**6. Risk factors**

General risk factors for alcohol abuse are plenty. Individual, social, physiological and genetic factors influence alcohol use. Not all of these factors have the same level of importance, and some risk factors are still to be identified, as adolescents admitted with alcohol intoxication are a fairly new patient group. Also, risk seeking behavior overlaps with alcohol use. The different definitions of alcohol use, alcohol intoxication, problematic alcohol consumption etc., most likely lead to different outcomes in research and they should perhaps be looked at as different entities. However, known risk factors should be taken into account in individuals presenting with alcohol intoxication and are therefore discussed here.

A physiological process that could contribute to alcohol intoxication in adolescence is decreased sensitivity to most consequences of ethanol, which may lead to relatively high levels of alcohol consumption. For example, children do not have an explicitly stumbling walk when intoxicated. Possibly, sensitivity of cerebellar receptors is not yet fully developed. At the same time, adolescents seem to be more sensitive to other symptoms of alcohol use such as the social facilitation which occurs at low doses of alcohol (5;6).

Among adolescents admitted with alcohol intoxication, boys have a higher ethanol concentration than girls (7). Gender distribution is equal in the population, and duration of unconsciousness is equal between boys and girls. This shows that boys drink more, but it also suggests that girls become intoxicated at lower blood alcohol levels than boys (8). Girls probably are more sensitive to the toxic, suppressive effects of alcohol on the central nervous system.

The role of the socio-economic position in alcohol use is not completely clear. Negative health behavior is often confined to lower income families. More strikingly, it is one of the main factors by which socioeconomic health differences arise (9). Alcohol-related mortality is higher in lower socio-economic classes, mainly among middle-aged men (10). The educational level of the parent is associated with alcohol consumption. Highly educated mothers are correlated with less alcohol consumption (11). At the same time, unskilled occupational level of the father is positively correlated with the amount of alcohol consumed. Other reports conclude that children from families with higher incomes drink more frequently and they more often drink without supervision (12). Material factors such as financial worries and material scarcity can also reduce adolescent alcohol consumption (9). Lower intelligence scores, familial alcohol problems, peer influence and parental attachment can be possible confounders.

Students at pre-vocational secondary education or pre-university secondary education all drink from an early age. It appears that patients with alcohol intoxication on the prevocational level are younger and drink less. Higher educational level it is an independent risk factor for higher BAC at admittance.

Parental knowledge of alcohol use and parental rules influence alcohol use amongst adolescents (13). These aspects are striking in clinical practice, with examples of parents

strikingly, 35% of the adolescents treated with alcohol intoxication have been served alcohol in the catering industry (as well). Adolescents report that their parents 'know to some extent ' or

General risk factors for alcohol abuse are plenty. Individual, social, physiological and genetic factors influence alcohol use. Not all of these factors have the same level of importance, and some risk factors are still to be identified, as adolescents admitted with alcohol intoxication are a fairly new patient group. Also, risk seeking behavior overlaps with alcohol use. The different definitions of alcohol use, alcohol intoxication, problematic alcohol consumption etc., most likely lead to different outcomes in research and they should perhaps be looked at as different entities. However, known risk factors should be taken into account in individuals presenting with alcohol intoxication and are therefore discussed here. A physiological process that could contribute to alcohol intoxication in adolescence is decreased sensitivity to most consequences of ethanol, which may lead to relatively high levels of alcohol consumption. For example, children do not have an explicitly stumbling walk when intoxicated. Possibly, sensitivity of cerebellar receptors is not yet fully developed. At the same time, adolescents seem to be more sensitive to other symptoms of

alcohol use such as the social facilitation which occurs at low doses of alcohol (5;6).

Among adolescents admitted with alcohol intoxication, boys have a higher ethanol concentration than girls (7). Gender distribution is equal in the population, and duration of unconsciousness is equal between boys and girls. This shows that boys drink more, but it also suggests that girls become intoxicated at lower blood alcohol levels than boys (8). Girls probably are more sensitive to the toxic, suppressive effects of alcohol on the central

The role of the socio-economic position in alcohol use is not completely clear. Negative health behavior is often confined to lower income families. More strikingly, it is one of the main factors by which socioeconomic health differences arise (9). Alcohol-related mortality is higher in lower socio-economic classes, mainly among middle-aged men (10). The educational level of the parent is associated with alcohol consumption. Highly educated mothers are correlated with less alcohol consumption (11). At the same time, unskilled occupational level of the father is positively correlated with the amount of alcohol consumed. Other reports conclude that children from families with higher incomes drink more frequently and they more often drink without supervision (12). Material factors such as financial worries and material scarcity can also reduce adolescent alcohol consumption (9). Lower intelligence scores, familial alcohol problems, peer influence and parental

Students at pre-vocational secondary education or pre-university secondary education all drink from an early age. It appears that patients with alcohol intoxication on the prevocational level are younger and drink less. Higher educational level it is an independent

Parental knowledge of alcohol use and parental rules influence alcohol use amongst adolescents (13). These aspects are striking in clinical practice, with examples of parents

even 'know exactly' how much alcohol they drink.

**6. Risk factors** 

nervous system.

attachment can be possible confounders.

risk factor for higher BAC at admittance.

offering alcohol to their underage children. Parents who set strict alcohol-specific rules early on delay the age of onset and reduce the frequency and quantity of adolescent alcohol consumption (14) (Koning). A strict attitude of parents towards alcohol diminishes adolescents' involvement in alcohol use. To positively influence problematic alcohol use in their children, parental attitude should be addressed in the treatment of these patients.

