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The Child with Substance Abuse - Alcohol Abuse

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The most common substances used by Canadian youth are alcohol, tobacco, and cannabis. In general, Canadian youth begin to use alcohol, tobacco, and cannabis around Grade 7 to 9. The rates of use increase significantly throughout this period.
 
Any alcohol use can be a concern. Childhood and adolescence are crucial periods in the final stages of brain development, the formation of personality, identity, and other aspects of socialization. The use of alcohol at this stage of life can interfere with all of the processes mentioned above.
 
Alcohol use becomes a clinical concern when certain patterns evolve, such as increased frequency of use, risky use, increased consequences as a result of use, and being unable to stop using.
 
Mental health specialists consider alcohol abuse to occur when a youth might show some of these problems for  longer than a year:

1.      does not meet their obligations at school or in the home
2.      uses drugs or alcohol in dangerous situations, such as while driving
3.      has legal problems related to their substance use
4.      has social or interpersonal problems related to their substance use
 
Mental health specialists consider alcohol dependence when a youth shows some of these problems for over a year:
1.      increases in the amount of substance use to get the same effect
2.      withdrawal symptoms when they go off the substance
3.      inability to cut down on their use
4.      spends excessive time in obtaining the substance, or using, or recovering after use
5.      shows impairment in social, school or work activities because of their substance use
6.      continues to use, even though they are experiencing physical or psychological consequences of use
 
Whether or not alcohol use develops into a problematic pattern is the result of the interaction of many factors. Research has concentrated on understanding risk and protective factors. These factors appear to be numerous and are found in all of the environments that make up the child’s world, including the community, the home and the school. Risk factors relate to genetics, physiological, psychological and social indicators. Below are some of the major factors that might be observed by parents.
 
Risk Factors
Protective Factors
Individual
·       experimenting with substances illegal for children (i.e., tobacco and/or alcohol)
·       positive substance use attitude & expectancies
·       sensation seeking personality
·       criminal behaviour
·       low self-esteem
·       lack of assertiveness
·       impulsivity
·       mental health concerns/disorders (e.g., depression, anxiety, eating disorders,
ADHD)
·       exposure to trauma at home or elsewhere
·       solid self esteem
·       age appropriate levels of assertiveness
 
School
·       poor school performance
·       frequent absenteeism or truancy
·       lack of commitment to school academically and/or socially
·       conflict at school, with students, teachers or administrators
·       strong school performance
·       school bonding (i.e., enjoys being at school, fits in)
 
 
Friends
·       associating with peers who engage in substance abuse
·       social isolation or few friends
·       involvement with gangs
·       overly strong peer orientation
·       peer rejection
·       strong friendships
·       considerable social connection and support
·       peer group that does not encourage criminality, truancy or substance abuse
 
Extracurricular
·       unusually committed to competitive sports
·       employed and works more than 15 hours per week
·       engagement in structured peer activities, extracurricular programs, and sports
·       employed, but only if works less than 15 hours per week
Home
·       domestic violence in the home
·       parent or sibling involved in substance abuse
·       incompetent, inconsistent or chaotic parenting (e.g. lack of supervision/monitoring)
·       no warm supportive relationships with any adults
·       lives in neighbourhood with easy access to substances
·       supportive parent(s) with good disciplinary practices
·       warm nonviolent home
·       warm supportive relationship with at least one appropriate adult
 



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Alcohol use is exceedingly rare in this age group. For further information see the section for Middle Childhood.     Back to top

   

Several of the protective factors listed in the Introduction should be apparent within the child’s home school and community and few of the listed risk factors. Youth should be achieving adequately in school, enjoying a number of good social relationships and appear to be generally happy and well adjusted.
 
  • Youth does not associate regularly with friends who are known to engage in substance use or any criminal behaviour.
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Several risk factors listed in the Introduction are present and protective factors absent. This is not conclusive; parents will need to weigh their observations based on all that they know. The risk factors that inherently represent significant concern include:

 
  1. Alcohol in the home is missing or supply diminished
  2. Youth keeps to themselves locked in their rooms
  3. Negative moods emerge out of nowhere; they may seem depressed, angry
  4. Relationships with family members and friends become tense or broken
  5. Increased need for money; youth may even sell their possessions or steal from family or friends
  6. Associating with older group of friends or a group known to be involved with alcohol use.
  7. Problems with the law
  8. Frequent absences, apathy about school, or a sudden drop in academic performance
  9. Child is victim of peer rejection at school
  10. Previously diagnosed mental condition (e.g., depression, anxiety, ADHD)
  11. Positive attitude toward alcohol use (e.g., makes jokes about getting drunk)
  12. Sexually precocious behaviour, especially for girls
  13. Conflict in the home
 
Whether or not the child is involved with alcohol use, these behaviours could indicate a mental health problem.
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  The youth is showing several risk factors listed in the Introduction as well as several concerns described in the Yellow Light zone. Whether or not the child is involved with alcohol use, these behaviours could indicate a mental health problem.
 
