 However, the they are likely to reach a BAC much survey respondents 12 to 20 years of overall pattern of results and higher than 0.08% with 5 drinks in age had similar rates of drinking in correlates of alcohol use are strikingly a 2-hour period.11 Lower cutoff the past month (23% and 22.5%, similar to those of non-LGBT youth.18

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 3, September 2015 e719 Rates of drinking were significantly that adolescence is a critical risk and impulsivity.33 Sensation seeking lower in African American LGBT period for initiation of alcohol use, is a personality characteristic that youth than in those of all other racial and the earlier onset is associated indicates the need for novel groups. Furthermore, alcohol use in with greater risk of developing experiences and the willingness to these youth has been associated with alcohol abuse and dependence.25,26 A take physical and psychological risks their experience of victimization, number of individual risk factors for for these experiences.33 The threats, or violence19 and by the alcohol misuse have been identified, connection of sensation seeking to chronic stress associated with societal and some may be relevant to our earlier onset of substance use among stigmatization.20 understanding of the onset and teenagers and young adults and to Underage drinkers typically obtain course of binge drinking, in particular. higher levels of substance use has ’ 34 alcohol from adults of legal drinking According to Bandura s Social been established. age, including at home from parents, Learning Theory, 2 constructs are Lastly, peer use is another important siblings, or other relatives, and they central to the initiation and risk factor. The social experience of drink most frequently in their own or maintenance of human behavior drinking in a group has been others’ homes.21 A recent study (ie, outcome expectancies and self- correlated with youth binge fi 27 showed that 13- to 20-year-olds ef cacy). The anticipated effects of drinking.35 As opposed to drinking drank hard , especially vodka, in alcohol ingestion, referred to as alone, group involvement leads to “ ” almost 44% of their recent binge- alcohol expectancies, play a crucial greater perceived and also drinking sessions; beer was involved role in decision-making for children greater consumption. As a cautionary in less than a third of all the reported and adolescents. These expectancies note, adolescents who drink alone are binge-drinking episodes.22 may be both positive and negative. in a very high-risk group and need Positive expectancies are often Binge drinking is a costly problem. referral for treatment. Studies shaped by , which Excessive alcohol consumption in indicate that students often seek out is ubiquitous and portrays its use as 2006 cost states a median of $2.9 others to drink with, and when they being a normal part of adolescent and billion ($703 per person or enter college this tendency may adult social life. As a result, the fl approximately $1.91 per drink), with in uence their choice of living negative expectancies usually present more than 70% of the cost arrangements. Living in dormitories in children are slowly replaced by attributable to binge drinking.23 correlates with higher drinking levels positive expectancies as they enter 36 Although the majority of these costs than living off campus. adolescence.28 were related to adult drinking, The biological basis for binge underage drinking alone was Greater positive expectancies have drinking is also being researched. responsible for a median of $361.4 been associated with binge drinking Developmental stages during million in economic costs.23 These and have been noted more frequently adolescence influence the effects of costs include health care in boys and men.29 Among girls and alcohol and the risk of heavy expenditures, loss of worker women, those with a history of drinking. The pharmacokinetics of productivity, criminal justice system childhood maltreatment endorse the alcohol (the way alcohol is absorbed, expenses, property damage from reduction of ongoing tension as distributed, and eliminated) vary by motor vehicle crashes and fires, and a positive expectancy, and this is gender and by age, with higher BACs special education needed for those associated with later heavy drinking. in younger subjects as compared with with fetal alcohol spectrum Bandura’s second construct would adults with similar levels of disorders.23 Because the costs refer to drinking refusal and self- consumption, as noted previously. described relate only to the directly efficacy; that is, youth with low Hormonal changes during puberty attributable costs, they are likely to resistance skills would be more may also affect sensitivity to alcohol, underestimate the actual economic susceptible to peer pressure to binge making adolescents less sensitive to impact of binge drinking. drink.27,30 the effects of intoxication (ie, sedation Similar to