Patricia T. Castiglia, PhD, RN-C, PNP Dean, The University of Texas at El Paso College of Nursing and Allied Health El Paso, Texas
n
W
Alcohol
Use by Children
hen most people think about alcohol use during childhood, they think about the period of adolescence only. However, studies have found that most children take their first drink at age 12 today, which is documented as being 2 years earlier than the youth of 40 to 50 years ago (Gordon & McAlister, 1982). Alcohol use has persisted over time as the number one drug problem among American youth. Unfortunately alcohol use has been identified as an activity that precedes other forms of drug use/abuse. The rampant use of alcohol persists despite the fact that the use of alcohol is illegal for anyone under 21 years of age anywhere in the United States. Unhealthy behaviors that have been associated with alcohol use include automobile accidents, suicide, homicide, violent crimes such as robbery and rape, and bulimia nervosa. Almost one half of all traffic fatalities are alcohol related, and the leading cause of death for persons between 16 and 24 years of age is driving while alcohol impaired. An analysis of causes of violent death in males 15 to 34 years of age in which blood alcohol concentration was measured, found that 35% of the suicides and 23% of other fatalities were related to intoxication (Abel & Zeidenberg, 1985). Other negative behaviors may be more subtle, but the analysis of these behaviors indicates a pattern of pathologic use accompanied by impairment in educational or social settings. Signs to be assessed by the school nurse, parent, or teacher include irregular school attendance, a drop in school grades, the sudden development of a new group of friends, a change in appearance or grooming habits, an increased need to be secretive or isolated, an increased need for money accompanied by a decreased ability to account for the money, and the inability to account for periods of time (Kinney & Leaton, 1991). Substance abuse, including alcohol abuse, results in personality changes for the user, often evidenced by guilt and remorse (Gomey-Lucero, 1992). This disease affects the structure and functions of the family unit. Children living in families in which substance addiction is present in parents usually do not seek help as they try JOURNAL
OF PEDIATRIC
HEALTH
CARE
n
to identify normal behavior for families. It is frightening to realize that 28 million Americans have at least one addicted parent and that 12 to 15 million children under 16 years of age are being reared in homes with at least one addicted parent. Children of alcoholics have a four times greater risk of developing alcoholism than children of nonalcoholics. Children of alcoholics and siblings of children who use alcohol may be confronted with pressure to drink, the desire to “cover-up” for the parent or sibling, fear of the intoxicated parent or sibling who may exhibit uncontrolled violence, the inability to concentrate on school work, and the desire to avoid relationships outside the home because they may feel ashamed. Genetic factors have been found to exert a significant influence on alcohol use (Blum et al., 1990). Many studies have investigated factors in the environment that promote alcohol use, including actual exposure to alcohol use in the home and portrayals in the media. Alcohol use is more commonly portrayed in television programs today than smoking. Drinking is frequently portrayed as a component of daily life. In fact, the estimate is that by the time a child is 18 years of age, 75,000 drinking scenes on television programs will have been viewed (National Council on Alcoholism and Drug Dependence, Inc., 1990). Not surprisingly, therefore, the Center for Science in the Public Interest in Washington, DC, found that young children can name more alcoholic drinks than they can name United States presidents (MADD, 1990). Although the use of alcohol and drugs is not limited to any one racial or socioeconomic group, some predisposition does appear to be related to racial socioeconomic status. The postulation is that more black children live in inner cities where they are exposed to a high incidence of alcohol and drug use. The National Institute on Drug Abuse (1985) reported that blacks are three times more likely to be in treatment for alcohol/drug abuse problems than are whites. A study by Brinson (1991) included 71 black adolescents, aged 12 to 20 years, who reported themselves as persons who 271
272
Growth
and
Development
drank at least once per week and used medium amounts of alcohol on each occasion. This study found that alcohol affected the perception of family environment among black males and females. Females reported that their family environments were more expressive (the expression of feelings by family members). Females also perceived more structure or organization in the family, greater independence, and more emphasis on moralreligious issues. This study has significance in that it proposes a social development model that may account for differences between black male and female alcohol users. Gender perceptions of behaviors may have implications for identifying precipitators of alcohol use. The Brinson study suggests that males may turn to alcohol to help themselves express feelings or to gain social acceptance. Therefore they may see alcohol use as facilitative and nondisruptive of family life. Males may also view the use of alcohol as a common male transition to adulthood and as a way of life. Because approximately 12% of our population is black, this study has implications for identifying at-risk black adolescents and for developing preventive strategies. A study of another high-risk group was conducted by Smart, Adlaf, Porter-field, and Canale ( 1990). A convenience sample of 145 street youth in Toronto, Canada, was studied; of these, 95% were current drinkers and 