All families have their own values around alcohol in the home. Some may permit youth to drink a small amount of wine with the family on special occasions. As a general guideline, concerns are raised if:
 
  1. the child uses any alcohol outside of parental supervision
  2. child/youth drinks to the point of intoxication: smells of alcohol, shows clumsiness, difficulty walking, slurred speech, sleepiness, poor judgment and is silly or giddy.
 
There are also indirect clues that youth is using alcohol recreationally, such as possession of a false ID card.
 
 
Certain risk factors may not be absolutely conclusive for alcohol/substance abuse, but are significant enough on their own to warrant action:
  1. serious behavioral problems (e.g., aggression)
  2. other mental health concerns (e.g., depression, anxiety)
  3. domestic violence at home
  4. alcohol/substance abuse by siblings or parents
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Several of the protective factors listed in the Introduction should be apparent within the child’s home school and community and few of the listed risk factors. Youth should be achieving adequately in school, enjoying a number of good social relationships and appear to be generally happy and well adjusted.
 
  • Youth does not associate regularly with friends who are known to engage in substance use or any criminal behaviour.
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  Several risk factors listed in the Introduction are present and protective factors absent. This is not conclusive; parents will need to weigh their observations based on all that they know. The risk factors that inherently represent significant concern include:
 
  1. Alcohol in the home is missing or supply diminished
  2. Youth keeps to themselves locked in their rooms
  3. Negative moods emerge out of nowhere; they may seem depressed, angry
  4. Relationships with family members and friends become tense or broken
  5. Increased need for money; youth may even sell their possessions or steal from family or friends
  6. Associating with older group of friends or a group known to be involved with alcohol use.
  7. Problems with the law
  8. Frequent absences, apathy about school, or a sudden drop in academic performance
  9. Child is victim of peer rejection at school
  10. Previously diagnosed mental condition (e.g., depression, anxiety, ADHD)
  11. Positive attitude toward alcohol use (e.g., makes jokes about getting drunk)
  12. Sexually precocious behaviour, especially for girls
  13. Conflict in the home
 
Whether or not the child is involved with alcohol use, these behaviours could indicate a mental health problem.
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The youth is showing several risk factors listed in the Introduction, as well as several concerns as described in the Yellow Light zone. Whether or not the youth is involved with alcohol use, these behaviours could indicate a mental health problem.
 
Many youth begin to try alcohol when they are 12-14 years old and this does not always mean that a pattern of abuse or dependence will emerge. The following patterns associated with alcohol use would indicate increased concern:
1.     Risky drinking (e.g., driving, operating machinery, swimming, etc.)
2.     Drinking causes problems with school, relationships, or the law
3.     Using alcohol in inappropriate places (e.g., school)
4.     Signs of alcohol withdrawal, such as being shaky, agitated, sweaty
5.     Indirect clues that alcohol is being consumed on a frequent basis, such as possession of a false ID card
6.     Drinking excessive amounts. This is sometimes defined as:
6.1. For males: 5 or more drinks on one occasion or more than 14 drinks over 1 week
6.2. For females: 4 or more drinks on one occasion or more than 9 drinks over 1 week
 
One drink is defined as:



Mental Health specialists consider alcohol abuse to occur when a youth  shows some of these problems for longer than a year:
1.     does not meet their obligations at school or in the home
2.     uses drugs or alcohol in dangerous situations, such as while driving
3.     has legal problems related to their substance use
4.     has social or interpersonal problems related to their substance use
 
 
Mental Health specialists consider alcohol dependence when a youth shows some of these problems for longer than a year:
a.     increases in the amount of substance use to get the same effect
b.     withdrawal symptoms, meaning problems when they go off the substance
c.     inability to cut down on their use
d.     spends excessive time in obtaining or using the substance, or recovering after use
e.     shows impairment in their social or work activities because of their substance use
f.      continues to use, even though they are experiencing physical or psychological consequences of use
 
Certain risk factors may not be absolutely conclusive for alcohol/substance abuse, but are significant enough on their own to warrant action:
a.     serious behavioral problems (e.g., aggression)
b.     other mental health concerns (e.g., depression, anxiety)
c.     domestic violence at home
d.     alcohol/substance abuse by siblings or parents
 

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Several of the protective factors listed in the Introduction should be apparent within the child’s home school and community and few of the listed risk factors. Youth should be achieving adequately in school, enjoying a number of good social relationships and appear to be generally happy and well adjusted.
 