outcome expectancies, and loss of coordination). Lack of RISK FACTORS FOR BINGE DRINKING IN another risk factor described is one’s sensitivity to alcohol, in turn, may THE CONTEXT OF ADOLESCENT “drinking motives.” Drinking to be related to the developmental DEVELOPMENT enhance positive emotional states immaturity of the neurotransmitter The onset and progression in alcohol (enhancement motives) has been receptor system in youth. use are influenced by the related to heavy drinking and in turn The rising limb theory postulates that developmental changes in children is linked to certain personality in the early phase of drinking, binge as they enter adolescence.24 characteristics, such as sensation drinkers are more sensitive to the Epidemiologic studies clearly indicate seeking,31 low inhibitory control,32 subjective positive euphoric effects of

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e720 FROM THE AMERICAN ACADEMY OF PEDIATRICS alcohol than light drinkers but are a person is in an alcohol-induced ordered changes in brain structure less sensitive to the sedative effects in torpor, and pulmonary that hone the functioning of neural both the early rise and the fall in aspiration may occur.38 Alcohol circuits in the service of achieving alcohol concentrations. Drinkers who poisoning may occur when the BAC optimal cognitive, emotional, and do not binge drink, on the other hand, increases beyond the higher-order executive are more likely to have greater level, usually around a median of functioning.42 Thus, the potential sedation in the early phase of 450 mg/dL.38 Manifestations include for alcohol to disrupt critical drinking.37 Thus, young people, who stupor, coma, and death by processes underlying adolescent are more sensitive to the subjective respiratory with brain maturation is concerning, euphoric effects in the early phases of respiratory and given accumulating supporting drinking, are more likely to become hypotension.38 scientificevidencetothateffect. binge drinkers. Studies indicate that cumulative Binge drinking may result in alcohol use together with the The question now is whether there is a “blackout,” or losing memory of severity of and withdrawal a common factor that influences both events that occurred during symptoms predicts cognitive this biological response to alcohol a drinking episode.38 The loss of functioning.43 and the associated personality and memory is usually temporary but neurocognitive variables. Research on may persist hours to days after the brain development in adolescence has drinking episode and is probably the BINGE DRINKING AND ALCOHOLISM determined that areas of the brain result of acute dysfunction of the that control cognition, impulsivity, .38 Alcohol specifically Current research estimates that and sensitivity to rewards mature at interferes with the brain’s ability to approximately half the risk for different rates in different make long-term memories from alcoholism comes from genetic adolescents, and a delay in this short-term memories and factors, and the other half comes from development may contribute to experiences.39 Blackouts are based on environmental risk factors. fl externalizing behaviors, such as the the amount of alcohol consumed and Environmental in uences probably initiation of substance use. are more common in adolescents than have more of a role in initiation of adults.38 On average, among alcohol use, whereas genetics have fl adolescents and college students more of an in uence on development NEUROBIOLOGY OF INTOXICATION, of an . An ongoing study to BLACKOUT, AND HANGOVER males consume 9 drinks and females consume 5 drinks before determine candidate genes, called the Intoxication is the feeling of a blackout.38 During a blackout, Collaborative Study on the Genetics of drunkenness or inebriation drinkers are disinhibited and may Alcoholism and supported by the associated with alcohol consumption. engage in high-risk behaviors or NIAAA, recognizes that no single gene 44 As alcohol enters the bloodstream, suffer an adverse outcome, including explains all facets of this condition. the liver must metabolize it for Rather, variations in many different having unprotected sexual excretion, which occurs at a fixed genes interacting with the intercourse, which may lead to rate. Consequently, intoxication, environment place some people at unplanned pregnancy.40 which usually occurs at a BAC of 50 to significantly higher risk for the 150 mg/dL, is the consequence of A “hangover” is a constellation of disease. DNA regions with alcohol entering the bloodstream symptoms that usually occur within susceptibility genes have been found faster than it can be metabolized by 6 to 24 hours after a heavy or on chromosomes 1 and 7, and DNA the liver. Because alcohol readily prolonged drinking episode.38,41 The regions with protective genes have crosses the blood–brain barrier, the symptoms include headache, been found on chromosome 4. Of concentration of alcohol in the