Introduction:
Adolescence is a period of development of the individual that extends from 10 to 19 years and has particular biological and psychological characteristics. This definition, which varies according to the source, is not consensual as regards the psychological, physical and social development of each one.
Adolescence begins with pubertal phenomena that will result in many changes in the body, and totally alter the relationship to the body at different ages. The start of puberty can take place between 9 and 15 years in the boy whereas in the girl it can take place between 8 and 13 years.
The majority of individuals begin and model their drinking in adolescence. Alcohol, as well as tobacco, is one of the first products encountered by the adolescent, one of the most accessible and therefore logically the one most often consumed. The annual epidemiological work of the French Observatory on Drugs and Drug Addiction (OFDT) clearly underlines this.
Unlike their elders, adolescents consume alcohol preferentially outside meals. This consumption is initially occasional, discontinuous, often at the family home during festive events, authorized by the parents themselves. In fact, 70-80% of teenagers before the age of 11 have already tasted beer, wine or champagne and more than 20% have already been drunk.
The risks associated with alcohol use vary according to the pubertal stage of the adolescent: a 14 year old adolescent reacts very differently to alcohol exposure depending on the pubertal period in which he is. The risks associated with the use of alcohol also vary according to the stage of psychological development of the consumer.
The psychotropic effect of alcohol is generally more harmful in developing subjects, as it affects a brain in full pubertal maturation and can interrupt natural neurobiological programs.
Clinically, this may lead to cognitive impairment, altering interactions with others and / or the environment.
Studies in functional magnetic resonance imaging (MRI) have revealed some abnormalities in adolescents with pathological alcohol consumption.
The search for sensations and the search for novelties are factors that must be taken into account both in the understanding of consumer behavior at the level of society and when it comes to addressing, on an individual level, a given teenager. Finally, the peer group occupies a central place in the adolescent’s life and there is a profound desire to experiment with new behaviors to shape one’s own identity.
Epidemiology:
Different epidemiological studies such as the Survey of Representations, Opinions and Perceptions on Psychotropic Drugs (EROPP), Health and Consumer Surveys in the Defense Preparation Appeal (ESCAPAD), the French Observatory of Drugs (OFDT), the Health Barometer, the European School Survey Project on Alcohol and Other Drugs (ESPAD) and INSERM, are used to assess levels of alcohol use among adolescents and recent developments in the different forms of consumption at the end of adolescence.
Over the past thirty years, regular consumption of wine has gradually been replaced, especially for the new generations, by occasional consumption of beer – the drink most frequently consumed by adolescents with little variation depending on the socio-economic level -, d the main characteristics of which are detailed below.
Compared to other countries such as Denmark, Greece, Belgium and the United Kingdom, where the figures are high, the percentage of 15-year-olds drinking beer at least once a week is relatively low (20 % for boys and 8% for girls).Moreover, the proportion of young people who consume beer regularly decreased in France in 16 years, unlike some countries like Russia. The daily consumption of young people decreases significantly in favor of consumption over the weekend.
The analysis of the ESCAPAD survey shows that 76% of girls and 84% of boys have ever used alcohol in the last 30 days. An important point to note is the difference in regular use of alcohol, defined by 10 drinks during the last month, according to sex. Indeed, 21% of boys have a regular use of alcohol whereas this figure is 8% for girls.
Regular drunkenness, defined by at least 10 drunkenness during the year, is rare before the age of 16, as opposed to 17-18 years when most boys and girls consume alcohol.
In Europe, 7% of French teenagers aged 16 declare a regular use, placing France in 21st place among the European countries, Holland being the country with the highest regular consumption (25%) and Finland the one where it is the lowest (3%). Differences in alcohol consumption between countries can be explained.
These include the national contexts of alcohol consumption, the social status of alcohol, the influence of advertising campaigns, the role of the family environment, relationships between young people and the weight of initiation and regular consumption.
Risk factors for installing an addictive driving:
In order to assess the risks of alcohol consumption, it is imperative to investigate the existence of unsafe drinking patterns and individual and environmental risk factors during the first interviews with the adolescent.
