Young people's exposure to alcohol in Britain is a major cause of concern to alcohol workers, yet little impact has been made on the problem despite extensive research and numerous recommendations for tackling it. To some extent, this is due to permissive public attitudes and the general lack of knowledge among the public and professionals of the dangers of alcohol misuse, but lack of leadership by government and targetting of alcohol at the young by the drinks industry must take some of the blame. Particular issues of relevance to young people are excessive drinking in pregnancy, which may affect the fetus, alcoholic parents, drinking among 11–15 year olds, and heavy consumption by older adolescents. The pressure that these put on social and health sevices (and the expense) is considerable. Rather than concentrating resources on treating the damage, greater emphasis should be placed on prevention and detection, for example recognizing risk factors — immaturity, poor educational performance, antisocial behaviour, mental heath problems and dysfunctional families — which lead to harm. This will require better education about alcohol for child specialists, teachers, social workers, the police, the legal professions, and others who have to deal with young people. Self-help groups among the young could help spread the message of sensible drinking among their peers. In addition, the number of alcohol agencies in the community which support parents and young people, at present woefully inadequate, need to be increased as a matter of urgency.
‘It is better to put a fence at the top of a cliff than to station an ambulance at the bottom’
Attributed to Sir Truby King (1858-1938), New Zealand paediatrician
Drinking by young people in Britain is a matter of considerable concern. English 11–16 year old girls drink more than their sisters in France and Spain; Welsh children of both sexes and all ages head the European league table of 20 countries for numbers drinking every week and for getting drunk. Reports from authoritative bodies, such as the British Medical Association (1986), the Home Office (1987), the Health Education Authority (1995), and the Scottish Council on Alcohol (Crawford and Allsop, 1996) have addressed the problems (only too well known to alcohol workers) and offered solutions, yet it is obvious that they have had precious little impact.
In 1995 a joint working party of the Royal College of Physicians and the British Paediatric Association (now the Royal College of Paediatricians) issued a report which had more than 30 recommendations. A conference was convened in October 1998 by Philip Graham, emeritus professor of child psychiatry, Institute of Child Health, and chairman of the original working party, to see what progress had been made. What follows is a personal (and sometimes critical) account of that meeting, which, although aimed at doctors, attracted a gratifyingly large number of other health and social professionals concerned with children's drinking.
PARENTS AND CHILDREN
When doctors speak about alcohol, they tend to concentrate on serious physical problems, which are rare in comparison with social harm and therefore of limited interest to most alcohol workers. This was well illustrated by the first paper, in which Hans-Christoph Steinhausen, professor of child psychiatry at Zurich, described the features (unique to alcohol) of the fetal alcohol syndrome in a group of 154 children in Berlin. This was interesting in itself, and the audience was able to familiarize themselves with the facial appearances by studying a large series of photographs. But the full-blown syndrome is extremely rare, and only a minority of women who drink excessively during pregnancy produce affected children, so that few alcohol workers are likely to encounter the condition. What is more, not much can be done to reverse the resulting mental retardation and neuropsychiatric disorders in severely affected children. Little was said about the possibility that smaller but still excessive quantities of alcohol might produce more subtle damage to the fetus (which has low levels of alcohol dehydrogenase), so that the child might be treatable if detected early. But do obstetricians, midwives and paediatricians always enquire about alcohol intake? How often, for example, would a paediatrician ask when faced with a mother and baby or young child?
A million children in Britain are being, or have been, brought up by alcoholic parents, and the devastating effects of parental drinking have recently been highlighted by ChildLine (Houston et al., 1997). Jim Orford, professor of psychology at Birmingham, described a study which he had conducted with Richard Velleman, where they interviewed 164 young adults about their retrospective views of being brought up in such families. They were highly embarrassed by their parent's drinking, but more important to them were the rows and violence, both between parents and to children. This resulted in detachment in order to cope, fear and self-protection, and escape to the company of peers. Boys tended to develop antisocial behaviour, girls to become withdrawn, demoralized, and poor performers at school. Children most at risk were from families that were dysfunctional in other ways, such as poverty, unemployment, use of other drugs, and lack of social skills. The picture, though, was very variable: not all families suffered violence, and many children exhibited considerable resilience.
Ian McGregor, director of Haringey Advisory Group on Alcohol (HAGA), said that young carers of alcoholic parents were often isolated, confused, insecure and burdened by having to keep their parent's drinking secret. Very little help was available for them, and a high proportion had problems with mental health. With the aid of a grant from the National Lotteries Board, he had set up a family support service for parents and children. In the past year, 80 children aged 5–15 had attended, either referred from social services or, in the case of older children and especially girls, making their own way to the clinic. They had had no difficulty in accepting the milieu of an alcohol unit. As well as the usual counselling service for parents, a wide variety of options was provided, including a crèche, parenting skills, detailed assessment of children for social services, court reports and separation orders, occupational and play therapy, and a children's group to combat isolation. He advised careful planning, because there were a number of practical issues, such as provision of equipment which could be expensive (toys for children from ethnic groups, for example because they have to be specially designed); building alterations to make the unit child-friendly; and the need for police checks on all staff.