Parental attachment can be another factor of interest in parental involvement. It has been described that poor parental attachment is related to an earlier onset of drinking. The inverse explanation can be that the younger the adolescent starts using alcohol, the less strong the attachment with the parents is (13). The influence of the relation between parent and adolescent needs to be clarified further.

A family history of alcohol use is associated with more alcohol consumption in adolescents; and with even higher transmission between parents and adolescents of the same gender (15). Alcoholism of the parents is associated with heavy drinking and binge drinking patterns during adolescence (16). The explanation of these tendencies can be found in the direct exposure to alcohol, as well as in assimilating certain standards and beliefs on alcohol use. Adolescents tend to imitate role models. On the other hand, a positive family history has been found to lead to a relatively lower sensitivity to alcohol.

Students living with peers during their college years drink more alcohol (17). Peer influence is a risk factor in many risk-seeking attitudes, such as smoking, substance abuse and sexual risk behavior. Children are particularly prone to the influence of peers during adolescence. Also, underage drinkers can gain access to alcohol through peers by having older friends who work in a store.

Alcohol use is related to substance use. Cannabis in particular is common, but amphetamines are used as well, as are ecstasy, happy mushrooms and cocaine. Cooccurrence is common and therefore patients admitted with alcohol intoxication should always be screened for substance abuse (18).

Cultural influences are connected to local politics, either nationally- or statewide. Determining legal drinking age has a strong influence on the availability of alcohol for adolescents (19;20). However, this seems to be just one of several factors to be considered. A prosperous society and a change in the available types of drinks are likely to have an effect on alcohol consumption. An increase in drinking among youngsters has been observed in the past decade (21). For Dutch adolescents purchasing alcohol is one of the leading expenses (22-24).

The relationship between alcohol or substance abuse and psychiatric disorders such as ADHD is described as a consequence as well as a cause (25;26). Symptoms like physical aggression, conduct disorders and violence as well as hyperactivity and oppositional behaviors at a young age appear to be risk factors for alcohol use in later life (27). In particular, higher quantities of alcohol consumption have been associated with a lack of restraint (disinhibition) (28;29). The interpretation of these associations can be causal and consequential and are interesting subjects of research still to be carried out. Depression and anxiety disorders in relation to alcohol use are mainly studies in adult populations (and not in adolescents or children). However, depression occurs more frequently in patients with alcohol abuse (30).

A New Approach in Adolescent Alcohol Intoxication –

contributors to mortality of adolescents.

concentration of 20-50 mg/dl (0.2-0.5%).

150-250 1,5-2,5 Stupor


Table 3. Symptoms of alcohol intoxication

electrocardiogram, liver function)


done:

300 3,0 Unconsciousness 400 4,0 Respiratory failure


dementia and stroke.

**8. Acute care** 

Clinical Pediatric Experience and Research Combined 225

Alcohol consumption is one of the leading preventable causes of death in the United States (37). The WHO recently identified alcohol use amongst young people (10-24 years) as the most important factor contributing to disability adjustable life years (DALY's) (38). In particular, consumption of alcohol is associated with injuries and accidents, which are major

Apart from the psychiatric disorders discussed before, alcohol use is also associated with medical conditions such as hepatitis and liver cirrhosis, hypertension, pancreatitis, cardiomyopathy, pneumonia and tuberculosis. Also cancers of the mouth, esophagus, pharynx, larynx and breast are more common in patients with excessive alcohol consumption. Neurologic disease is not uncommon, and alcohol use is associated with peripheral neuropathy and myopathy, as well as with central nervous diseases such as

The acute care of an adolescent presenting with alcohol intoxication is being done conform the Advanced Pediatric Life Support protocol (APLS). Most hospitalizations occur during the evening or night (93%), (see Epidemiology section). The announcement of an adolescent having become unwell at a party or an unconscious youngster smelling of ethanol usually gives away the diagnosis. However, as the presentation is often severe, especially the level of consciousness, ABCD-assessment should always be done. Reports of reduced consciousness vary from a couple of minutes up to 48 hours (!), with an average of 2 hours and 11 minutes. According to Dutch research, average time of unconsciousness has risen during the past years from 2,2 hours in 2007 to 3,1 hours in 2010 (7). Other presentations include traffic accidents, aggression and violence and even suicide attempts (1%). These type of symptoms of alcohol intoxication (Table 3) usually appear at a blood alcohol

Blood Alcohol Concentration Symptoms Mg/dl ‰

100-150 1,0-1,5 Disturbed balance and gait

50-100 0,5-0,10 Decreased coordination and reactivity

20-50 0,2-0,5 Gross motor impairment, difficulty concentrating

At admission of a patient with alcohol intoxication, the following assessments should be


The clustering of social problems and alcohol intoxication was a particular observation of interest in a project carried out at the Reinier de Graaf Hospital in Delft, The Netherlands (see Protocol chapter). The rate of self-reported social problems was high among the adolescents admitted for alcohol intoxication. Among them were family histories of addiction (35.3%), divorce or a deceased parent (19.1% and 11,3% respectively); parent-child interaction was aberrant in many cases (44.6%), as were school problems (34.3%) and sexual abuse (4.4%) or life-events (e.g. severe illness, emotional problems (41.2%). Also common were underlying psychiatric disorders (40%) (autism, attention deficit hyperactivity disorder, depression or eating disorders).

These percentages show that the clustering of personal and social issues during puberty makes this group vulnerable.