  • Youth does not associate regularly with friends who are known to engage in substance use or any criminal behaviour.
    Back to top

  Several risk factors listed in the Introduction are present and protective factors absent. This is not conclusive; parents will need to weigh their observations based on all that they know. The risk factors that inherently represent significant concern include:
 
  1. Alcohol in the home is missing or supply diminished
  2. Youth keeps to themselves locked in their rooms
  3. Negative moods emerge out of nowhere; they may seem depressed, angry
  4. Relationships with family members and friends become tense or broken
  5. Increased need for money; youth may even sell their possessions or steal from family or friends
  6. Associating with older group of friends or a group known to be involved with alcohol use.
  7. Problems with the law
  8. Frequent absences, apathy about school, or a sudden drop in academic performance
  9. Child is victim of peer rejection at school
  10. Previously diagnosed mental condition (e.g., depression, anxiety, ADHD)
  11. Positive attitude toward alcohol use (e.g., makes jokes about getting drunk)
  12. Sexually precocious behaviour, especially for girls
  13. Conflict in the home
 
Whether or not the child is involved with alcohol use, these behaviours could indicate a mental health problem.
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The youth is showing several risk factors listed in the Introduction, as well as several concerns as described in the yellow light zone. Whether or not the youth is involved with alcohol use, these behaviours could indicate a mental health problem.
 
The majority of youth use alcohol by the time they are 15 years old and this does not always mean a pattern of abuse or dependence will emerge. The following patterns associated with alcohol use would indicate increased concern:
1)     Risky drinking (e.g., driving, operating machinery, swimming, etc.)
2)     Drinking that causes problems with school, relationships, or the law
3)     Using alcohol in inappropriate places (e.g., school)
4)     Signs of alcohol withdrawal, such as being shaky, agitated, sweaty
5)     Indirect clues that alcohol is being consumed on a frequent basis, such as possession of a false ID card
6)     Drinking excessive amounts. This is sometimes defined as:
a)     For males: 5 or more drinks on one occasion or more than 14 drinks over 1 week
b)     For females: 4 or more drinks on one occasion or more than 9 drinks over 1 week
    
One drink is defined as:
 


 
Mental Health specialists consider alcohol abuse to occur when, for longer than a year a youth might show some of these problems:
1)     does not meet their obligations at school or in the home
2)     uses drugs or alcohol in dangerous situations, such as while driving
3)     has legal problems related to their substance use
4)     has social or interpersonal problems related to their substance use
 
Mental Health specialists consider alcohol dependence when, for longer than a year, a youth shows some of these problems:
1)     increases in the amount of substance use to get the same effect
2)     withdrawal symptoms, meaning problems when they go off the substance
3)     inability to cut down on their use
4)     spends excessive time in obtaining or using the substance, or recovering after use
5)     shows impairment in their social or work activities because of their substance use
6)     continues to use, even though they are experiencing physical or psychological consequences of use
 
Certain risk factors may not be absolutely conclusive for alcohol/substance abuse, but are significant enough on their own to warrant action:
a.    serious behavioral problems (e.g., aggression)
b.    other mental health concerns (e.g., depression, anxiety)
c.    domestic violence at home
d.    alcohol/substance abuse by siblings or parents


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Genetics
Heritability is defined as: the extent to which genetic individual differences contribute to individual differences in observed behaviour. The heritability of the risk for alcohol dependence has been estimated to be approximately 50-60%. Several genes have been identified as being associated with alcohol dependence
 
Certain ethnic groups (Chinese, Japanese, and Koreans) are protected from developing alcohol abuse/dependence because of differences in the way their body metabolizes alcohol
 
Personality Factors
The following personality traits, which are inherited and present from birth, have been found to increase predisposition towards alcohol/substance use, abuse, and dependence:
a.     Risk-taking and sensation/novelty-seeking behaviour
b.     Impulsivity and lack of emotional control
c.     Difficulty with interpersonal relatedness (i.e., establishing and maintaining relationships)
 
Other Psychiatric Disorders
Persons who have some mental health problems may also have associated problems with alcohol or substance use, abuse, and dependence. This is particularly the case in persons who have problems with aggressive and defiant behaviour, persons with problems regulating their attention, and persons who have problems with depression, regulating their mood, or controlling their anxiety.
 