We should remember that it is not just alcoholic parents who damage their children. While, of course, it is right that parents should introduce their children to alcohol, it is worrying that a third of 13–16 year olds who drink regularly obtain their alcohol from parents, and a quarter from other adults and older siblings. No wonder children are cynical about the double standards of their elders; by setting bad examples, we are all guilty of abusing our children.
CHILDREN AS DRINKERS
Two papers provided insights into young people's drinking. Rachel Herring of the Health Education Authority followed four young male friends on their Friday evening drinking spree. Clearly they aimed to drink a lot, and binged in order to consume as much as possible; thus, their behaviour tended to get out of control as they got more drunk. But they had carefully planned their evening: who was to act as minder, how much money they had to spend, and how to keep out of trouble. Why, she asked, are adults so hung up about adolescent drinking? They seem to have forgotten their own youth. The need to experiment and to rebel against authority, especially when a particular activity is condemned, are normal features of growing up, and alcohol is part of this. The majority come to no harm, and drinking levels fall as they get older. Rather than criticizing them, we should concentrate on detecting the minority whose drinking is part of a wider problem of anti-social behaviour. A further thought: should we not separate the ‘normal’ drinking pattern of 16 year olds and above from that of 11–15 year olds, whose drinking is often chaotic and may result in serious physical damage?
By contrast Dr Christopher Luke gave a lurid description of the mayhem caused in an Accident and Emergency (A&E) department in Liverpool by the large number of people — up to 1000 a month — with alcohol-related problems. His colleague, Dr Joan Robson, had found a similar situation at the Royal Liverpool Children's Hospital, Alder Hey, where the number of 11–15 year olds attending A&E under the influence of alcohol had risen in 10 years from 20 to ~200 a year, many of whom needed admission. While intoxication and injuries are obviously a serious state of affairs for A&E departments it is worth bearing in mind that, like all other forms of physical harm, only a minority of drinkers are affected. Dr Luke suggested tackling the problem by replacing glass in pubs by plastic, toughening up licensing laws, easily understandable labelling of drinks, employment of specialist nurses trained in alcohol misuse, and producing national guidelines for A&E departments.
‘All of us’, said Dr Eilish Gilvarry from the Newcastle Alcohol and Drug Service, ‘could identify the risk factors of the one in three young drinkers who come to harm. Ask any teacher.’ (Is the proportion that high? Most reported figures are nearer one in ten.) What should we be looking for: immaturity and low self-esteem, poor educational performance, mental health problems, anti-social behaviour, and dysfunctional families? The challenges were how to ensure access to services and how to coordinate the large number of different bodies that need to be involved in child-centred care. At present, there were few suitable facilities and few studies of recognized forms of treatment. In this context, Gillian Tober of the Leeds Addiction Unit suggested that motivational interviewing might be useful, because change could be achieved in a small number of sessions, which would appeal to young people. What was now required was a national commissioning body to provide services, and the formation of new alliances between different agencies. Better alcohol education for social workers, teachers and the legal professions, as well as for child specialists, was vital.
Most children, said Jean Coussins, director of the drinks industry's Portman Group, were not taught about sensible drinking, neither by parents nor at school. There was little instruction in English schools and virtually none in Scotland, and there should be a module on alcohol in teacher training colleges. But, says the report of the Royal College of Physicians and the British Paediatric Association (1995) ‘There is a lack of sound evidence that health education in schools has much impact on the behaviour of children and young people’. The Portman Group had set up nine panels of young people in various parts of the country as a form of self-help in making their own decisions. (This sits rather oddly with the industry's promotion of alcopops, beerfests, and vodka for young drinkers.) Scotland also has an initiative called PUDS (Prevent Underage Drinking Scheme), set up by a student, David Crosbie, to encourage young people to take responsibility for their own drinking and to hear what the problems are from those with experience including doctors, teachers and the police. The next step presumably would be for those who have learnt the lessons to go out and proselytize their peers.
So what have we learnt? (1) that adults are alarmed by the extent of young people's drinking; (2) that a significant proportion of 5–15 year olds are likely to be damaged by their own or their alcoholic parent's drinking; (3) that heavy drinking from 16 years onwards is part of growing up and causes harm in under 10% of adolescents; (4) that we need more robust data; (5) that doctors are interested in physical harm rather than in prevention; (6) that knowledge about alcohol is deficient in all sectors of society, and that young children, parents, school teachers, and other professionals who have dealings with the young need to be educated; (7) that doctors, and particularly hospital specialists, do not routinely take an alcohol history; (8) that facilities for treating young people with alcohol problems are virtually non-existent; (9) that we know most of this already. The time has long since passed when we should have stopped talking and taken action.