**12. Tools for screening**

228 Complementary Pediatrics

employee or nurse will help the adolescent to answer questions on alcohol use on a government-funded website. Parents are also referred to websites for further information. Most of the patients leave the hospital in good clinical health within a day after admittance. After discharge, a program starts at the outpatient department of pediatrics and child

After treatment of the acute problems and sobering up, the multiple alcohol-use related

Many treatments for alcohol use disorders can be applied to decrease alcohol use. Among them are family treatment, (short) motivational enhancement therapy and behavioral therapy,

After receiving information in the hospital setting, the patients visit a pediatrician and a pediatric psychologist at the outpatient clinic. The program consists of several

At the appointment with the pediatrician, the patient's general alcohol and drug use, school problems and social issues are addressed. By means of a presentation several alcohol related problems are addressed, such as epidemiology, metabolism, neurological and physical consequences, case reports, peer pressure (for example at sport facilities), media attention and marketing strategies of alcohol industries. The role of the parents is emphasized as well; alcohol-specific rules are pointed out, such as; rules on vacation are the same as those at home, parents are not supposed to drink in front of their children, not to mention invite them to try. To optimize the effect of the intervention, these issues can be individualized

The child psychologist performs a psychological interview to screen for underlying problems. The patient is also evaluated based on behavioral questionnaires (Youth Self Report (YSR), Child Behavior Checklist (CBCL) and Teacher Report Form (TRF), to be filled in by patient as well as parents and teachers), and earlier and recent educational performance. The interaction between parents and adolescent is taken into account, and life events and psychosocial history also are important issues for discussion. Once again the

When indicated, psychological, social, medical or addiction-related treatment is offered. Some services can be offered within the setting of the outpatient clinic, for others, the patient can be referred elsewhere. Although treatment is not always necessary, follow-up is done at all times. After the first appointments the patient will be contacted within 6 months after the event to discuss alcohol use and general well-being. However, often the pediatrician or child psychologist finds it necessary to see the patient in the mean time because of related issues. In conclusion, underlying social and neuropsychological problems can come to light during psychological and pediatric screening and can be treated when indicated. The dangers of alcohol are being explained extensively to patients as well as parents. Help can consist of

psychological treatment or referral to detox clinics or other youth care institutions.

which all seem to have a significant positive effect on alcohol and substance use (41).

problems mentioned above should be attended to in an evaluation.

psychology.

appointments.

**11. Intervention & follow up** 

depending on the patient's interest.

dangers of alcohol use are explained.

Screening for problematic alcohol use can be useful during follow up of the patients. It can be expected that questions about lifestyle are delicate, particularly during adolescence and in the direct vicinity of parents or adults. At the same time, detection of problematic alcohol use at a young age can reveal alcohol dependency and ensure a more effective intervention. So far, no standard screening method has been identified.

Various self-report questionnaires are available for rapid assessment of drinking behavior, such as the Alcohol Use Disorders Identification Test (AUDIT), TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Cut Down), the Michigan Alcohol Screening Test, CAGE (Cut Down, Annoyed, Guilty, Eye Opener) and the Alcohol Dependence Scale. The AUDIT was developed by the World Health Organization (WHO) as a measure for alcohol consumption, dependence and alcohol-related problems. The TWEAK focuses more on tolerance. It was specifically developed for women and aims to identify possible hazardous drinking patterns. The CAGE places emphasis on behaviors consistent with alcohol dependence.

These various screening methods are rapid, non-invasive and inexpensive, but they have different outcome parameters and were developed for adults. Applicability for adolescents has been investigated and seems to support the AUDIT as the better screening method (42), due to its focus on frequency of use, quantity and frequency of binge drinking. This can be an advantage in adolescents, because here the early detection of drinking problems is the main goal. However, reliability is low because of self-report.

Biological screening methods can offer more objectivity. Amongst them is the extensively used blood alcohol concentration, which is generally determined during the first care. However, this test only gives information during a short period after consumption of alcohol. It has no role in screening for alcohol use at the outpatient clinic.

Other traditional and new markers can add to the suspicion of problematic alcohol use. The more established markers of alcohol use are mean corpuscular volume (MCV), gammaglutamyltransferase (GGT), aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Increased values can lead to the differential diagnose of alcohol dependency. Direct markers, which are all products of ethanol metabolism, are acetyldehyde, acetic acid, fatty acid ethyl ester (FAEE) and ethyl glucuronide (EtG).