 


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Research has shown that the following factors related to the family environment are consistently associated with alcohol or substance use, abuse, and dependence:
 
1.    Parental alcohol/substance abuse/dependence
2.    Parental personality disorders and other psychiatric disorders
3.    The parent/child relationship, especially lack of parental monitoring and warmth
4.    Lack of closeness as a family
5.    Sibling influences
6.    Parenting style: either too permissive or too punitive
7.    Transitions or changes in family life (recent move, loss of a family member, parental separation)
8.    Domestic violence (see below)


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Of all the mental health disorders experienced by youth, perhaps alcohol use disorders, such as Alcohol Abuse and Alcohol Dependence, are the most difficult for individuals to understand as a disability. Many people see the youth as simply making poor choices. This may be even more relevant for alcohol than for other substances because it is legal and commonly consumed by a large portion of the population. 
 
It is important for parents to understand that when patterns of abuse and dependence emerge, it is usually in the context of other factors that are beyond the youth’s control, including the co-existence of other psychiatric disorders. 
 
When youth have reached the point where they meet criteria for alcohol dependence, the pattern has developed a life of its own. The youth has literally become dependent on alcohol to function. They have become caught up in a cycle of use, which is extremely difficult to escape without outside help.


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Anything about the youth that makes them feel different from their peers could lead to increased stress and possible alcohol abuse. Many of these are listed under Risk Factors in the Introduction, but could include difficulties with school performance/learning, problems fitting in with peers, bullying, problems in the home, etc.

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Girls tend to have lower threshold to the effects of alcohol, but experience problems and dependence at the same rate as boys. Certain protective and risk factors hold equal weight for boys and girls (social support, academic achievement, poverty). Other risk factors tend to be more important for girls, such as negative self image, weight concerns, early onset of puberty, higher levels of anxiety and depression, or a boyfriend’s drug/alcohol use. Also, certain protective factors such as parental support, consistent discipline and self-control, tend to be more important for girls. Girls may have more difficulty with peer pressure.
 
Alcohol/substance use tends to be higher among Aboriginal youth, likely as the result of increased difficulties such as marginalization, poverty, unemployment, and other problems.
 
Among New Canadian youth, attitudes about substance use and practices vary widely between cultures. Youth are more at risk if there is generally poor knowledge of the harm linked to substance use among new Canadians and parents tend to be less involved in health promotion and prevention programs due to language and cultural factors. However, identifying with an ethnic group and engagement with its culture is a protective factor in reducing risk for alcohol/substance abuse and dependence.
 
Several studies have found the following factors are conducive to alcohol/substance use, abuse, and dependence:
1.    Low income, living in an impoverished and stressful neighbourhood; increased stress leads to misuse of alcohol/substances as a means of coping
2.    Likewise, the stress of cultural change through migration can also lead to coping through the use of alcohol/substances
3.    Living in an environment where drinking and drug use are the norm and includes substance using social networks
4.    Neighbourhood social disorganization; lack of cooperation of local residents toward common goals, higher rates of gang activity
5.    Experiences of discrimination towards racial/ethnic minorities
6.    Youth marginalized because of sexual orientation or transgender issues


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There is overwhelming evidence from research studies that document the strong association between the experience of trauma and alcohol/substance use disorders. 
Many youth who abuse alcohol/substances have experienced one or more traumatic events in their life and experience unresolved recurrent stress and anxiety. The most common causes of trauma in Canadian children are sexual or physical abuse, or witnessing the abuse of their mothers. In addition, emotional/verbal abuse, as well as neglect should also be considered forms of child maltreatment. Loss of a loved one, or significant changes in living situation (through immigration or frequent moves) can also be significant stressors. Youth try to reduce overwhelming stress by whatever means possible. Some youth feel that they have few options other than using alcohol and/or substances. Victims of trauma often use alcohol and/or substances to avoid painful memories and feelings.

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Alcohol use is exceedingly rare in this age group. For further information see the section for Middle Childhood.



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Be clear about the family’s rules and consequences regarding alcohol use. Set a good example by:
1.    Not using alcohol heavily; for guidelines regarding safe drinking see Red Light sections for adolescents above, Actions
2.     Not using alcohol in a way that is problematic (i.e., abuse or dependence) as described in the introduction
Work towards having good communication in general with your child. 
 
