Alcohol and Alcoholism Vol. 35, No. 6, pp. 630, 2000
© 2000 Medical Council on Alcoholism
Book Reviews
Alcohol use among Adolescents.
By M. Windle. Sage Publications. 1999, 160pp., £15.99. ISBN: 0761909206.
This book is one in the Sage series Developmental Clinical Psychology and Psychiatry. It provides a readable and comprehensive American overview of the subject. Professor Windle has attempted to cover the breadth of the subject with five stand-alone chapters on: Scope of Adolescent Alcohol Use; Measurement and Diagnosis; Risk and Protective Factors; Approaches to Prevention; Conceptual and Methodological Issues and Future Research Directions.
The beauty of the book is in the detail, and the selection of research findings which encourage one to go to the 12 pages of references to seek out the original papers. This book is written for the American market and would have been greatly enriched with a chapter on national differences (which are striking in adult psychiatry) and would probably be expected to be even more disparate in adolescence where there are tremendous variations in prohibiting or condoning alcohol use in the young.
The book is developmentally informed, putting forward a strong argument that adolescents in treatment are very different from adults, and stating the inadequacies of using adult criteria for diagnosis. Each chapter ends with a summary which allows readers to consolidate the most important information therein.
The book defines adolescence around a chronological age of 13 to 20 years. As the minimum drinking age is 21 years throughout the USA, the book is necessarily dealing with an illegal activity. This is very different to the UK, where it is illegal to give alcohol to any child under 5 years of age, but older children can consume alcohol with meals in restaurants, at home or even in public house beer gardens. However buying alcohol or drinking alcohol in public houses in the UK is not legal until 18 years of age.
It is stated that there is little societal support for the enforcement of laws surrounding underage drinking. I suspect that this is not the case in the UK, where both shopkeepers and licensees are regularly charged for selling to underage youths.
Over the past 30 years, there has been increasing alcohol use and an earlier age for commencing alcohol use. We know that it is early unsupervised drinking which is associated with serious alcohol problems later. I was interested to read that, since 1988, when all 50 states embraced a Minimum Drinking Age of 21 years, there has been a reduction in alcohol consumption both in the senior year and at age 25! This clearly has positive health connotations for the whole population.
Professor Windle states that between 3 and 32% of adolescents meet the criteria for lifetime alcohol disorder, but does not state why there is such a disparity in the figures from the different studies, or at which end of the continuum he believes the true figure to be.
Having an early diagnosis of conduct disorder and of attention deficit/hyperactivity disorder appears to predict later problem drinkers. So it is probably this group which needs to be targeted for treatment interventions. It is known that polysubstance users and abusers have higher rates of psychiatric morbidity than adults in treatment settings; however, alcohol dependence disorder is rarely seen in adolescence.
The ISPF family intervention successfully delayed the initiation of alcohol-use problems. The targets for change were peer socialization practices, poor supervision of children, inconsistent disciplinary practices, poor quality of parent–child relationships, excessive family conflict, high levels of family chaos and stress, family social isolation, parental and sibling drug usage, and poor parental mental health. However, McGee showed that parental problem drinking and family functioning were not strongly associated with adolescent alcohol use, but that sibling influences appear to be more important.
It seems that the most powerful interventions to reduce teenage and adult alcohol problems are more political than medical, involving social policy interventions: increasing minimum drinking age, increasing the price of alcohol through taxation, limiting advertising, zero tolerance to youth drink-driving to name but a few.
Although psychosocial interventions have an effect, despite a proliferation of adolescent substance use prevention programmes, rates of teenage substance use behaviours have been increasing in recent years. Disappointingly for prevention, a number of researchers have found virtually no programme effects for adolescents who had an earlier onset of substance use behaviours and who may therefore be at greater risk of later substance use problems. The positive effect of these programmes appears to be short term, the effect is greater on the lightest users whom naturally one is less concerned about, and the effect appears to be less on alcohol consumption than on other drug usage. Similarly, treatment programmes that emphasize abstinence are not likely to be successful with adolescent heavy problem drinkers.
Windle either fails to mention or puts insufficient emphasis on: (1) anxiolytic use of alcohol, particularly for social phobias, (2) advertising — for instance the boundaries our own country puts on advertisements targeting young people or making it look as though consuming alcohol can be associated with sexual attractiveness, (3) the ‘unit’ of alcohol and safe drinking limits, (4) the Cage Questionnaire used for adult drinkers, (5) the overlap of alcohol consumption with non-prescribed drugs. In the UK, excessive alcohol consumption is not associated with criminality in the way in which drug usage is, however there is a marked correlation with violence and aggression, (6) the vulnerability of teenagers to the physical effects of alcohol, (7) cost or cost efficiency of programmes for prevention.
This is a useful research-based book on teenage drinking, but it is too biased towards the American market to enable me to recommend it to readers outside North America.
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