6% reported daily drinking. These young people consumed an average 15.1 drinks in the week before the interview, and 20% reported consuming 29 or more drinks the previous week. Almost one half (46%) reported that they had clinically significant drinking problems, and 15% had received treatment because of their drinking. Of those reporting clinically significant drinking problems, 74% did not receive any treatment. Of serious concern is that 77% of those treated for alcohol still reported serious problems during the previous year. Alcohol problems were identified in most of their families; 42% reported that their biologic father had an alcohol problem, and 34% said alcoholism in the home was a cause of their leaving home. They reported that their own use of alcohol was to help with coping or to escape. This is in contrast to other youth who typically report alcohol use for the purpose of social recreation. Prevention programs geared at alcohol abuse have evolved from the “knowledge” approach of the 1960s to the social-psychologic model of the 1980s. The first model fallaciously assumed that imparting knowledge alone would reduce alcohol use. Some studies actually found an inverse relationship from this approach. The second model attempted to acquaint students with the major social influences of their behavior and to teach them strategies for resisting these pressures. These programs did not take peer influence into consideration, however.
Volume 6, Number 5, Part 1 September-October 1992
Newer prevention models use multicomponent approaches that are designed to establish social-psychologic deterrents through skill building and personal competencies (Kreutter, Gewirtz, Davenny, & Love, 1991). The life skills training curriculum developed by Botwin (1981) is used in many schools for grades 6 through 10. Evaluation of this curriculum found that knowledge increased for all grades. Kreutter et al. (1991) also found that this curriculum increased selfesteem and decreased passivity. Prevention actually begins before birth with prenatal education and must continue in a systematic, planned manner. Several organizations have been successful in educating and bringing about a change in alcohol use. Students Against Driving Drunk (SADD) is an international effort that encourages positive peer pressure to adopt a no-use lifestyle, to promote a dialogue between parents and children, and to empower students to conduct awareness programs. Mothers Against Drunk Driving (MADD) has been active in passing drunkdriving laws and in the establishment of a uniform minimum drinking age of 21. MADD also has youth programs in every state. Self-help support groups include Alcoholics Anonymous (AA), a 12-step program of recovery for alcoholics; Al-Anon for children, spouses, parents, and friends of alcoholics; Co-Dependents Anonymous (CODA), a 12-step program of recovery from codependency; and Alateen, a program for young people whose lives have been affected by alcoholism in family members or close fkiends. The manifestations of alcohol use associated with adolescence begin much earlier in the child’s development. Although peers exert an important influence, parental influence remains significant (Castiglia, Glenister, Haughey, & Kanski, 1989). The Castiglia et al. study sought to determine whether children’s attitudes toward alcohol consumption changed with age and to what extent peers influenced decisions to drink alcoholic beverages. The study used forced decision-making situations based on Kohlberg’s stages of moral development. Age was the only variable found to be significantly related to decision making for the sample of children 8 to 15 years of age. Attitudes did appear to change, with drinking alcohol becoming more favorable. The data suggest that parents are more influential in decision making than they or their children might think. This study suggests that reinforcement of attitudes negating the value of alcohol consumption may be most effective at 12 to 13 years of age. This study also supports an earlier study by Moore, Moore, and Hanck (1982), which found that most people use substances such as alcohol because they have developed favorable attitudes toward them. Predisposing factors for alcohol use must be identi-
Journal of Pediatric
Growth
Health Care
fied, and interventions for the family unit must be initiated. These interventions should be implemented over extended time, and children must be made to feel safe in “normalizing” their environment. REFERENCES Abel, E. L., & Zeidenberg, l?. (1985). Age, alcohol and violent death: a posnnortem study. Journal of Stdics on Alcubol, 46,228-223. Bhun, K., Noble, E., Sheridan, P., Montgomery, A., Ritchie, T., Jagadeeswaran, I?., Nogamic, H., Briggs, A., & Cohn, J. (1990). Allelic association of human dopamine Da receptor gene in alcoholism. Journal of the Ammim Me& Associutim, 263,20552059. Botwin, G. J. (1981). Liji skills trainiq: Teacher’s manual. New York: Smithfield Press. Brinson, J. A. (1991). A comparison of the family environments of black male and female adolescent alcohol users. Adokxmce, 26, 877-844. Castiglia, I?. T., Glenister, A., Haughey, B. P., & Kanski, G. W. (1989). Iniluences on children’s attitudes toward alcohol consumption. Peti Ntcning, 15, 263-266. Gordon, N. I?., & McAlister, A. (1982). Promoting adohznt ha&b,
and Development
273
rzddcsmt drinkiqg: isnus and research, (p. 204). New York: Academic Press. Gomey-Lucero, M. J. (1992). Effects of substance abuse on children and families. In I?. Castigha & R. Harbin (Eds.). Child health CUYC: procwr anR pracciu (pp. 471-487). Philadelphia: JB Lippincott. Kinney, J., & Leaton, G. (1991). Lmxcniqg the@: a handbook of alrohol i@m&urz (4th ed.). St. Louis: Mosby-Year Book, Inc. Kreutter, K. J., Gewirtz, H., Davenny, J. E., & Love, C. (1991). Drug and alcohol prevention project for sixth graders: first year findings.
