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Alcohol and the Young

Drinking alcohol is an accepted and pleasurable part of social life. Most adults have at least an occasional drink with friends and, apart from those who may abstain for religious and other reasons, many would expect alcohol to be provided at a family celebration or a party. Yet, as is well known, alcohol in excess can kill. As has already been highlighted by four major reports it can affect an individual even before birth, and is responsible for significant ill health and unhappiness, destroying careers and wrecking family life. Heavy alcohol consumption sometimes begins in adolescence. It is therefore important both to educate young people about alcohol so that they can take informed decisions and to protect young children from its harmful effects.

religious and other reasons, many would expect alcohol to be provided at a family celebration or a party. Yet, as is well known, alcohol in excess can kill. As has already been highlighted by four major reports [1][2][3][4] it can affect an individual even before birth, and is responsible for significant ill health and unhappiness, destroying careers and wrecking family life. Heavy alcohol consumption sometimes begins in adolescence. It is therefore important both to educate young people about alcohol so that they can take informed decisions and to protect young children from its harmful effects. This report aims to assist parents and young people to make good choices, to provide government with information concerning policies that would make those choices easier, and to help professionals in their tasks of prevention and treatment. The report outlines the extent of alcohol-related harm among the young and considers preventive and treatment measures.

Problem drinking by parents
Alcohol can and does affect fertility and increases the risk of spontaneous abortion. Drinking in pregnancy can harm the fetus which is most liable to be damaged in the very early stages of pregnancy. It is therefore wise for women planning to become pregnant to abstain or drink very little from the time of their period until the first six weeks of their pregnancy, and subsequently to drink only occasionally and well within recommended limits during the rest of the pregnancy. Those who drink moderately or, more especially, heavily around the time of conception risk having babies born with the full or partial fetal alcohol syndrome. While this syndrome may involve many physical abnormalities, mental retardation is its most common and disabling feature.
Parents who drink alcohol excessively cannot supervise their children properly. Consequently their children have an increased risk of accidents, and their physical and emotional needs may be neglected. Furthermore, problem drinking by parents and others looking after children increases the risk of uncontrolled violence and physical abuse within the home.
Much domestic violence is carried out when the offender is drunk. Alcohol is sometimes an enabling factor in child sexual abuse.
2. Assessment and management of children of parents with a drinking problem All professionals, especially those in the health and social services field, have a responsibility to recognise when problem drinking affects people's capacity to be good parents. Some aspects of unwise drinking, such as occasionally consuming more than the recommended limits, will not, of course, in themselves significantly impair parenting. But all health professionals have a duty to consult the local social services department if their observations suggest a child is suffering or is likely to suffer significant harm and, with this in mind, when working with parents and children should be able to take a drinking history and to assess the degree to which alcohol might be impairing parenting capacity. They should have the skills to counsel parents to help them to reduce their intake, refer them to the appropriate agencies if unsafe drinking continues, and, as far as possible in partnership with parents, ensure that adequate child protection measures are taken if the child is at risk of significant harm.
3. Patterns of drinking behaviour in the young: prevalence, influences and impact Most children in the UK have had their first alcoholic drink by the time they reach their teenage years. This, in itself, is of little, if any, significance. What is more worrying is the degree to which young people and sometimes children get drunk with a consequent risk of damaging themselves or others. The report documents evidence of the extent of problem drinking in children and young people. We present evidence from a cross-national study that 13 and 15 year-olds in Wales head a list of ten countries in the frequency with which 13 to 15 year-olds get drunk, with Scotland not far behind (the study did not include England.) After considering the development of 'normal' drinking behaviour, and the background factors related to excessive consumption, the report then discusses the effects of alcohol including the extent to which intoxication in the young increases the risk of road traffic accidents, unsafe sex, and violence. For example, more than one in ten 16 to 19 year-old young men drinking under 21 units a week, and more than four in ten drinking over the recommended limits have been involved in a physical fight as a consequence of drinking alcohol.
The degree to which alcohol consumption is sometimes a 'gateway' to consumption of illicit drugs is documented in the report. For many young people, illicit drugs are as accessible as alcohol. The alcohol and drug scenes are closely related and need to be considered together. 4. Assessment and treatment of alcohol problems in the young After parents, the main responsibility for identifying problem drinking in the young lies in the primary care services, broadly defined to include not only family doctors and practice nurses, but also school nurses, dentists, doctors (to whom teachers should be able to refer readily) and social workers. These professionals should be able to provide effective front line counselling. There should also be a defined multidisciplinary Young People's Alcohol and Drug Service in each district to which referrals can be made. Bearing in mind the reluctance of the young, like older people, to acknowledge their alcohol consumption as causing a problem, such a service would need to pay particular attention to its accessibility, acceptability and sensitivity to local needs and the local pattern of services.

