Screening Children

Screening Children

The American Academy of Pediatricians (AAP) has recommended that doctors screen all of their young patients for alcohol use starting in middle school, the Wausau Daily Herald reported May 15. The AAP Committee on Substance Abuse released a revised policy statement on youth alcohol use on May 1. "A remarkable amount of brain development is still occurring for young people through their 20s," said report lead author Patricia Kokotailo of the University of Wisconsin School of Medicine and Public Health. "This policy statement provides better evidence about how alcohol affects the brains of young people and why it is important to screen children."

Those worried about problems of drug abuse and dependency should approve of this policy. So should those who know that the most effective public health programs focus on prevention and detection, not simply on developing after-the-fact cures.

Alcohol is, without a doubt, the most dangerous drug in society. Long-term alcohol-related diseases cause over 100,000 deaths a year in addition to several thousand acute intoxication deaths, most of these in young people. Over 15,000 die each year in car wrecks involving drivers who have been drinking. Alcohol is the only drug the consumption of which has been causally connected to violent crimes. Domestic violence is the most prominent of these, but homicides and aggravated assaults are also common. Alcohol abuse is also responsible for a significant part of lost productivity (including absenteeism) and workplace injuries.

What should screening accomplish? About two-thirds of the population consumes some alcohol and around ten to fifteen per cent of those develop a dependency on it. Those with alcohol dependencies display most of the abusive behavior, causing the problems described.

Early alcohol use is one of the factors with the highest correlation with later dependencies and abusive behavior. Screening will provide opportunities for intervention and possibly prevent later abuse and dependency. It will also allow long-term longitudinal studies of alcohol use for the first time, creating the data to determine the ways in which alcohol use develops in the individual.

One side effect of this screening may prove almost as worthwhile as the direct benefits. It should also provide a means for studying, predicting, and intervening in the abusive and dependent use of other drugs.

Early use of alcohol has been shown to be antecedent to excessive use of other drugs. Virtually all of those who use other drugs in a destructive fashion first began using alcohol by the age of ten or twelve. Although marijuana is often accused of being a gateway drug – a claim thoroughly rebutted in the 1995 Institute of Medicine report on medical marijuana -- the correlation of early use of alcohol with later abuse of other drugs is much higher than is that of any other activity, significantly higher than that of marijuana use for instance. Identifying, and intervening with, those children using alcohol by their middle-school years should greatly decrease the number of those abusing other drugs as these children mature.

While the number of users of other drugs is miniscule compared to alcohol, it is high enough to raise legitimate social concerns. Excluding tobacco and marijuana, less than ten per cent of the population uses drugs other than alcohol. Of those users, like alcohol users, only around ten per cent develop dependencies or use abusively.

Tobacco use has decreased from a majority of the adult population in the 1950s to around twenty per cent today. However, a much higher percentage – possibly as high as twenty per cent – of the tobacco users become dependent, and diseases causally related to tobacco result in over 400,000 deaths annually.

Many more people use marijuana than use any other illegal drug. Among the young, rates of marijuana use may approach those of tobacco. However, marijuana users develop dependencies at a much lower rate than the rates for other drugs, and those dependencies are much weaker and easily broken. The best estimate is that only about three per cent of marijuana users ever show any signs of dependent or habitual use. Marijuana use has few, if any, health consequences for the user and marijuana has not been shown to have a causal relation to any consequential social harm.

Surprisingly little is known about drug dependency from a medical standpoint. So far debate still rages about whether it is a disease, a disorder, or merely a cluster of symptoms that may evidence other underlying diseases or disorders. Only a few rules of thumb have been agreed on. As already mentioned, early alcohol use is an almost universal precursor. Most of those dependent on drugs, including alcohol, experienced physical or sexual abuse as children. A large majority come from broken or dysfunctional families. Some genetic component or components are probably involved. Attempts at rehabilitation (except in the case of marijuana) are unsuccessful, with the best ones failing at a rate of over eighty percent, a rate that has not changed measurably since first determined among heroin addicts at the Federal Narcotics Farms in the 1930s.

Wide-spread screening of middle school children for alcohol use becomes important for several reasons. It identifies those likely to develop problems with all drugs (including alcohol) before dependencies and patterns of abusive use develop. It provides opportunities to intervene and prevent those dependencies from developing in the first place and to develop effective means for that intervention. But the most important benefit is that it will provide the data from large numbers of longitudinal studies that will eventually provide the scientific and medical knowledge necessary to prevent dependency and abuse problems in the first place.