The following approach has been described by Catherine Ketcham and Nicholas Pace in Teens Under the Influence
Listen
1.    Express a sincere desire to understand what your children are thinking and feeling
2.    Ask questions that motivate them to explore their feelings
3.    Let them talk without interrupting
4.    When they are finished, ask them if they are finished talking
5.    Repeat back to them what you think they said
 
Educate
1.    Educate yourself and your child about the problems associated with alcohol use
2.    Educate yourself about how to screen for problems with alcohol use


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Address other Issues
1.    Address conflict within the home or substance problems with other family members, including spouse. Get Your Loved One Sober by Robert Meyers and Brenda Wolfe is a good resource for helping adult loved ones struggling with substance abuse. Most communities also have Al-Anon groups available, which are groups for concerned loved ones that are consistent with Alcoholics Anonymous (AA).
2.    Address any problems with school. Connect with teachers to advocate for extra support if appropriate.
3.    Find out who your child is socializing with at school and elsewhere.
 
 
Address any suspected mental health problems (e.g., mood, anxiety, and attention)
1.    Refer to other sections of this website for concerns (e.g., the “sad child”, etc.)
2.    Seek advice from a family physician or pediatrician, who may suggest a referral to a mental health professional, such as a psychiatrist or psychologist
 
Screen for a problem with alcohol use
a.     Be direct: ask your child if they are using alcohol with friends


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A thorough assessment of the substance use should be strongly recommended at this point. Next steps depend on what resources are available. 
1.    A school guidance counselor, psychologist, consulting professional (e.g., psychiatrist) can help assess the situation and help with making referrals to other services, including substance abuse programs if appropriate. 
2.    A family physician or pediatrician can be a good starting point in terms of assessment, treatment and/or referral to more specialized services.
3.    Many treatment programs are self (or family) referred.  Start doing your research (see treatment options in Introduction).  
 
Treatment Programs
Some programs insist on abstinence and others on controlled use.
Abstinence programs, such as 12 step programs (the approach used by AA or Alcoholics Anonymous) can be extremely effective, but programs geared toward youth are not always available.  However, programs may be abstinence-based, without necessarily being a 12 step program. If a youth has been identified as having a problem with alcohol, he/she would ideally achieve complete abstinence, as this would eradicate any risk and is associated with the best long term outcome.
 
Yet other programs with a “Harm Reduction” or “Controlled Use” approach do not insist on abstinence. Clinicians or programs settle for a goal of “controlled use” if it is the only way to begin to engage a youth in treatment with the hope of eventually moving towards the goal of abstinence. Furthermore, youth with less severe problems associated with alcohol use may be able to sufficiently improve their overall situation by being helped to achieve controlled use.
It is important to decide which program might be the best fit for your child and this decision can be made with the help of the consulting professional involved (e.g., family physician, psychiatrist etc.).  
Other features of a treatment program to ask about:
1.    Includes families in the assessment and offers services/support for families
2.    Offers treatment for Concurrent Disorders (other mental health problems that often accompany alcohol use disorders, such as depression or anxiety)
3.    Offers a classroom where youth can continue with their education, which is sometimes helpful for youth who have difficulty with the mainstream education system
 
Most treatment takes place in an outpatient setting. Sometimes, however, there is a need for inpatient options. This decision will be made with the help of a professional as part of the assessment of the problem. Possible reasons for inpatient approaches include:
1.    Admission to the appropriate facility for detoxification (i.e., the natural release of the substance from the body following a period that it is no longer being consumed) if the youth experiences significant symptoms of withdrawal when stopping or cutting down alcohol use
2.    Residential treatment if the youth cannot resist the urge to stop using on their own without more extreme controls in place
3.    Admission to a hospital or psychiatric facility if there is a need for supervised detoxification. This may depend on the severity of withdrawal symptoms, which can be associated with extreme discomfort and/or serious medical problems.
4.    Admission to a hospital or psychiatric facility to address other mental health issues, or if there is a concern about imminent risk (e.g., youth is suicidal)
 