Modalities of consumption at risk:
These forms of risky use correspond to the age at which the drug is consumed, the self-therapeutic nature of the consumption, the solitary or massive use of alcohol, the repetition of consumption, the cumulative consumption of psychoactive substances and at risk under the influence of alcohol. We detail them in the following.
Age of early onset:
It is a risk factor for the further development of harmful use for health (or abuse) and / or dependence, especially if the consumption repeats. Particular care must be taken when the use is very early due to the possible long-term medical, psychological, psychiatric and social consequences.
Cumulative consumption of psychoactive substances:
Autotherapeutic use – anxiolytic, antidepressant or hypnotic – may be indicative of underlying psychopathological disorders in a number of adolescents.
Alcohol solitary use:
Apart from the usual situations of consumption, it is often synonymous with an increase in consumption.
Repetition of consumption:
It is a mode of consumption to be taken into consideration: the greater the number of drinking, the longer the time of exposure to the effects of alcohol over life, the greater the risk of complications.
The effect sought by frequent consumption and / or in high quantities, by consumption outside socially regulated conditions, is that of a search for “stoning”, anesthesia, escape and forgetting of reality.
Alcoholic Drugs:
Alone or coupled with the consumption of other products (cannabis, cocaine, psychotropic drugs, ecstasy …) they can be massive and frequent. In general, frequent use of cannabis is associated and was preceded by the consumption of tobacco and alcohol. The increase in alcohol intoxication and tobacco use was shown to be correlated with cannabis use.
Some situations at risk:
For example, driving vehicles (scooters, motorcycles, cars) under the influence of alcohol must attract the attention of the practitioner. A blood alcohol concentration of 0.5 g / l multiplies the risk of an accident by a factor of 2. Beyond 0.8 g / l, this risk is multiplied by 10. Young drivers are particularly affected by the problem of drinking and driving. As cannabis use is frequently associated, the accidental road hazard is potentiated (multiplied by a factor of 15). Recent prevention campaigns have insisted on this important risk. Other situations such as unprotected intercourse, behavioral problems and pregnancy under the influence of alcohol should also be sought.
Individual and environmental risk factors:
Individual risk factors include genetic, psychological and psychiatric factors.
Individual psychological factors:
Among the individual psychological factors, it is important to specify the personality traits of the subject; the existence of personality traits such as low self-esteem, shyness, self-depreciation, excessive emotional reactions, difficulties in dealing with certain events, difficulties in having stable relationships and resolving interpersonal problems must be account.
Individual psychiatric factors:
Different pathologies can exist and must be the subject of a precise analysis during the various interviews. This may include conduct disorder, attention deficit hyperactivity, depression, repeated suicide attempts, bipolar disorder, anxiety disorders (obsessive-compulsive disorder, phobic disorder , panic disorder, generalized anxiety disorder, post-traumatic stress disorder), eating disorder, borderline or other personality disorder such as antisocial personality.
Environmental factors:
A statistically significant correlation between family history of alcohol dependence and early age of consumption was found. Intra-family functioning, education, parental tolerance for alcohol use and for breaking rules, life events are risk factors for the installation of addictive behavior. As we have seen above, the role of friends is indisputable in the initiation of alcohol, tobacco or other drugs, but does not explain the pathological behavior of drinking alone. Finally, the loss of social benchmarks such as poverty, precariousness, unemployment, lack of schooling, marginality is also an important risk factor.
Clinic:
Any adolescent, during a consultation in general medicine, school or a specialist should benefit from a tracking on his use of psychoactive substances.
After researching risk factors for the installation of an addictive alcoholic behavior, the clinician will define the type of consumption of the patient, be able to use locating questionnaires and evaluate the overall impact of consumption.
Different types of consumption:
Use:
It is socially accepted consumption without any physical, psychological or social complications.
Harmful Health Use (ICD-10) or Alcohol Abuse (DSM IV TR):
The harmful use for health or alcohol abuse can be a modality of consumption quite common in adolescents.
ICD-10:
According to the Tenth International Classification of Diseases (WHO), the diagnostic criteria for harmful use of alcohol for health are as follows.
It is a mode of alcohol consumption that is detrimental to health.