Adolescmcc,
26, 287-293.
MADD. (1990). MADD-Tbc jbst ten ycavs (l-16). Hurst, Texas: MADD National Office. Moore, L. I?., Moore, J. W., & Hanck, W. E. (1982). Conditioning children’s attitudes toward akcohol, smoking and drugs. Jmmuzl of -!iqmimental Edumtim, 50, 154-158. National Council on Alcoholism and Drug Dependence, Inc. (1990). NCADD Fnct Sheet: Toutb and alcohol. New York National Council on Alcoholism and Drug Dependence, Inc. National Institute on Drug Abuse. (1985). Drug abuse among minorities. Tusk* on black and minmity health Washington, D.C.: DHHS. Unpublished manuscript. Smart, R. G., Adlaf, E. M., Porterfield, K. M., & Canale, M. D. (1990). Drrcgs, youth and the street. Executive Summary. Ontario, Canada: Addiction Research Foundation of Ontario.
n
W
Alcohol
Use by Children
hen most people think about alcohol use during childhood, they think about the period of adolescence only. However, studies have found that most children take their first drink at age 12 today, which is documented as being 2 years earlier than the youth of 40 to 50 years ago (Gordon & McAlister, 1982). Alcohol use has persisted over time as the number one drug problem among American youth. Unfortunately alcohol use has been identified as an activity that precedes other forms of drug use/abuse. The rampant use of alcohol persists despite the fact that the use of alcohol is illegal for anyone under 21 years of age anywhere in the United States. Unhealthy behaviors that have been associated with alcohol use include automobile accidents, suicide, homicide, violent crimes such as robbery and rape, and bulimia nervosa. Almost one half of all traffic fatalities are alcohol related, and the leading cause of death for persons between 16 and 24 years of age is driving while alcohol impaired. An analysis of causes of violent death in males 15 to 34 years of age in which blood alcohol concentration was measured, found that 35% of the suicides and 23% of other fatalities were related to intoxication (Abel & Zeidenberg, 1985). Other negative behaviors may be more subtle, but the analysis of these behaviors indicates a pattern of pathologic use accompanied by impairment in educational or social settings. Signs to be assessed by the school nurse, parent, or teacher include irregular school attendance, a drop in school grades, the sudden development of a new group of friends, a change in appearance or grooming habits, an increased need to be secretive or isolated, an increased need for money accompanied by a decreased ability to account for the money, and the inability to account for periods of time (Kinney & Leaton, 1991). Substance abuse, including alcohol abuse, results in personality changes for the user, often evidenced by guilt and remorse (Gomey-Lucero, 1992). This disease affects the structure and functions of the family unit. Children living in families in which substance addiction is present in parents usually do not seek help as they try JOURNAL
OF PEDIATRIC
HEALTH
CARE
n
to identify normal behavior for families. It is frightening to realize that 28 million Americans have at least one addicted parent and that 12 to 15 million children under 16 years of age are being reared in homes with at least one addicted parent. Children of alcoholics have a four times greater risk of developing alcoholism than children of nonalcoholics. Children of alcoholics and siblings of children who use alcohol may be confronted with pressure to drink, the desire to “cover-up” for the parent or sibling, fear of the intoxicated parent or sibling who may exhibit uncontrolled violence, the inability to concentrate on school work, and the desire to avoid relationships outside the home because they may feel ashamed. Genetic factors have been found to exert a significant influence on alcohol use (Blum et al., 1990). Many studies have investigated factors in the environment that promote alcohol use, including actual exposure to alcohol use in the home and portrayals in the media. Alcohol