Other tips
1.    Stop “Enabling” (anything you do that makes it easier for your child to keep using and avoid consequences, such as giving them money). 
2.    Don’t be a “fixer” (e.g., lying to teachers to help your child get a better/passing grade, making excuses, blaming friends.
3.     Enforce negative consequences: take away privileges until child agrees to get help.
4.    It is just as important to communicate using positive statements, as opposed to nagging or finger wagging. For example, “you’re such a pleasure to be around when you are not drinking” or “your grades have really improved since you stopped drinking” or “Remember how good your grades were when you weren’t drinking”.
5.    Avoid labeling the youth or even using the word “alcoholic” which can cause stigma and result in more harm. At the same time, keep in mind that this is a serious problem that may represent a form of mental illness.
6.    Be sure to provide praise/positive reinforcement whenever it is deserved in other areas in life so that the child feels generally confident and capable, which are important qualities that will help them tackle their substance use problem.
7.    Get help for yourself. Whether or not your child agrees to participate in an assessment or treatment, seek support for yourself and other family members. Many treatment programs offer support for parents even if the youth are not involved in the program themselves.
8.    In cases where there appears to be considerable risk of harm to the child, such as violence at home or evidence of significant alcohol/substance abuse by parents, use various crisis services, such as local Child Protection Services or the emergency room at your local hospital. Know where your nearest family shelters are located. When there is imminent threat of danger, sometimes even the police should be involved. This also applies to situations where it is the youth themselves who pose a threat to the rest of the family.


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Be clear about the family’s rules and consequences regarding alcohol use. Set a good example by:
1.    Not using alcohol heavily; for guidelines regarding safe drinking see Red Light sections for adolescents above, Actions
2.     Not using alcohol in a way that is problematic (i.e., abuse or dependence) as described in the introduction
Work towards having good communication in general with your child. 
 
The following approach has been described by Catherine Ketcham and Nicholas Pace in Teens Under the Influence
Listen
1.    Express a sincere desire to understand what your children are thinking and feeling
2.    Ask questions that motivate them to explore their feelings
3.    Let them talk without interrupting
4.    When they are finished, ask them if they are finished talking
5.    Repeat back to them what you think they said
 
Educate
1.    Educate yourself and your child about the problems associated with alcohol use
2.    Educate yourself about how to screen for problems with alcohol use


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Address other Issues
1.    Address conflict within the home or substance problems with other family members, including spouse. Get Your Loved One Sober by Robert Meyers and Brenda Wolfe is a good resource for helping adult loved ones struggling with substance abuse. Most communities also have Al-Anon groups available, which are groups for concerned loved ones that are consistent with Alcoholics Anonymous (AA).
2.    Address any problems with school. Connect with teachers to advocate for extra support if appropriate.
3.    Find out who your child is socializing with at school and elsewhere.
4.    Address any suspected mental health problems (e.g., mood, anxiety, and attention).  Seek advice from a family physician or pediatrician, who may suggest a referral to a mental health professional, such as a psychiatrist or psychologist.
5.    Refer to other sections of this website for concerns (e.g., the “sad child”, etc.).
 
Screen for a problem with alcohol use by asking your child the following CRAFFT questions:
(1) Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
(2) Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
(3) Do you ever use alcohol or drugs while you are by yourself Alone?
(4) Do you ever Forget things you did while using alcohol or drugs?
(5) Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
(6) Have you ever gotten into Trouble while you were using alcohol or drugs?
 
Scoring: 2 or more positive items indicate the need for further assessment. From: Knight JR; Sherritt L; Shrier LA//Harris SK//Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent 156(6) 607-614, 2002.


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A thorough assessment of the substance use should be strongly recommended at this point. Next steps depend on what resources are available. 
1.    A school guidance counselor, psychologist, consulting professional (e.g., psychiatrist) can help assess the situation and help with making referrals to other services, including substance abuse programs if appropriate. 
2.    A family physician or pediatrician can be a good starting point in terms of assessment, treatment and/or referral to more specialized services.
3.    Many treatment programs are self (or family) referred.  Start doing your research (see treatment options in Introduction).  
 
Treatment Programs
Some programs insist on abstinence and others on controlled use.
Abstinence programs, such as 12 step programs (the approach used by AA or Alcoholics Anonymous) can be extremely effective, but programs geared toward youth are not always available.  However, programs may be abstinence-based, without necessarily being a 12 step program. If a youth has been identified as having a problem with alcohol, he/she would ideally achieve complete abstinence, as this would eradicate any risk and is associated with the best long term outcome.
 
