Alcohol Addiction in Children and Adolescents

Epidemiology:
Harmful use of alcohol results in the death of approximately 3 million people each year and the cost of diseases and injuries caused by alcohol use is high. The World Health Organization (WHO) has reported that the age of starting substance use and showing signs of addiction has decreased to 5-14 years. In a comprehensive study conducted in 2011 by the Turkish Monitoring Center for Drugs and Drug Addiction (TMCDD) with a total of 129 schools and 11812 students in 32 provinces, it was found that 19,4% of the students tried alcoholic beverages. One of the important findings of the study is that the age of onset of substance use is gradually decreasing (TUBIM 2012). 34.2% of 10th grade students participating in a study conducted in Istanbul in 2014 reported that they had tried alcohol at least once in their life (Evren et al. 2014). In another study conducted in Turkey 23.6% of adolescents who applied to addiction centers for help stated that they had alcohol use problems (Yüncü et al. 2014). According to the data of TMCDD, it is known that the rate of alcohol use at least once among students aged 8-15 in Turkey is 40%. In a study conducted with 2973 students studying at Ege University, it was found that alcohol use at least once in a lifetime was 76,2%, the risk of alcohol addiction was 12,1% and heavy drinking was 37,2% (Aldemir et al. 2018). In the Turkish Republic of Northern Cyprus (TRNC), alcohol use among 3rd grade secondary school students was found to be 61.96% in 1999. Again, in a study conducted among 5th grade primary school students in TRNC in 2015, it was seen that the rate of alcohol use at least once in their lifetime was 23.5% (Çakıcı et al. 2017). In the current studies conducted in the TRNC in 2019, it was observed that this rate decreased in both groups and the use of illegal substances increased. It has been determined that smoking-alcohol use and being drunk are risk factors for addiction (Çakıcı et al. 2019). At this point, it is possible to say that the use of cigarettes and alcohol carries the risk of being a transition substance to the use of illegal psychoactive substances. In the United States, it was found that the lifetime prevalence of alcohol use problems among youth is 8% (Merikangas and McClair 2012). In another recent study conducted in the USA, it was reported that the rate of 11-year-old students who tried alcohol at least once in their lifetime was 25.7%. In the study investigating the use of alcohol and other drugs in schools in Europe, the frequency of alcohol and other drug use among students in the last 30 days was questioned and it was seen that the frequency of use varies between 50-70% in many countries (The European School Survey Project on Alcohol and Other Drugs [ESPAD] 2016). According to the WHO, the current drinking prevalence is highest in Europe (59.9%), followed by America (54.1%) (WHO 2022). A study on alcohol consumption in Russia examined the prevalence of alcohol use and the overall consumption level to see whether the overall decline in consumption was statistically significant between 2006 and 2018 and it found that the frequency of alcohol use in the last 30 days decreased from 72.2% to 58.1% in women and from 84.3% to 69.5% in men (Radaev and Roshchina 2021). Bryant and Kim (2013), in several studies regarding alcohol consumption, have found that such a change in lifestyle increases the risk of excessive alcohol consumption among immigrants and that a higher cultural adaption level in immigrants predicts the likelihood of greater alcohol consumption. They have argued that the reason for the increase in alcohol consumption among immigrants is that immigrants consume alcohol to gain social acceptance and use it as a social ticket. In a study conducted with Korean adolescents, it was found that smoking, alcohol use and early initiation of sexual activity in adolescents are significantly associated with the socioeconomic status of adolescents. The early onset of prevalence of smoking, alcohol use and engaging in sexual activity risk behaviors (≤12 years) were found to be 4.8% 10% and 1.4%, respectively. The prevalence of early initiation of these risk behaviors was observed to be lower compared to Western Countries (Valencia et al. 2019). According to reports of the World Health Organization, per capita, alcohol consumption is lowest among children younger than 15 years in Muslim-majority counties, including Iran (less than 2.5 liters of pure alcohol per year). According to a modeling study carried out, per capita alcohol consumption remains lowest in Middle East and North African countries. The reason for this may be the fact that people living in the Middle East and North Africa are Muslims; therefore, avoid alcohol consumption (Manthey et al. 2019). In studies investigating the impact of the COVID-19 pandemic on youth alcohol use, the rate of increase during the onset of the pandemic was found to be lower than before the pandemic (Gohari et al. 2022). Increased social isolation was thought to be the likely cause of the decline in alcohol use (Dumas et al. 2020).