brain drowsiness, dizziness, inability great interest, the region on parallels the concentration in the to concentrate, dry mouth, chromosome 4 is in the general blood.38 Symptoms of intoxication gastrointestinal complaints including vicinity of the alcohol dehydrogenase include initial euphoria followed by nausea and vomiting, sweating, (ADH) genes. The primary enzymes incoordination, imbalance, , hyperexcitability, muscle weakness involved in the metabolism of alcohol sleepiness, loss of social inhibitions, or pain, tremors, tachycardia, in the body are ADH and aldehyde loquacity, depression, and hostility.38 hyperventilation, depression, dehydrogenase (ALDH). Both of these When the BAC exceeds 150 mg/dL, irritability, and anxiety.38,41 Thought enzymes occur in several forms more depressant symptoms, processes and learning are also encoded by different genes and including lethargy, bradycardia, impaired.38 Adolescence is a period influence both the level of hypotension, and respiratory of ongoing brain maturation that is consumption and the risk of depression, may occur.38 When characterized by specificand alcoholism.45 Most of the numerous

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 3, September 2015 e721 variants of these genes involve single factors that influence binge drinking The brain changes make the nucleotide polymorphisms. ADH and the subsequent development of adolescent more susceptible to both molecules do their work primarily in will be found. addiction and increased substance the stomach and the liver and convert use severity. Binge drinkers are also alcohol to acetaldehyde. more likely to use other substances at Mitochondrial ALDH oxidizes ADVERSE OUTCOMES ASSOCIATED WITH a younger age.51 Binge drinking may acetaldehyde to acetate. High-activity DRINKING affect school performance by ADH variants increase the rate of Drinking alcohol is associated with impairing study habits and may erode acetaldehyde generation, and a numerous adverse outcomes in the development of transitional skills 38 low-activity ALDH2 variant is associated underage drinkers, and binge to adulthood. In fact, adolescents with an inability to metabolize this drinking increases these risks. who reported binge drinking tend to 51 compound. The resultant Adolescents who binge drink are have lower grade point averages. pathophysiologic effect of this altered more likely to exhibit poor judgment Binge drinking has been associated alcohol metabolism may be mediated and engage in drunk driving, riding in with earlier sexual activity and more by the accumulation of acetaldehyde. the car with an impaired driver, riding frequent changing of sexual Many East Asians and American a bicycle without a helmet, and or partners.40 It has also been Indians experience a “flush other risky behavior.40 Alcohol use is associated with higher rates of syndrome” after alcohol consumption, involved in each of the major causes unwanted and teenage pregnancy, with facial flushing, tachycardia, of mortality in adolescents (ie, sexually transmitted infections, and headaches, nausea, and vomiting that accidents, suicides, and homicides). infertility.40 Adolescents are at higher may deter additional use of alcohol. Drinking alcohol impairs driving risk of becoming the victims of This is similar to the effect of ability,2 and among 15- to 20-year- unwanted sexual activity, actual or disulfiram (a medication used to treat olds, nearly a third of all fatal attempted forced sexual activity, and alcoholism). Similar variants have automobile crashes involve alcohol.40 sexual victimization when binge also been found in the Caucasian Binge drinking increases the risk of 40,52 fl drinking. population and may in uence the and attempted suicide.40,49 Pregnant adolescents who binge maximum number of drinks a person Drinking alcohol is also associated 46 drink put their growing fetuses at can handle. Low tolerance may be with an elevated risk for risk, because prenatal alcohol protective, whereas high tolerance nonautomobile accidents with other exposure causes a broad range of may make someone more vulnerable potentially fatal outcomes, including adverse developmental effects to alcoholism. severe injuries and drowning.2 In the collectively referred to as fetal alcohol A search is under way to determine United States, 50% of all head injuries spectrum disorder.53 Binge drinking whether there are genes that in adolescents are associated with exposes infants to high BACs over specifically influence binge drinking. alcohol consumption.40 Underage a short period of time, and in animal Investigators have evaluated the role drinkers are susceptible to immediate studies it was more harmful to the of g-aminobutyric acid receptors in consequences of alcohol use, fetus than more continuous drinking the brain in rat models and found including blackouts, hangovers, and patterns, even if the overall amount of a role for them in excessive drinking. acute alcohol poisoning.38 