Yet other programs with a “Harm Reduction” or “Controlled Use” approach do not insist on abstinence. Clinicians or programs settle for a goal of “controlled use” if it is the only way to begin to engage a youth in treatment with the hope of eventually moving towards the goal of abstinence. Furthermore, youth with less severe problems associated with alcohol use may be able to sufficiently improve their overall situation by being helped to achieve controlled use.
It is important to decide which program might be the best fit for your child and this decision can be made with the help of the consulting professional involved (e.g., family physician, psychiatrist etc.).  
Other features of a treatment program to ask about:
1.    Includes families in the assessment and offers services/support for families
2.    Offers treatment for Concurrent Disorders (other mental health problems that often accompany alcohol use disorders, such as depression or anxiety)
3.    Offers a classroom where youth can continue with their education, which is sometimes helpful for youth who have difficulty with the mainstream education system
 
Most treatment takes place in an outpatient setting. Sometimes, however, there is a need for inpatient options. This decision will be made with the help of a professional as part of the assessment of the problem. Possible reasons for inpatient approaches include:
1.    Admission to the appropriate facility for detoxification (i.e., the natural release of the substance from the body following a period that it is no longer being consumed) if the youth experiences significant symptoms of withdrawal when stopping or cutting down alcohol use
2.    Residential treatment if the youth cannot resist the urge to stop using on their own without more extreme controls in place
3.    Admission to a hospital or psychiatric facility if there is a need for supervised detoxification. This may depend on the severity of withdrawal symptoms, which can be associated with extreme discomfort and/or serious medical problems.
4.    Admission to a hospital or psychiatric facility to address other mental health issues, or if there is a concern about imminent risk (e.g., youth is suicidal)
 
Other tips
1.    Stop “Enabling” (anything you do that makes it easier for your child to keep using and avoid consequences, such as giving them money). 
2.    Don’t be a “fixer” (e.g., lying to teachers to help your child get a better/passing grade, making excuses, blaming friends.
3.     Enforce negative consequences: take away privileges until child agrees to get help.
4.    It is just as important to communicate using positive statements, as opposed to nagging or finger wagging. For example, “you’re such a pleasure to be around when you are not drinking” or “your grades have really improved since you stopped drinking” or “Remember how good your grades were when you weren’t drinking”.
5.    Avoid labeling the youth or even using the word “alcoholic” which can cause stigma and result in more harm. At the same time, keep in mind that this is a serious problem that may represent a form of mental illness.
6.    Be sure to provide praise/positive reinforcement whenever it is deserved in other areas in life so that the child feels generally confident and capable, which are important qualities that will help them tackle their substance use problem.
7.    Get help for yourself. Whether or not your child agrees to participate in an assessment or treatment, seek support for yourself and other family members. Many treatment programs offer support for parents even if the youth are not involved in the program themselves.
8.    In cases where there appears to be considerable risk of harm to the child, such as violence at home or evidence of significant alcohol/substance abuse by parents, use various crisis services, such as local Child Protection Services or the emergency room at your local hospital. Know where your nearest family shelters are located. When there is imminent threat of danger, sometimes even the police should be involved. This also applies to situations where it is the youth themselves who pose a threat to the rest of the family.


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Be clear about the family’s rules and consequences regarding alcohol use. Set a good example by:
1.    Not using alcohol heavily; for guidelines regarding safe drinking see Red Light sections for adolescents above, Actions
2.     Not using alcohol in a way that is problematic (i.e., abuse or dependence) as described in the introduction
Work towards having good communication in general with your child. 
 
The following approach has been described by Catherine Ketcham and Nicholas Pace in Teens Under the Influence
Listen
1.    Express a sincere desire to understand what your children are thinking and feeling
2.    Ask questions that motivate them to explore their feelings
3.    Let them talk without interrupting
4.    When they are finished, ask them if they are finished talking
5.    Repeat back to them what you think they said
 
Educate
1.    Educate yourself and your child about the problems associated with alcohol use
2.    Educate yourself about how to screen for problems with alcohol use



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Address other Issues
1.    Address conflict within the home or substance problems with other family members, including spouse. Get Your Loved One Sober by Robert Meyers and Brenda Wolfe is a good resource for helping adult loved ones struggling with substance abuse. Most communities also have Al-Anon groups available, which are groups for concerned loved ones that are consistent with Alcoholics Anonymous (AA).
2.    Address any problems with school. Connect with teachers to advocate for extra support if appropriate.
3.    Find out who your child is socializing with at school and elsewhere.
4.    Address any suspected mental health problems (e.g., mood, anxiety, and attention).  Seek advice from a family physician or pediatrician, who may suggest a referral to a mental health professional, such as a psychiatrist or psychologist.
5.    Refer to other sections of this website for concerns (e.g., the “sad child”, etc.).
 
Screen for a problem with alcohol use by asking your child the following CRAFFT questions:
(1) Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?
(2) Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
(3) Do you ever use alcohol or drugs while you are by yourself Alone?
(4) Do you ever Forget things you did while using alcohol or drugs?
(5) Do your Family or Friends ever tell you that you should cut down on your drinking or drug use?
(6) Have you ever gotten into Trouble while you were using alcohol or drugs?
 