Clinical Presentation:
The addiction cycle proceeds as follows; it emerges as a process that progresses in the form of experimenting with the thought that nothing will happen once, using it regularly, using it every day and addiction (Gürsel et al. 2004). Substance use purposes manifest themselves in three ways and these are “experimental use” (to discover themselves); “social use” (to be approved by family and friends); “characterological/operational use” (to escape from loneliness, alienation, emptiness, and other problems). Children and adolescents, who experience alcohol for the first time, enjoy the mood change and reach a sense of relief in the short-term with the removal of intractable emotions and start to need and use this substance regularly. Alcohol use, which increases with the feeling of comfort in the short-term, begins to show itself in the long-term with the state of addiction and its difficulties. The addicted youth becomes now dependent on alcohol to eliminate withdrawal symptoms and feel normal, experiences significant difficulties in academic life and faces with high rates of mental and social problems (Dilbaz et al. 2019). Research indicates that the primary influencer in initiating alcohol addiction and recovering from it is the social circle, with family ranking as the third most crucial factor. A study highlights that women tend to turn to alcohol due to issues related to self-esteem, while men often resort to it as a coping mechanism for depression and anxiety. Insights from a research study involving 100 participants with alcohol addiction who participated in Alcoholics Anonymous meetings reveal that individuals maintaining sobriety for over two years and having strong perceived social support tend to sustain longer alcohol-free lives. They exhibit elevated self-esteem and employ problem-focused coping strategies more effectively (Yücel et al., 2020). Moreover, a clinical observational study examined alcohol craving in abstinent individuals and those recovering from alcohol dependence and withdrawal syndrome. According to clinical observation, these patients periodically show symptoms of asthenia, anorexia, anxiety, irritability, aggression, insomnia, hyperactivity, and pleasant sensation seeking, boredom and depression. Alcohol use disorder is characterized by multifactorial pathogenesis with various clinical manifestations such as mental and behavioral disorders, internal medicine diseases, and neurological or psychiatric problems. Alcohol use is supported not only by operant conditioning processes, but also by the association of classical conditioning processes, that is, stimuli that were previously neutral in drinking situations with the generation and induction of alcohol cravings that lead to habitual use, the frequent association of alcohol with pleasant situations, mood elevation, disinhibition, and the suppression of the negative effects (Batra et al. 2016). Alcohol addiction has a high comorbidity with many other psychological disorders, including depressive disorders, anxiety disorders, attention-deficit-hyperactivity disorder, and personality disorders (non-social or avoidant personality disorder) including emotional instability and alcohol-induced aggression (Heinz et al. 2011). In a study, they listed psychiatric problems accompanying alcohol use as bipolar i (46%), bipolar type ii (39%), schizophrenia (34%), personality disorder (29%), and major depressive disorder (17%) (Arıkan 2011). There are some symptoms of alcohol use in children, such as a decrease in school performance, changes in the friend environment, avoidance of contact with the environment, introversion, sudden changes in mood, not giving importance to personal care, avoiding plans, trembling in the hands and insomnia. The diagnosis of substance use disorder in children and adolescents is evaluated according to the DSM-V diagnostic criteria used for adults (Eker et al. 2013). Furthermore, there are many psychometric assessment scales used in both clinical and research settings, especially for children and adolescents to be diagnosed with alcohol and substance addiction
Etiology:

1. Biological Factors:There are studies showing that alcohol addiction is associated with genetic predisposition. In a meta-analysis study of twins and adopted children, it was found that approximately 50% of alcohol use disorders are inherited (Verhulst et al. 2015). Therefore, alcohol use common in the family potentially creates a tendency towards alcohol for the child. In a study examining whether the children of alcohol-dependent fathers differ from those of non-alcoholic fathers in terms of both behavioral and cognitive functions, and psychopathology, it was found that children of alcohol-dependent fathers receive psychiatric diagnoses at a higher rate than children of nonalcoholic fathers (Kültür et al. 2006). In a study conducted in Finland, alcohol use problems and mental and behavioral problems of children who were born in 1997 and whose parents were alcohol-dependent were examined. Mental or behavioral problems were observed in 15.4% of boys and 0.6% of girls who were followed up for 15 years. In addition, it has been observed that the alcohol addiction of the mother or father increases the risk of alcohol addiction of the child (Raitasalo et al. 2019). In a study conducted on 2800 adolescents in the 14- 15 age group in Australia, it was examined how their parents’ being heavy drinkers influenced children. It was found that the father’s drinking is more strongly associated with the periodic heavy drinking of the female adolescent living in the same house and that the heavy drinking of the mother does not make a difference in terms of gender on the girls and boys, and the heavy drinking of the parents is an important risk factor for the adolescent (Homel, & Warren 2019). According to the findings of a recent study, the relationship between the frequency of alcohol use by mothers and adolescent excessive drinking is stronger for girls and the relationship between the frequency of alcohol use by fathers and adolescent excessive drinking is stronger for boys (Espinosa-Hernandez et al. 2022). In a longitudinal study, data from children followed from infancy to age 14 found that boys and girls who experience precocious puberty have a higher risk of drinking alcohol during adolescence, compared to their peers who experience puberty on time (Bucci et al. 2021). Alcohol involvement sometimes starts but more often escalates between 16 and 20 years of age, when youths are also experiencing dramatic physical, emotional, and social changes. Specifically, a variety of forms of hazardous drinking emerge during middle to late adolescence and, for many youths, these problematic patterns of drinking continue to escalate through 18 to 20 years of age, the period of greatest risk for the onset of an alcohol use disorder (Brown et al. 2008). In a study, the results of toxicological analysis of children and adolescents in Izmir in 2015-2016 were retrospectively analyzed and it was aimed to determine the substance use profile of children and adolescents. As a result of the study, alcohol and/or drugs were detected in 13.2% of the cases, with cannabis (33%), amphetamine-type stimulants (15%), polysubstance use (15%) and alcohol (13%) being the most common among the positive cases. While cannabis, polysubstance use and amphetaminetype stimulants were most common in males, ethyl alcohol, amphetamine-type stimulants and benzodiazepines were most common in females. In 2016, a significant increase was observed in the rate of substance use compared to the previous year (Aslan et al. 2022). In a study evaluating trends and gender differences in alcohol and substance use behavior in young people who applied to an addiction center in Istanbul for treatment, the substance use tendencies of 2755 children between 2011 and 2014 were examined. As a result of the study, there was an increase in the total number of young people admitted for substance use in 2014 (31.4% in 2011, 68.6% in 2014). From 2011 to 2014, there was a significant increase in polysubstance use and in the number of girls applying for treatment. In 2014, there was an increase in the use of alcohol, ecstasy, synthetic cannabinoids and heroin, and a decrease in the use of volatile drugs, cannabis, and prescription drugs (Doksat et al. 2016).

