CCPR: Welcome, Dr. Yule. How prevalent is teen drinking?
Dr. Yule: While there has been a decline in alcohol use since the 1980s, alcohol remains the substance most widely used by adolescents. When we look at past-month use by 12th graders in 2019, 5.7% had smoked cigarettes, 22.3% had used cannabis, and 29.3% had used alcohol (www.niaaa.nih.gov/publications/brochures-and-fact-sheets/underage-drinking). It’s not just that they’re drinking a beer or two; 17.5% of 12th graders had been drunk in the past month.

CCPR: Are they aiming to get drunk?
Dr. Yule: Yes. They may not drink as frequently as some adults, but when they do drink, they’re drinking very heavily.

CCPR: Talk to us about the mortality risk associated with youth drinking.
Dr. Yule: The consequences of drinking are striking. Between 2006 and 2010, alcohol was a factor in the deaths of 4300 young people under the age of 21. It’s frequently a factor in motor vehicle crashes and homicides, alcohol overdoses, falls, burns, and drownings. Alcohol is also often involved in completed suicides in adolescents. And kids die from alcohol overdoses—the term alcohol overdose is an important shift in language from alcohol poisoning. To me, “alcohol poisoning” makes it seem accidental or out of an individual’s control. With increased attention to the opioid epidemic, the general public seems to have a greater awareness and understanding that an overdose is dangerous. I think it is helpful to use the same terminology when discussing alcohol.

CCPR: And what about morbidity that falls short of mortality?
Dr. Yule: Alcohol impairs judgment, increasing the risk of physical and sexual assault. I hear so many stories of sexual assaults on young women who’ve been intoxicated, and physical fights or violence among young men who are intoxicated. It is also important to recognize that a blackout is not a trivial thing—it is a significant neurologic event.

CCPR: What is the risk that kids will develop an alcohol use disorder (AUD)?
Dr. Yule: According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), people who start drinking before the age of 15 are four times more likely to meet the criteria for alcohol dependence at some point in their life (www.niaaa.nih.gov/publications/brochures-and-fact-sheets/underage-drinking). DSM-IV-TR’s “alcohol abuse” translates to a mild substance use disorder (SUD) in the DSM-5, and DSM-IV-TR’s “alcohol dependence” is generally equivalent to a moderate or severe SUD in the DSM-5.

CCPR: What current research is there that compels child psychiatrists to intervene?
Dr. Yule: Teens are at high risk for serious consequences associated with heavy alcohol use. Early onset means kids are at even higher risk for an SUD later in life. Kids with psychiatric disorders are at higher risk for an SUD relative to kids who don’t have psychiatric disorders (Groenman AP et al, J Am Acad Child Adolesc Psychiatry 2017;56(7):556–569).

CCPR: What should child psychiatrists be doing?
Dr. Yule: We may not be able to change the fact that the frontal lobe of an adolescent’s brain is still developing and they are more likely to take risks. However, we can be talking with children, adolescents, and their parents about risks associated with alcohol use in adolescence. Other adults in an adolescent’s life, like high school teachers or pediatricians, often have less contact with parents and/or less time during an appointment to address these issues. As child psychiatrists, we are well positioned to screen and provide preventative messages about the risks related to alcohol use, especially if kids are transitioning to college. And since the youth we work with are at elevated risk for an AUD, it’s our job to address this. We have often been working with children since they were younger through adolescence and have developed a strong relationship with their family.

CCPR: Talk to us about specific screens.
Dr. Yule: The CRAFFT (www.crafft.org) is a great tool to assess for substance use and problems related to substance use. But it is hard in the moment to remember that CRAFFT stands for Car Relax Alone Forget Friends Trouble.

CCPR: Is there something better than the CRAFFT?
Dr. Yule: NIAAA developed two screening questions that I find easy to remember, and they’re tailored to the child’s developmental age, whether 9 to 11 years old, 11 to 14, or 14 to 18 (www.niaaa.nih.gov/alcohols-effects-health/professional-education-materials/alcohol-screening-and-brief-intervention-youth-practitioners-guide). I like this screener because it sends the message to screen early and often and gives us language that we can use with a 9- to 11-year-old, since they are at a different stage of development than a 14- to 18-year-old. You might see the 9- to 11-year-old with the parents in the room, and it’s OK to ask these questions. Ideally, we screen without parents in the room to get the most open and valid answer, but if the parents are present, you’re sending a message that alcohol use in a child or an adolescent is not the norm. The media portrays heavy substance use as a rite of passage of adolescence, and it’s not.

CCPR: With middle schoolers, I ask, “Do you know kids at school who have already started fooling around with alcohol and other stuff, maybe cigarettes?” If they say yes, I say, “Well, how much have you—not ‘if,’ but how much have you seen that stuff?” And they will or they won’t tell me.
Dr. Yule: That’s how the screener works: For middle schoolers, ask about friends’ use, then their use: “Do any of your friends drink? How about you? Have you ever had more than a few sips?” For adolescents, it starts with them and then moves to friends. It is also important to ask adolescents how they are accessing alcohol, since kids use what they access. If you’re able to access alcohol easily, you’re more vulnerable to use alcohol early and develop an AUD.