use is more commonly portrayed in television programs today than smoking. Drinking is frequently portrayed as a component of daily life. In fact, the estimate is that by the time a child is 18 years of age, 75,000 drinking scenes on television programs will have been viewed (National Council on Alcoholism and Drug Dependence, Inc., 1990). Not surprisingly, therefore, the Center for Science in the Public Interest in Washington, DC, found that young children can name more alcoholic drinks than they can name United States presidents (MADD, 1990). Although the use of alcohol and drugs is not limited to any one racial or socioeconomic group, some predisposition does appear to be related to racial socioeconomic status. The postulation is that more black children live in inner cities where they are exposed to a high incidence of alcohol and drug use. The National Institute on Drug Abuse (1985) reported that blacks are three times more likely to be in treatment for alcohol/drug abuse problems than are whites. A study by Brinson (1991) included 71 black adolescents, aged 12 to 20 years, who reported themselves as persons who 271
272
Growth
and
Development
drank at least once per week and used medium amounts of alcohol on each occasion. This study found that alcohol affected the perception of family environment among black males and females. Females reported that their family environments were more expressive (the expression of feelings by family members). Females also perceived more structure or organization in the family, greater independence, and more emphasis on moralreligious issues. This study has significance in that it proposes a social development model that may account for differences between black male and female alcohol users. Gender perceptions of behaviors may have implications for identifying precipitators of alcohol use. The Brinson study suggests that males may turn to alcohol to help themselves express feelings or to gain social acceptance. Therefore they may see alcohol use as facilitative and nondisruptive of family life. Males may also view the use of alcohol as a common male transition to adulthood and as a way of life. Because approximately 12% of our population is black, this study has implications for identifying at-risk black adolescents and for developing preventive strategies. A study of another high-risk group was conducted by Smart, Adlaf, Porter-field, and Canale ( 1990). A convenience sample of 145 street youth in Toronto, Canada, was studied; of these, 95% were current drinkers and 6% reported daily drinking. These young people consumed an average 15.1 drinks in the week before the interview, and 20% reported consuming 29 or more drinks the previous week. Almost one half (46%) reported that they had clinically significant drinking problems, and 15% had received treatment because of their drinking. Of those reporting clinically significant drinking problems, 74% did not receive any treatment. Of serious concern is that 77% of those treated for alcohol still reported serious problems during the previous year. Alcohol problems were identified in most of their families; 42% reported that their biologic father had an alcohol problem, and 34% said alcoholism in the home was a cause of their leaving home. They reported that their own use of alcohol was to help with coping or to escape. This is in contrast to other youth who typically report alcohol use for the purpose of social recreation. Prevention programs geared at alcohol abuse have evolved from the “knowledge” approach of the 1960s to the social-psychologic model of the 1980s. The first model fallaciously assumed that imparting knowledge alone would reduce alcohol use. Some studies actually found an inverse relationship from this approach. The second model attempted to acquaint students with the major social influences of their behavior and to teach them strategies for resisting these pressures. These programs did not take peer influence into consideration, however.