Prevention
Alcohol consumption in the young mirrors that in the total population. The number of people suffering from alcohol-related harm is correlated with the annual consumption of the population. Therefore governments motivated to reduce alcohol-related harm in the young (as well as in the rest of the population) will pursue measures to cut total consumption. The single, most effective way of achieving this aim is price control through taxation. Other measures play a part, and in the Recommendations (see below) relating to prevention, the working party have taken into account evidence suggesting that action on advertising, marketing codes of practice, and labelling would have a useful effect. They point to the confused state of our laws on limiting access of young people to alcohol, and the degree to which these laws are ignored. The report also includes evidence to suggest that the introduction of random breath testing and lower limits of blood alcohol for drivers would further cut alcohol-related road traffic accidents. There is a lack of sound evidence that health education in schools has much impact on the behaviour of children and young people. While acknowledging the right of children and young people to information and the acquisition of social skills enabling them to reduce their alcohol intake, the report indicates that health education appears to be an unsafe plank on which to base an entire, effective preventive policy.

Training
All professionals in touch with children, young people and parents need information on the extent of alcohol-related harm and on the means of identifying and treating parents and young people who are at risk. Existing training of nurses, doctors, social workers, youth workers, teachers, and many other relevant professionals is currently inadequate. Recommendations are made on the core curriculum content in this subject that should form the basis of training, with additional special consideration being given to other issues, depending upon the setting in which the professional group in question will be working.

Research
Research into alcohol problems in parents and the young is still exceedingly small in relation to the size of the problem and our lack of knowledge on important issues. For example only limited information is available on the continuity of problem drinking from adolescence to adulthood; there are no effective screening methods to identify problem drinking in young people in primary care settings, and virtually nothing is known about the pattern of drinking in second and third generation immigrant families with a tradition of abstinence. There is a need for a greatly expanded, coherent research programme in this field, with research activity much less dependent than is currently the case on financial support from the drinks industry.
The report recommends the NHS Research Directorate should take responsibility for the development of a co-ordinated research programme.

Introductory statement
The working party recognises that many sectors of our society play a role in ensuring that young people adopt a safe approach to the use of alcohol. To each of these we address specific recommendations which we hope will be implemented within their organisations. We also urge people at all levels of society?from children, young people and parents themselves to professionals and to politicians at a national level?to undertake a public advocacy role in favour of safe drinking. (Numbers in parentheses at the end of each recommendation refer to chapters in the full report.) National policy recommendations 1 Annual consumption: in the light of the fact that the alcohol consumption of young people is a reflection of the consumption of the total population, steps should be taken to ensure that this should not rise above the present level of 9.1 litres of alcohol per person in the population aged over 15 years (equivalent to 2.5 units per day). Further, government should act to reduce annual consumption to about 5 litres (or 1.5 units a day) per head over the next 10 years. (5) 2 Pricing/taxation: the real price of alcohol and alcohol products should be regularly increased by taxation in order to achieve a strong price disincentive on alcohol for young people. (5) 3 Advertising and promotion: all forms of alcohol sales promotion directed towards the young (including arts and sports sponsorship by alcohol companies) should be subject to tighter regulation. (5) 4 Marketing codes of practice: the code of practice for marketing alcohol products to young people should be reviewed in the light of an increasing tendency for alcohol companies to target their products towards the young. In particular, marketing methods which blur the distinction between alcohol and illicit drugs should be banned.