Scoring: 2 or more positive items indicate the need for further assessment. From: Knight JR; Sherritt L; Shrier LA//Harris SK//Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent 156(6) 607-614, 2002.



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A thorough assessment of the substance use should be strongly recommended at this point. Next steps depend on what resources are available. 
1.    A school guidance counselor, psychologist, consulting professional (e.g., psychiatrist) can help assess the situation and help with making referrals to other services, including substance abuse programs if appropriate. 
2.    A family physician or pediatrician can be a good starting point in terms of assessment, treatment and/or referral to more specialized services.
3.    Many treatment programs are self (or family) referred.  Start doing your research (see treatment options in Introduction).  
 
Treatment Programs
Some programs insist on abstinence and others on controlled use.
Abstinence programs, such as 12 step programs (the approach used by AA or Alcoholics Anonymous) can be extremely effective, but programs geared toward youth are not always available.  However, programs may be abstinence-based, without necessarily being a 12 step program. If a youth has been identified as having a problem with alcohol, he/she would ideally achieve complete abstinence, as this would eradicate any risk and is associated with the best long term outcome.
 
Yet other programs with a “Harm Reduction” or “Controlled Use” approach do not insist on abstinence. Clinicians or programs settle for a goal of “controlled use” if it is the only way to begin to engage a youth in treatment with the hope of eventually moving towards the goal of abstinence. Furthermore, youth with less severe problems associated with alcohol use may be able to sufficiently improve their overall situation by being helped to achieve controlled use.
It is important to decide which program might be the best fit for your child and this decision can be made with the help of the consulting professional involved (e.g., family physician, psychiatrist etc.).  
Other features of a treatment program to ask about:
1.    Includes families in the assessment and offers services/support for families
2.    Offers treatment for Concurrent Disorders (other mental health problems that often accompany alcohol use disorders, such as depression or anxiety)
3.    Offers a classroom where youth can continue with their education, which is sometimes helpful for youth who have difficulty with the mainstream education system
 
Most treatment takes place in an outpatient setting. Sometimes, however, there is a need for inpatient options. This decision will be made with the help of a professional as part of the assessment of the problem. Possible reasons for inpatient approaches include:
1.    Admission to the appropriate facility for detoxification (i.e., the natural release of the substance from the body following a period that it is no longer being consumed) if the youth experiences significant symptoms of withdrawal when stopping or cutting down alcohol use
2.    Residential treatment if the youth cannot resist the urge to stop using on their own without more extreme controls in place
3.    Admission to a hospital or psychiatric facility if there is a need for supervised detoxification. This may depend on the severity of withdrawal symptoms, which can be associated with extreme discomfort and/or serious medical problems.
4.    Admission to a hospital or psychiatric facility to address other mental health issues, or if there is a concern about imminent risk (e.g., youth is suicidal)
 
Other tips
1.    Stop “Enabling” (anything you do that makes it easier for your child to keep using and avoid consequences, such as giving them money). 
2.    Don’t be a “fixer” (e.g., lying to teachers to help your child get a better/passing grade, making excuses, blaming friends.
3.     Enforce negative consequences: take away privileges until child agrees to get help.
4.    It is just as important to communicate using positive statements, as opposed to nagging or finger wagging. For example, “you’re such a pleasure to be around when you are not drinking” or “your grades have really improved since you stopped drinking” or “Remember how good your grades were when you weren’t drinking”.
5.    Avoid labeling the youth or even using the word “alcoholic” which can cause stigma and result in more harm. At the same time, keep in mind that this is a serious problem that may represent a form of mental illness.
6.    Be sure to provide praise/positive reinforcement whenever it is deserved in other areas in life so that the child feels generally confident and capable, which are important qualities that will help them tackle their substance use problem.
7.    Get help for yourself. Whether or not your child agrees to participate in an assessment or treatment, seek support for yourself and other family members. Many treatment programs offer support for parents even if the youth are not involved in the program themselves.
8.    In cases where there appears to be considerable risk of harm to the child, such as violence at home or evidence of significant alcohol/substance abuse by parents, use various crisis services, such as local Child Protection Services or the emergency room at your local hospital. Know where your nearest family shelters are located. When there is imminent threat of danger, sometimes even the police should be involved. This also applies to situations where it is the youth themselves who pose a threat to the rest of the family.


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