CCPR: Do you have any tips for sorting out the extent of a substance problem in teens?
Dr. Yule: When I’m working with kids in clinic, one of my first questions is, how are they functioning? How are they doing in school? Are they attending school? These are markers of how much someone’s struggling, and sometimes you can use them to engage a kid in being more motivated to make a change. When you have an adolescent who’s trying to educate you on how you’re “wrong” and that there’s no problem with their substance use, try to look at functioning and what’s important to them and you can sometimes can find an edge to get them to think a little bit more about it. For instance, they may notice that their athletic performance is impaired when they’re hung over or if they’re really high on marijuana. They may tell you, “I don’t have a problem with alcohol or marijuana,” but then they tell you that they never drink heavily before a game or meet. Why is that? These are the edges where you can try to build some insight or build motivation for change.

CCPR: The diagnostic criteria can be confusing to apply when working with adolescents.
Dr. Yule: Yes. It’s tricky because the diagnostic criteria we use to make the diagnosis of an SUD were designed for adults and don’t match youth very well. But any child, adolescent, or young adult who’s running into serious consequences related to their substance use would benefit from therapies or interventions addressing that use. So, if someone comes to the emergency room after an alcohol overdose, we want to very closely monitor their substance use in the near future, even if they don’t technically meet the criteria for an AUD.

CCPR: How do you approach parents—in particular, those families that traditionally allow youth to have some wine with dinner?
Dr. Yule: With drinking that is part of family culture, it is helpful to think about how half a glass of wine with your family at the table is very different than binge drinking with your friends. And even if alcohol use is part of family culture, if their child is struggling with an AUD, as a family they may need to make the decision not to have alcohol in the house.

CCPR: Teens often listen to peers more than parents.
Dr. Yule: Parents often think that the messages they send don’t matter, because it’s all about the kid’s friends, but authoritative parenting—not authoritarian parenting—is actually very effective in decreasing the risk for heavy alcohol use among adolescents (www.niaaa.nih.gov/publications/brochures-and-fact-sheets/parenting-prevent-childhood-alcohol-use). It involves sending a clear message about the importance of not drinking, avoiding heavy alcohol use. Those things matter and can change an adolescent’s drinking patterns.

CCPR: What words does an authoritative parent use?
Dr. Yule: “Our family’s expectation is that you’re not going to drink before the age of 21, and it’s important to us that you make healthy choices that support your growth and development.” For kids with mental health challenges who say that other kids use and are doing fine, you need to tell them, “You’re working hard and using therapy and medication, and you are at higher risk for making things a lot worse if you use alcohol or other substances.” They might respond “you suck” and slam the door, but they hear the message that this is the expectation and the concern.

CCPR: What about teen activities and how they play into drinking?
Dr. Yule: It can be hard for older adolescents or young adults to find activities or access things that don’t involve substances. Parents should consider making the extra effort to facilitate their child going to the rock climbing gym on a Friday night, instead of going to a friend’s house where the friend’s parents might not be there. It’s not about saying they can’t ever leave the house or have fun anymore. We want to help them connect with other activities that are healthy and fun for them. It often takes quite a bit of problem solving and brainstorming to help them do that.

CCPR: How do you motivate teens to not drink?
Dr. Yule: Motivational interviewing is an important tool. There are a lot of data supporting the use of motivational enhancement therapy paired with cognitive behavioral therapy (CBT) for treating SUDs in adolescents. The challenge is you can’t do CBT with someone who’s not ready to change yet. You have to develop their motivation to be ready to make a change. Try to understand why the teen might want to drink and what might drive them to drink. Then provide them with education about why you’re concerned about their substance use, teach them skills, and provide them with structure.

CCPR: Are there specific disparities in risk and treatment among members of Black, Latinx, and LGBTQIA+ ­communities?
Dr. Yule: Regarding racial and ethnic disparities, access to care is not equal to Caucasians. LGBTQIA+ kids are at higher risk for problems with substance use, and so it’s really important to be screening and keeping an eye on that. The other thing to be aware of is gender differences. While there are equal rates of alcohol use disorders among adolescent boys and girls, boys are more likely to receive treatment than girls for all SUDs, including AUD. Substance use, in particular alcohol use, is an equal-opportunity problem across genders, races, and ethnicities. We need to identify it and support teens’ access to care in all cases.

CCPR: Why don’t girls get treatment? Is their use not as obvious?
Dr. Yule: Unfortunately, there hasn’t been a lot of emphasis on looking at why girls with an SUD are less likely to be in treatment than adolescent boys.

CCPR: Do you have a bottom-line message to share with our readers?
Dr. Yule: The kids we work with are at higher risk than other adolescents, and we really need to be screening and identifying alcohol use and sending a message that this is not a normal part of adolescent development. Child psychiatrists often get discouraged that kids are unlikely to change their substance use. But if they’re drinking heavily or smoking marijuana all day, it’s going to impact how effective your medication and other treatments are, so you can’t ignore it. And they do change. They do get better.

CCPR: Thank you for your time, Dr. Yule.