5
Labelling: legislation should be introduced to require alcoholic drinks to be prominently labelled with their alcohol content by units. Alcoholic drinks should also be labelled with recommended limits to assist consumer choice and self-monitoring. (5)   6 A revieiv of legislation: there should be a government review of existing licensing legislation concerning the young with the aim of introducing legislation that is consistent, reduces the risk of alcohol-related harm to children and young people, and is enforceable. (5) 7 Minimum legal age for sales of alcohol: current legislation prohibiting sales of alcohol to young people under 18 years should be fully and firmly enforced. Licensees: all licensees should be required to possess the British Institute of Innkeeping Licensee Certificate. In addition, children's licensing certificates should only be issued where trained service/bartenders are present at all times. The age of alcohol servers should not be less than 18 years. 10 Drunken driving deterrence: the existing limit of 80mg% should be reviewed. 11 Learner drivers: the legal limit of blood alcohol should be reduced to 20mg% for learner drivers and those who have passed their driving test in the previous two years. This is the lowest limit that can be reliably measured, and inexperienced young drivers should be advised not to drink at all before they drive.
Parents, children and young people 12 Would-be parents and all young women should be particularly aware of the dangers of alcohol consumption in pregnancy around the time of conception. So it is wise for those women planning to become pregnant to abstain or to drink very little from the time of their period until the first six weeks of their pregnancy, and subsequently to drink alcohol only occasionally and well within recommended limits.
13 Parents should be aware of the potential impact of their drinking habits on those of their children, and ensure that their alcohol consumption does not impair their capacity to care for their children properly. (2) 14 Parents whose children drink alcohol should try to ensure that it is consumed in moderate and safe quantities. (3) 15 Parents should try to make opportunities to discuss alcohol consumption with their children in the context of their general health. If they think their child has a drinking problem, they should seek help and encourage their child to do so. (3) 16 Parents should be alert to the dangers of allowing their children to drink alcohol unsupervised or in situations where it is potentially dangerous. (3) 17 Children and young people should be aware of the dangers of alcohol abuse. (3) 18 Children and young people should know that it is dangerous to encourage their friends to get drunk or to drink over the recommended limits. (3) Commissioners of health, education and social services 19 Monitoring patterns of alcohol use: levels of alcohol drinking among young people at district level should be monitored by health and social services and social care agencies, and published on a regular basis. To this end, purchasers should commission periodic surveys to monitor levels of drinking among the young. (5) 20 A Young People's Drug and Alcohol Service: commissioners of health services should ensure that all children and young people in need have access to a multidisciplinary specialist centre for the assessment and management of children and young people? a Young People's Drug and Alcohol Service. They should ensure the service is accessible and relevant to local needs and, when a young person refuses help from it, should be capable of counselling parents and teachers. (4) 21 Alcohol education: schools should provide opportunities for alcohol education in the personal and social component of the curriculum. (5) hi particular: ? Young people should be assisted to resist social and marketing pressures to drink alcohol in excess by being taught appropriate personal and social skills in school; ? Relevant information should be provided to young people on the short-term risks of acute alcohol intoxication, and on longer term health effects of problem drinking; ? Primary and secondary schools should be used as efficient settings for contacting large numbers of young people with educational programmes; ? Family, parents and carers should be involved with teachers in alcohol education to reinforce teaching in the class room.
Providers of health, education and social services 22 Services for adults: all professionals should be alert to the possibility that the quality of childcare by parents and others may be impaired in those drinking over the recommended limits. Professionals in the health and social services should, in these circumstances: ? identify parents and others who are caring for children who are drinking unwisely, counsel them about their drinking habits, and work with them to reduce their consumption to within recommended limits; ? refer, if necessary, to the appropriate service: GP, psychiatric or substance abuse service, etc; ? refer to the local social services department if there is a suspicion that a child is suffering or is likely to suffer significant harm. (4) 23 Services for children and young people: all professionals, especially general practitioners, school nurses and social workers, should be capable of identifying and counselling or, if necessary, referring children and young people who are drinking over the recommended limits, or are otherwise at risk of alcohol-related harm, to the appropriate agencies. (4) 24 Prevention: all professionals should regard prevention of alcohol harm as part of their work, giving special attention to the peri-conceptual period in would-be parents, as well as to parents of young children, and to adolescents. (5) 25 Health education: health education material about alcohol use should be made available in those settings of medical and dental care, youth clubs, schools etc, where young people and parents are likely to see them. (5) 26 Drinking on health, education and social services premises: as is now commonly the case with smoking control, school, youth club and social service policies on alcohol control should be established and implemented for staff working at these sites as well as for young people attending them. Where a social function involves alcohol consumption, it should be held away from the work place. (5) 27 Counselling for professional staff working with young people: better training should be provided for a wide range of professionals on the hazards of excessive alcohol consumption, on means of limiting intake, and on appropriate procedures for obtaining help for colleagues who appear to be at risk of alcohol-related harm. (5) Organisations validating and undertaking professional training Professionals for whom this recommendation is relevant include all health professionals, teachers, social workers, the police, probation officers, youth workers, psychotherapists and clinical psychologists. 28 A common core programme relevant to safe drinking should be introduced into the basic training and continuing education of all those working with parents, children and young people. The programme should impart a basic understanding of alcohol, alcohol problems and their management, and how skills relevant to the profession in question can be applied to enable others to consider their own drinking behaviour. (6) Recreation and sports clubs for young people, youth workers, etc. 29 Sale of alcohol: on licensed premises where alcohol is sold, the existing laws should be strictly and firmly enforced. (5) 30 No-alcohol and loiv-alcohol drinks: the sale of noalcohol and low-alcohol drinks should be encouraged by a policy of low pricing and attractive packaging. (5) 31 Dealing with drunkenness in the young: staff working in licensed premises should be given clear guidelines on the management of young people who are obviously drinking over the recommended limits and/or are intoxicated. (5) Alcohol industry 32 Availability of low-alcohol drinks: the availability of low-alcohol drinks in public houses, restaurants and off-licences should be increased, and they should be marketed at more competitive prices in order to increase their attraction. (5) 'Major research funding bodies (Department of Health, Medical Research Council and Wellcome Trust) 33 An expanded programme of research: research activity in issues relevant to alcohol and the young should be generally strengthened, and the number of UK centres involved in such activity should be increased. (7) agencies, independent of the alcohol industry. Research funded by the alcohol industry is welcomed, but the industry should not constitute the main source of funding. (7) 35 Co-ordinated research programme: the NHS Research