Binge alcohol consumed was less.54 Another candidate gene is the drinking can also lead to fatal alcohol Longitudinal human studies have serotonin transporter gene (5-HTT). poisoning.2 Many of these alcohol- shown severe cognitive and Studies indicate that students who associated adverse outcomes could behavioral deficits in children of are homozygous for its short version lead to hospitalization or, in severe mothers who were binge drinkers are at risk for anxiety and depression cases, death. Adolescent binge during pregnancy.54 and that they also report higher drinking may also lead to liver levels of alcohol intake, suggesting disease, hypertension, disease, There is evidence of brain volume that they may use alcohol for tension , and breast and other cancers reduction in adolescents who are reduction.47 Those who are in the future. Adolescents who start heavy drinkers. A longitudinal study heterozygous consume a smaller drinking before 15 years of age are at demonstrated that 3 areas in the number of drinks at each episode. 4 times the risk of developing alcohol brain’s frontal region and cerebellar Other authors have noted that dependence as those who start white matter had preexisting volume students with this gene drink drinking after 20 years of age.38,40 differences in heavy drinkers and expressly for the purpose of The developing adolescent brain is nondrinkers, and over the next 3 becoming drunk.48 These initial more vulnerable to alcohol-induced years, those who drank showed studies hold hope that a common and cognitive greater volume reductions in factor that underlies the various risk impairment than the adult brain.50 subcortical and temporal regions than

Downloaded from www.aappublications.org/news by guest on September 29, 2021 e722 FROM THE AMERICAN ACADEMY OF PEDIATRICS did the nondrinkers undergoing more important.59 A multipronged that 80% of teenagers say their normal adolescent developmentally approach has been suggested that parents are the biggest influence on related neural pruning.55 The frontal includes a national adult-oriented their decision whether to drink.61 regions found to be affected in this media campaign, targeting alcohol In a 2013 study, parental study are regions involved in advertising and the entertainment communication on alcohol use before executive control, including inhibitory media, increasing community college entry was more likely to functioning, attention, impulsivity, interventions, limiting access to prevent nondrinking students from and self-regulation.56,57 Poorer alcohol, and increasing alcohol excise transitioning to heavy drinking status inhibitory functioning in those who taxes. School-based health education and was also 20 times more likely to have not used substances has been programs should teach life skills in reduce heavy drinking patterns found to predict future substance use addition to knowledge of the dangers among those who had started this and could therefore explain the of use and should include drinking pattern before college entry transition to heavy drinking in the training that promotes healthy than among students who did not study subjects.55 Changes noted after alternatives to risky behavior through receive parental advice.62 drinking were in brain regions activities designed to teach students involved in language and visuospatial the necessary skills to resist social Screening and abilities and may account for these (peer) pressure to smoke, drink, and During office visits, because alcohol fi de cits noted in adolescent drinkers. use . These life skills programs use is so common, it is important for Adverse outcomes associated with also help students develop greater pediatricians to screen every fi 60 underage drinking include legal self-esteem and self-con dence. adolescent for alcohol use. Just using considerations for youth and their Pediatricians should encourage their one’s clinical impression can parents. Because the legal drinking local schools to consider adopting this underestimate substance use, and age in every state is 21 years, minors approach. therefore structured screening who are caught consuming or under instruments are recommended.63 the influence of alcohol could suffer Anticipatory Guidance When time does not permit, alcohol- fines, forced community service, In the office setting, there are only screening tools may be suspension of driving privileges, programs designed to help a reasonable approach.24 A quick mandatory alcohol awareness classes, pediatricians deliver messages to screening tool developed by the or jail time, depending on the parents. Surveys indicate that NIAAA in collaboration with the circumstances.58 Social hosting children start to think positively American Academy of Pediatrics can liability laws and dram shop laws about alcohol between ages 9 and 13 quickly identify youth at risk for vary widely by state, but parents of years. The more young people are alcohol-related problems.64 This minors who