Volume 6, Number 5, Part 1 September-October 1992
Newer prevention models use multicomponent approaches that are designed to establish social-psychologic deterrents through skill building and personal competencies (Kreutter, Gewirtz, Davenny, & Love, 1991). The life skills training curriculum developed by Botwin (1981) is used in many schools for grades 6 through 10. Evaluation of this curriculum found that knowledge increased for all grades. Kreutter et al. (1991) also found that this curriculum increased selfesteem and decreased passivity. Prevention actually begins before birth with prenatal education and must continue in a systematic, planned manner. Several organizations have been successful in educating and bringing about a change in alcohol use. Students Against Driving Drunk (SADD) is an international effort that encourages positive peer pressure to adopt a no-use lifestyle, to promote a dialogue between parents and children, and to empower students to conduct awareness programs. Mothers Against Drunk Driving (MADD) has been active in passing drunkdriving laws and in the establishment of a uniform minimum drinking age of 21. MADD also has youth programs in every state. Self-help support groups include Alcoholics Anonymous (AA), a 12-step program of recovery for alcoholics; Al-Anon for children, spouses, parents, and friends of alcoholics; Co-Dependents Anonymous (CODA), a 12-step program of recovery from codependency; and Alateen, a program for young people whose lives have been affected by alcoholism in family members or close fkiends. The manifestations of alcohol use associated with adolescence begin much earlier in the child’s development. Although peers exert an important influence, parental influence remains significant (Castiglia, Glenister, Haughey, & Kanski, 1989). The Castiglia et al. study sought to determine whether children’s attitudes toward alcohol consumption changed with age and to what extent peers influenced decisions to drink alcoholic beverages. The study used forced decision-making situations based on Kohlberg’s stages of moral development. Age was the only variable found to be significantly related to decision making for the sample of children 8 to 15 years of age. Attitudes did appear to change, with drinking alcohol becoming more favorable. The data suggest that parents are more influential in decision making than they or their children might think. This study suggests that reinforcement of attitudes negating the value of alcohol consumption may be most effective at 12 to 13 years of age. This study also supports an earlier study by Moore, Moore, and Hanck (1982), which found that most people use substances such as alcohol because they have developed favorable attitudes toward them. Predisposing factors for alcohol use must be identi-
Journal of Pediatric
Growth
Health Care
fied, and interventions for the family unit must be initiated. These interventions should be implemented over extended time, and children must be made to feel safe in “normalizing” their environment. REFERENCES Abel, E. L., & Zeidenberg, l?. (1985). Age, alcohol and violent death: a posnnortem study. Journal of Stdics on Alcubol, 46,228-223. Bhun, K., Noble, E., Sheridan, P., Montgomery, A., Ritchie, T., Jagadeeswaran, I?., Nogamic, H., Briggs, A., & Cohn, J. (1990). Allelic association of human dopamine Da receptor gene in alcoholism. Journal of the Ammim Me& Associutim, 263,20552059. Botwin, G. J. (1981). Liji skills trainiq: Teacher’s manual. New York: Smithfield Press. Brinson, J. A. (1991). A comparison of the family environments of black male and female adolescent alcohol users. Adokxmce, 26, 877-844. Castiglia, I?. T., Glenister, A., Haughey, B. P., & Kanski, G. W. (1989). Iniluences on children’s attitudes toward alcohol consumption. Peti Ntcning, 15, 263-266. Gordon, N. I?., & McAlister, A. (1982). Promoting adohznt ha&b,
and Development
273
rzddcsmt drinkiqg: isnus and research, (p. 204). New York: Academic Press. Gomey-Lucero, M. J. (1992). Effects of substance abuse on children and families. In I?. Castigha & R. Harbin (Eds.). Child health CUYC: procwr anR pracciu (pp. 471-487). Philadelphia: JB Lippincott. Kinney, J., & Leaton, G. (1991). Lmxcniqg the@: a handbook of alrohol i@m&urz (4th ed.). St. Louis: Mosby-Year Book, Inc. Kreutter, K. J., Gewirtz, H., Davenny, J. E., & Love, C. (1991). Drug and alcohol prevention project for sixth graders: first year findings.
Adolescmcc,
26, 287-293.
MADD. (1990). MADD-Tbc jbst ten ycavs (l-16). Hurst, Texas: MADD National Office. Moore, L. I?., Moore, J. W., & Hanck, W. E. (1982). Conditioning children’s attitudes toward akcohol, smoking and drugs. Jmmuzl of -!iqmimental Edumtim, 50, 154-158. National Council on Alcoholism and Drug Dependence, Inc. (1990). NCADD Fnct Sheet: Toutb and alcohol. New York National Council on Alcoholism and Drug Dependence, Inc. National Institute on Drug Abuse. (1985). Drug abuse among minorities. Tusk* on black and minmity health Washington, D.C.: DHHS. Unpublished manuscript. Smart, R. G., Adlaf, E. M., Porterfield, K. M., & Canale, M. D. (1990). Drrcgs, youth and the street. Executive Summary. Ontario, Canada: Addiction Research Foundation of Ontario.