Complications can be physical (hepatitis, polyneuropathy, pancreatitis …) or psychic (major depressive episode secondary to high alcohol consumption, attempted suicide …).
The diagnosis is based on clear evidence that the use of alcohol alone or in combination with other substances has led to psychological or physical problems.
This mode of consumption often gives rise to criticism and often has negative social consequences. Disapproval by others or by the cultural environment, and negative social consequences (police arrest, temporary detention, separation, etc.) are not enough to make the diagnosis.
This diagnosis is not made when the subject has a syndrome of addiction, a psychotic disorder or other specific disorder related to the use of alcohol or other psychoactive substances.
DSM IV:
According to DSM IV revised version (DSM IV-TR), the diagnostic criteria for alcohol abuse are as follows.
Inadequate use of alcohol leading to functional impairment or clinically significant suffering characterized by the presence of at least one of the following events over a 12-month period:
• repeated use of alcohol leading to inability to fulfill major obligations at work, at school, or at home (repeated absences or poor performance at work due to alcohol use, absences , temporary or permanent school disqualifications, neglect of children or household chores);
• repeated use of alcohol in situations where it can be physically dangerous (eg, when driving a moped, scooter, car or operating a machine while is under the influence of alcohol);
• relationship to the use of alcohol;
• alcohol use in spite of persistent or recurring interpersonal or social problems caused or exacerbated by the effects of alcohol (eg, disputes with the spouse about the consequences of intoxication, fights).
The symptoms have never met the criteria for substance dependence for this class of substance.
Addiction:
Addiction is a rare phenomenon in adolescence.
We will use the diagnostic criteria of DSM IV to define it.
This is an inadequate use of a clinically significant substance that leads to a functional impairment or suffering, characterized by the presence of three (or more) of the following symptoms at any one time continuous period of 12 months:
• tolerance, defined by any of the following symptoms: C require significantly higher amounts of the substance to achieve intoxication or the desired effect; C significantly decreased in the case of continuous use of the same quantity of the substance;
• weaning characterized by one or the other of the following manifestations:
C weaning syndrome characteristic of the substance; C the same substance (or a very close substance) is taken to relieve or avoid withdrawal symptoms;
• the substance is often taken in greater quantities or for a longer period than expected;
• there is a persistent desire, or unsuccessful effort, to decrease or control the use of the substance;
• a significant amount of time has gone into activities necessary to obtain the substance (eg, to smoke continuously), or to recover from its effects;
• significant social, occupational or recreational activities are abandoned or reduced because of the use of the substance;
• the use of the substance is continued although the person is aware of a persistent or recurring psychological or physical problem that may have been caused or exacerbated by the substance (eg continued cocaine use although the person admitted cocaine-related depression, or continued alcoholic beverages, although the subject acknowledged an aggravation of an ulcer as a result of alcohol consumption).
Specify whether:
• with physical dependence: presence of tolerance or withdrawal;
• no physical dependence: no tolerance or withdrawal.
Clinical features of the adolescent:
Various elements concerning the pathological consumption of alcohol in adolescents have been raised in the literature.
Consumption behaviors during adolescence are much less fixed than in adults. As we have seen, these behaviors are different according to sex and variable according to individuals.
Dependence is a very rare phenomenon, but harmful use of alcohol for health (or abuse) is possible in adolescents.
In the adolescent, we speak of alcohol misuse because the adolescent does not completely answer the various diagnostic criteria of abuse or dependency defined in the adult.
Alcohol misuse in adolescents does not meet the WHO criteria (21 drinks per week in men and 14 drinks per week in women) and manifests itself in weekend drinks in large quantities between buddies, with the search for sensations and drunkenness.
Unlike adults, there are no biologic markers (CDT [desulphurised transferrin] …) to detect and affirm a disorder related to the use of alcohol in adolescents.
Consequences of pathological alcohol consumption :
The somatic complications of alcohol consumption usually found in adults such as alcoholic hepatitis, cirrhosis, peripheral neuropathies, and pancreatitis are very rare in adolescence.
The main consequences of an alcohol misuse in the adolescent are on the one hand social and on the other hand psychological.