supply alcohol or allow exposed to alcohol advertising and screening tool consists of 2 questions underage drinking in their home are marketing, the more likely they are to that vary slightly for elementary, subject to civil and criminal drink, and if they are already middle, and high school patients. For penalties.21 Such liability may include drinking, this exposure leads them to those in elementary school (9–11 criminal or civil charges, depending drink more. Therefore, it is very years of age), ask the “friends (any on the state, and may include costs of important to start talking to children drinking)” question first: “Do you police, fire, or other emergency about the dangers of drinking as early have any friends who drank beer, services. as 9 years of age. One such program wine, or any drink containing alcohol developed by the in the past year?” Ask the “patient and Mental Health Services (any drinking)” question next: “How GUIDANCE FOR PEDIATRICIANS Administration is Talk. They Hear You about you—have you ever had more (www.underagedrinking.org). than a few sips of beer, wine, or any Universal Preventive Interventions Resources available through the Web drink containing alcohol?” For those As with any high-risk behavior, site include background information, in middle school (11–14 years of age), prevention plays a more important talking points, and other material to after the same “friends (any role than later intervention. distribute in an office setting. All of drinking)” question, the patient Preventive measures are important, this material can be customized to question is, “How about you—in the because underage heavy drinking is include the pediatrician’soffice past year, on how many days have difficult to control and cannot be address and contact information. you had more than a few sips of beer, successfully addressed by intervening Web-based role playing simulations wine, or any drink containing alcohol?” with youth alone. In a society in that can be played on a TV monitor in For those in high school (14–18 years which alcohol use is normative, waiting areas are also included. of age), ask the “patient (any a collective strategy is believed to be Physicians can also inform parents drinking)” question first, followed by

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 136, number 3, September 2015 e723 the “friends (how much?)” question: Practitioner’s Guide. www.niaaa.nih. LIAISONS “If your friends drink, how many gov/YouthGuide Vivian B. Faden, PhD – National Institute of Alcohol drinks do they usually drink on an Substance Abuse and Mental Health Abuse and Alcoholism occasion?” This very brief screen can Gregory Tau, MD, PhD – American Academy of Child Service Administration. Talk. They and Adolescent detect risk early, is empirically Hear You. www.samhsa.gov/ 65,66 based, and is a good predictor underage-drinking STAFF of current and future negative Renee Jarrett, MPH consequences of alcohol use. The The Guide to Community Preventive screen result categorizes adolescents Services. Preventing Excessive Alcohol REFERENCES as low, moderate, or high risk on the Consumption. www. basis of their responses to the thecommunityguide.org/alcohol 1. 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Vital signs: binge interviewing delivered over $1 Parent Handbook for Talking With drinking prevalence, frequency, and sessions and based in health care or Adolescents About Alcohol. www. intensity among adults—United States, educational settings is effective at bucknell.edu/Documents/ 2010. MMWR Morb Mortal Wkly Rep. – reducing levels of consumption and Communication/WHPS/ 2012;61(1):14 19 68 alcohol-related harm. More BU_ParentAlcoholHandbook2014.pdf 5. Office of Juvenile Justice and research is needed on the benefitof Delinquency Prevention. Drinking in these brief behavioral counseling Mothers Against Drunk Driving. America: Myths, Realities, and methods for long-term morbidity and Underage Drinking. www.madd.org/ Prevention Policy. Washington, DC: US mortality.69 underage-drinking Department of Justice, Office of Justice Substance Abuse and Mental Health Programs, Office of Juvenile Justice and The approach to substance use Delinquency Prevention; 2005 screening, brief intervention, and Service Administration. National 6. National Institute on Alcohol Abuse and referral to treatment for pediatricians Registry of Evidence-Based Programs Alcoholism. What is a standard drink? has also been outlined in detail in and Practices. www.nrepp.samhsa. gov/AdvancedSearch.aspx Available at: www.niaaa.nih.gov/alcohol- a policy statement from the American health/overview-alcohol-consumption/ Academy of Pediatrics.70 The issue of what-standard-drink. Accessed June 25, LEAD AUTHORS college binge drinking is beyond the 2015 scope of this document. Lorena M. Siqueira, MD, MSPH, FAAP Vincent C. Smith, MD, MPH, FAAP 7. Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. 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