Sociocultural Factors:
Familial and environmental factors play an important role in sociocultural variables. A child whose parents smoke is four times more likely to smoke than a child whose parents do not smoke. It has been found that the presence of psychiatric, marital, or legal problems in the family and the absence of social support are associated with the increase in substance use (Cloninger et al. 1995). In the research carried out, it was found that the substance use of adolescents whose peers use substances is increasing (Jacob and Johnson 1997; Karaaziz and Keskindağ 2016). However, it is reported that the prevalence of substance use is higher in children and adolescents who are homeless (Kaya Kılıç and Aslantürk 2019). The media has also a significant impact on substance use (Oktuğ Zengin 2013). In a study examining the effect of advertisements on alcohol consumption in 17 countries between 1970 and 1983, it was found that there was a 16% decrease in alcohol consumption in countries that banned alcohol advertisements compared to those that did not (Saffer 1991). In addition to all these, the expectation effect creates a serious risk factor for alcohol addiction in children and adolescents. The existence of thoughts that alcohol facilitates social relations causes the person to start using alcohol more easily and earlier. Moreover, it is observed that curiosity, wannabe, and modelling family members who drink are risk factors for starting alcohol in children and adolescents (Karaaslan 2017). In a study conducted with Danish adolescents, the relationship between sociocultural and school-related risk factors and alcohol consumption of 1453 15-year-old students was examined. Whereas school-related risk factors were effective in the alcohol consumption of adolescent girls with low socioeconomic status, dislike for a school affected the drinking behavior of adolescent girls with high socioeconomic status. It was found that inadequate parental support and dislike for school are associated with drinking behavior in male adolescents with low socioeconomic status while difficulty in decision-making skills is associated with drinking behavior in adolescents with high socioeconomic status (Anette et al. 2007). In a study conducted with 7037 university students in Brazil, risky behaviors while driving on low alcohol were examined and it was found that age group, illegal substance use, gender, marital status, and employment status affect risk-taking behavior in traffic (Gonçalves et al. 2012). In a study involving 671084 adolescents from 33 countries, including North America and European countries, the alcohol consumption of adolescents and the alcohol policies of the countries they live in were examined. Along with the fact that limiting the affordability of alcohol is the most effective policy, it has been found that the adolescent’s perception of the low or high socioeconomic level of her or his family is a factor that increases alcohol consumption (Leal-López et al. 2020). Although many sociocultural variables are involved in adolescent alcohol use, most studies focus on school and family risk factors. In a study conducted with individuals who have immigrated to Izmir, it has been found that the rate of starting substance use is higher than the rate of starting substance use of individuals who have not immigrated due to the feelings of anxiety, loneliness and alienation arising from exposure to negative conditions such as unemployment, working conditions, the number of children and siblings and difficulty in adapting to the city and culture (Şaşman Kaylı et al. 2016). In a study comparing alcohol and substance use of English and French adolescents’ 15-16 age groups were compared. When the variables predicting alcohol and substance use in adolescents were examined, it was found that the parents’ knowledge of their children’s whereabouts on Saturday evenings is the strongest factor and that while the family structure is important in both countries, paternity relationships are very important among French students (Ledoux et al. 2002). In a study conducted on one of the social networking sites, Facebook 189 adolescents were asked to review premade profile pages for their older peers with and without alcohol use. Craving, attitudes towards alcohol use and how images affect perceived vulnerability were investigated. As a result of the research, it was found that adolescents who perceive their alcohol use as normative are at higher risk in terms of cognitions that predict alcohol use (Litt and Stock 2011). In a study examining the effect of visual media on alcohol and cigarette use, it was found that the participants who watched the movies estimated that the alcohol and cigarette use took longer than they usually do and that it created an increasing effect on craving (Yedekçi 2017). In a study conducted with Ugandan youth, a positive correlation was found between the positive perception of alcohol advertisements and alcohol consumption in society, and alcohol consumption. In terms of factors that may exacerbate the link between the positive perception of alcohol advertisements in the society and the intention to drink alcohol, it was also found that only a non-drinking peer group is protective and buffers against the intention to drink (Swahn et al. 2022).