Socially, school absenteeism, school failure, behavioral problems with fighting, delinquency, risk-taking in the sphere of sexual life (absence of contraception and protection in the event of sexual intercourse, sexual violence) and road accidents. In the latter case, the risk of accidents is magnified by the relative inexperience of many young people, by a denial of the danger and by the fact that their bodies are not yet accustomed to the consumption of large quantities of alcohol.
Psychologically, it is essentially hyperactivity with attention deficit, anxiety, depression and attempted suicide.
No longitudinal studies have been performed in France to assess the evolution of adolescent misuse in adults.However, prospective studies have provided some answers: a relative stability of pathological consumption behaviors has been shown over time (over a 2-year period, 50% of problematic consumers remained in this category); in a prospective follow-up of six years, compared to a control population, there was a 3.7-fold increase in alcohol abuse or dependence on previous pathological drinking.
Tracking questionnaires:
Several French and English-language instruments are used to identify and evaluate the pathological consumption of alcohol and other psychoactive substances, particularly illicit substances, in adolescents. Alcohol misuse is commonly associated with cannabis in adolescents.
We will not make an exhaustive list of the existing tools, we will take as examples some of them that have been the subject of work in France.
The CRAFFT questionnaire was constructed and validated in the United States for the early detection of harmful uses of various addictive substances (cannabis, alcohol, other products) in adolescents. CRAFFT is the acronym for Car, Relax, Alone, Forget, Family / Friends, Trouble.
ADOSPA, French version of CRAFFT, is the acronym for the following items: Auto / motorcycle (Driving under influence or someone under the influence of alcohol or other drugs), Relaxation (self-treatment) (Problems, Friends / family (reproaches made by friends or family).
This tool was subjected to a general population validation study which showed that this tool was performing well in the early identification of regular uses, the daily use of cannabis and mixed drunkenness. At the score of 2, CRAFFTADOSPA showed qualities of widespread identification of the harmful use and at the score of 3, it detected the gravity of the consumptions. The recommendations recommended by the authors were that a score greater than or equal to 2 at CRAFFT-ADOSPA indicated a moderate risk and a score of 3 or more a high risk of harmful use in the adolescent or the young adult.
The POSIT, an acronym for the Problem Oriented Screening Instrument for Teenagers, is a locator instrument for adolescents aged 12 to 19 years that was developed by the National Institute on Drug Abuse (NIDA) in the United States and validated in schools. It identifies psychological and social health issues that may warrant further evaluation and require treatment. It is a questionnaire that evaluates 10 areas (or factors) classified from A to J: psychoactive substance use, physical health, mental health, intrafamilial relationships, relationships with family, academic situation, vocational guidance, social skills, recreation and aggressive behavior / delinquency. It contains 139 simple closed questions (yes / no).
Other questionnaires, such as the RISQ (Research and Intervention on Psychoactive Substances – Quebec), DEPADO (ADOlescents Screening), ADI (Adolescent Drinking Index), ADIS (Adolescent Drug Involvement Scale), ADAD Drug Abuse Diagnosis), the DAP (Drug and Alcohol Problem) can be cited.
Therapeutic care:
Prevention:
Before a teen consumes, talk with him about the harms and risks of alcohol, tobacco, cannabis and / or other illicit psychoactive products is a first approach.
It is essential to prevent this by informing the population known to be the most vulnerable to alcohol and its close circle, especially to adults in contact with adolescents (educators, teachers, teachers, school doctors, school nurses).
Identify the various signs of appeal of the adolescent in difficulty and the factors of vulnerability and risk favoring early use, work on the fact that the adolescent is sometimes out of step with his / her own beliefs of a risky behavior, inform on the apparent and damaging consequences of alcohol (more than the inventory of somatic consequences) are important elements to be taken into account.
Global evaluation:
First, a therapeutic alliance should be established with the adolescent and his / her parents in order to establish a dialogue that is often broken and to recognize the difficulties and sufferings of the patient. It should be borne in mind that the adolescent builds his / her own identity and remains very sensitive to the role of peers who influence their relationships and consumption.