Newer biomarkers include carbohydrate-deficient transferrin (CDT), total serum sialic acid (TSA) and 5-hydroxytryptophol (5-HTOL). Transferrin is a plasma protein that carries iron through the bloodstream to the bone marrow. Transferrin is a polypeptide with two Nlinked polysaccharide chains. The chains are branched with sialic acid residues. Consuming

A New Approach in Adolescent Alcohol Intoxication –

without parental awareness and acute alcohol consumption (47).

by decreasing availability near educational institutions.

identification cards is another way to obtain alcohol.

use can decrease alcohol use within modern societies.

Pediatr (Phila) 2011; 50(3):244-251.

**14. References** 

Clinical Pediatric Experience and Research Combined 231

Another factor that influences alcohol use is media portrayals. The ambience that movies and television series create in relation to alcohol increases alcohol consumption, partly through the 'modeling theory' In particular, the so-called 'product placements' which are hidden in television shows and movies are often located tactically. Direct relations have been described between alcohol use in movies and early-onset teen drinking, drinking

External risk factors that should be considered when carrying out prevention measures are matters of social, economic, physical and legal availability, which are the most important predictors of adolescent alcohol consumption, drinking patterns and alcohol-related harm (48). Social availability refers to the social context into which drinking is incorporated. As was mentioned before, teens and adolescents drink alcohol in the company of their peers. Another social factor related to higher alcohol use is parental alcohol consumption. Economic availability relates to, prices of alcohol and especially to special promotions which increase alcohol consumption. The most frequently used governmental tool to prevent alcohol use is increasing taxes on alcoholic beverages. Higher prices lead to lower consumption (49). A third factor that can be used in prevention is physical availability, which focuses on outlet density and opening hours. Higher outlet density is related to higher availability. Especially outlet density and location should be considered, for example

A very important factor is legal availability. Alcohol policies for various age groups differ around the world, but the increasing number of patients admitted with alcohol intoxication demonstrates the infectivity of these laws. All legislation concerning the purchase, sale, consumption and possession of alcohol should be critically arranged for underage citizens. One of the prime governmental tools to influence alcohol consumption is setting age limits, because binge drinking, drinking at school and drinking and driving are related especially to the sale of alcohol to underage persons. Research has shown that higher legal age limits are related to a decrease of alcohol-related car crashes and other injuries. However, despite legal age limits it is still possible for many underage adolescents to obtain alcohol in commercial places. Strikingly, compliance with age legislation in commercial establishment is not guaranteed; and alcohol can easily be obtained and consumed (50). Falsification of

Prevention of alcohol use among adolescents should be aimed at patients, parents and politics. A conjunct of medical, political and sociological awareness of the dangers of alcohol

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[2] Bouthoorn SH, van der Ploeg T, van Erkel NE, van der Lely N. Alcohol intoxication

[3] Monshouwer K, Verdurmen J, van Dorsselaer S, Smit, E, Gorter A, Vollebergh W. Jeugd

among Dutch adolescents: acute medical complications in the years 2000-2010. Clin

en riskant gedrag 2007: kerngegevens uit het peilstationsonderzoek scholieren.

and pathologic role. Drug Metab Rev 2004; 36(3-4):511-529.

significant quantities of alcohol increases the proportion of transferrin with low saturation of sialic acid residues. They are referred to as carbohydrate-deficient transferrins (CDT). CDT testing is available in a regular hospital lab.

Sialic acid is a monosaccharide carbohydrate. As a consequence of excessive alcohol consumption, saturation of transferrin with sialic acid decreases and total serum sialic acid rises. Determination of TSA provides a means of detecting alcohol abuse. 5 hydroxytryptophol (5-HTOL) is a human metabolite of serotonin (5-hydroxytryptamine, 5- HT) and is excreted in the urine, where it mainly occurs conjugated with a glucuronic acid and, to a lesser extent, in free form or conjugated as a sulphate. After alcohol consumption, the 5-HTOL level in various body fluids will rise above normal values.

The value of these new biomarkers for screening purposes is still under discussion. Several factors are of importance; such as detection period after abstinence, patterns of alcohol use (episodic drinking, non-heavy chronic patterns, etc.), associated medical disorders, demographic differences and cost and availability. Sensitivity and specificity are of particular interest and are highly dependent on cut-off points, which have not yet been established (43;44)

The indirect marker CDT and direct marker EtG seem to have the most advantages for allaround utility. Combinations of different markers, especially CDT and GGT, have been studied, and application at multiple time points could significantly increase their usefulness.

Still, little research has been done among adolescents. Some studies among adults include a sub-analysis of patients under 20 years of age, and these show minimal association of alcohol consumption and markers (43;44).

In conclusion, biomarkers of alcohol use are of interest to pediatricians dealing with adolescents at the outpatient clinic for obtaining useful information on drinking patterns, which would otherwise be obtained by less reliable means like questionnaires. The exact role of biomarkers should be clarified further.