An overall assessment of the situation highlights individual risk factors, environmental factors, type of consumption (whether it is festive or occasional use, abuse or harmful use, dependence), possible consumptions (cannabis, other drugs …) and the importance of the risks incurred in order to adapt therapeutic management. Different therapeutic objectives will be proposed depending on the severity of the situation (binge drinking, associated psychopathology, harmful use for health or poly-consumptions).
In the adolescent, we must neither trivialize nor dramatize the consumption of alcohol and avoid confrontation.Depending on the clinical history, it is necessary to involve the family more or less in the care because its role is essential and to strengthen their skills is useful.
The different types of intervention used are most often based on validated techniques in adults, which adapt to the specific characteristics of adolescent development and its problems at this time of life. An orientation in the event of real problems with alcohol towards places of listening can facilitate a start of care.
Different therapeutic techniques:
In a patient in difficulty with alcohol and in request of assistance, the practitioner puts in place strategies to reduce or stop drinking.
It is necessary to inform the teenager about the product and its short-term damage more than long-term. Educational work plays a benchmark and information role in dealing with the risks the young person may face in order to respond to or oppose it.
Awareness of the risk involved often involves the use of self-evaluation scales associated with clinical interviewing to provide an informative exchange.
It may be useful to propose, as in adults, a therapeutic withdrawal time, and to emphasize that abstinence may have positive consequences on the overall functioning of the adolescent.
Different therapeutic techniques can be used.
Short intervention strategies have demonstrated their effectiveness in alcohol misuse. These are interventions of short duration and limited duration (12 sessions over a semester, for example), which are often inspired by motivational techniques.
They can be used on an outpatient basis or during hospitalization. They include a short evaluation with feedback, different objectives to be achieved, references to self-help techniques, and an assessment of changes in consumption patterns.
Motivational interviews, a patient-centered approach, invited to talk about the positive and negative aspects of its use, showed a statistically significant reduction in alcohol behaviors in adolescents with alcohol problems.
Cognitive and behavioral therapies with work on beliefs and expectations, developing coping skills, assertiveness.
Systemic family therapies: many studies have shown their efficacy.
Family speaking groups, telephone support.
The combination of these different therapeutic techniques with pharmacotherapy may be necessary in some cases.
Finally, work involving social actors coupled with these different techniques is a must.
How to deal with harmful use of alcohol for adolescent health:
We should not just inform the patient at this stage. Most often, there are risk factors that cause difficulties that need to be identified. Having established a relationship of trust, the search for psychological suffering, relational or educational difficulties is an essential step in the care of the patient.
The management of the psychopathological disorders found is done by a psychotherapeutic approach and if necessary pharmacological associated with a regular and attentive medical follow-up.
Family support can be offered in case of conflict.
The minor must be protected by identifying and eliminating risky situations and harmful relationships with a young person who is ready to modify them.
In the absence of severity criteria, it is preferable not to stigmatize the adolescent by directing him at this stage towards a specialized structure.
How to deal with alcohol dependence in adolescents:
Adolescent dependence remains a rare phenomenon.
This type of addictive behavior is characterized by daily and repeated use, excesses, poly-consumptions, family and social problems that are often serious. Specific therapeutic measures will be implemented within the framework of an institutional network with a coherent and reassuring management.
Conclusion:
The initiation to alcohol, easy to access as tobacco and to the particular social status in France, is a significant phenomenon of adolescence. Dependence is a rare phenomenon at this time of life, it is more frequently found a harmful use of alcohol for health or even the notion of misuse, the peculiarities of adolescence making that these subjects do not fully fill the first two diagnostic categories mentioned above. Nevertheless, the pathological consumption of alcohol has harmful effects, in itself disrupting the psychic and social functioning of individuals, and at the root of an increased risk of certain psychiatric pathologies suicide) and road accidents. These pathological drinks are influenced by individual, familial and environmental risk factors that the practitioner should seek.
The training in addictology, the prevention and the use of different therapeutic techniques in case of a known disorder are essential to take charge of this type of patient.
Finally, it is necessary to develop longitudinal prospective studies in France on cohorts of statistically satisfactory size in order to evaluate the cognitive, psychological and somatic repercussions of the pathological consumptions begun in adolescence in adults.
