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The issue and prevalence of young people (under 18) drinking alcohol in recent years has become a matter of increasing public concern, with current trends ‘amongst the worst in Europe’ (Gunning et al 2010). Drinking during childhood, particularly heavy drinking is associated with a range of problems including physical and mental health problems, alcohol-related accidents, violence, and anti-social behaviour (Gunning et al 2010). Young bodies are still growing, and alcohol can harm their development; regular drinking can lead to cancer, liver disease, and heart disorders in later life (Bateman 2011). Deaths from liver disease have risen vastly in the 25-34 age groups over the last 10 years; thought to be a consequence of increased drinking starting from an earlier age (Thomson et al 2008).
In England in 2007/2008, ‘more than 7600 children under 17 were admitted to hospital as a result of drinking alcohol’ (Gunning et al 2010). It is believed that young people who start drinking alcohol at an early age, drink more, and drink more often than those who delay the onset of drinking until they are older. They are also more likely to develop alcohol abuse/dependence problems in adolescence and adulthood; dependence is also likely to occur from a much younger age (Gunning et al 2010).
A recent survey carried out in 2010 by the National Centre for Social Research (NatCen) to determine the ‘smoking, drinking and drug use of secondary school pupils aged 11 to 15’; (7,674 pupils in 247 schools through the use of questionnaires) interestingly found that the proportion of young people who ‘have drunk alcohol’ had decreased in comparison with earlier findings from 28 per cent in 2001 to 21 per cent in 2006 (DH 2008). However it must be stated that although there had been a marked decrease in the number of ‘young people’ who had ‘drunk alcohol’; many of the 11 to 15 year olds who do drink were described to be consuming larger amounts of alcohol, more often, to deliberately ‘get drunk’ (Bateman 2011). This study also conveyed that ‘18% of pupils had drunk alcohol recently, is equivalent to around 540,000 young people’ (Gunning et al 2010); suggesting that more still needs to be done to reverse these prominent trends, as despite the marked ‘decrease’ alcohol misuse in young people is still a serious problem that is affecting the health of the youth today and greatly impacting the wider community, in that alcohol misuse carries a financial burden; and has been estimated to cost nearly £11,000 million each year, in terms of health, social welfare and criminal justice resources (Waller et al 2002).
Collecting this type of data can prove difficult, as drug and alcohol misuse are of a sensitive nature and often individuals do not wish to share this information candidly when questioned. It is particularly difficult to obtain from ‘young people’ (under the age of 18), as this often has to be carried out within a school environment, via questionnaires. The extent to which ‘honest reporting’ occurs is again complex, as young people will often exaggerate to peers, and conceal from parents (Gunning et al 2010). Honesty is not the only factor affecting accuracy of responses in young people, precision of estimates and the recall of the amount of alcohol drunk can also be problematic, given that pupils’ patterns of behaviour between the ages of 11 and 15 may be described as ‘experimental’ and ‘sporadic’ opposed to ‘habitual’ and ‘regular’ (Gunning et al 2010). The National Treatment Agency (NTA) has recently stated that young people’s substance misuse is a relatively ‘new area of academic study’ and so research on effective treatment interventions are inconsistent (NTA 2010).
It is widely acknowledged that alcohol misuse in youth is inextricably linked to a number of factors; including the influence of parents/family, peers, environment, culture and socio-economic status (Templeton et al 2006). According to the Acheson report (1999), dependency upon alcohol is ‘significantly correlated with socio-economic position’, suggesting that the problem is one that is beyond the chemical impact of the substance itself (Nacro Youth Crime Section 1999) coinciding with more recent National statistics and research studies that indicate, ‘as well as sex and age, socio-economic status, ethnicity and geographical area of residence are among the factors linked to levels and patterns of harmful alcohol consumption’ (Waller et al 2002).
In order to target the issue of alcohol misuse within young people, these factors needed to be taken into account and have since been the guide by which policies regarding ‘youth’ and ‘alcohol’ are implemented (DH 2008); therefore providing alcohol education in schools; beginning in the primary phase, well before patterns of regular drinking become established, designed to educate and advise young people on sensible drinking patterns and the dangerous effects it may have upon them (DH 2008). Parents and carers also have a responsibility for whether their children drink, at all, and if they do, how much and how frequently they drink. However, for parents to ‘feel confident’ when talking to their children about alcohol and to empower them to set appropriate boundaries they need guidance from the appropriate services (DH 2008).
In terms of government strategies, to target the issue of alcohol misuse in young people; the coalition’s programme for government published in May 2010, outlines proposals designed to restrict the supply of alcohol to young people, less than 18 years of age, by increasing the control given to councils to close outlets that ‘persistently sell alcohol to children’; and to increase the maximum fines for under-age alcohol sales. Additionally, there will be a ‘ban on the sales of alcohol at below cost price’ (Gunning et al 2010), and a review of alcohol pricing and taxation, both policies expected to have particular impact on ‘young drinkers’ (Gunning et al 2010).
Whilst these policies are currently weighted towards prevention, and adopting preventative strategies, recent statistics suggest that the majority of young people accessing services and interventions have ‘problems with alcohol (37%) and cannabis (53%)’ (NTA 2010), thus suggesting that more needs to be done in the ‘preventative’ stages of alcohol awareness in children; as evidence suggests that the problem is clearly still on-going.
The choice and effectiveness of treatment approaches is typically dependent on a range of factors, such as the individual characteristics of the client for example motivation, family life, social circumstances and environment; in addition to the particular drug or drugs that are being used (Crow & Reeves 1994). The National Treatment Agency (NTA) defines young people’s treatment as: “â€¦ care planned medical, psychosocial or specialist harm reduction interventions aimed at alleviating current harm caused by a young person’s substance misuse” (NTA 2010).
Young people with drug related needs are supported by interventions and services within a ‘four-tiered model’ of drug and alcohol interventions which consists of a General Frontline service delivery for young people and their families (‘first port of call’) (tier 1), open-access services (such as drop in) (tier 2), Drug treatment within the community (‘Shared care’) (tier 3) and residential drug treatment (‘specialist services’) (tier 4) (NTA 2006).
Young drug and alcohol users are believed to differ from adults as they will typically not have used drugs for a prolonged period of time, in order to have developed a dependency to a substance; and as a result affecting the type of treatment generally provided to young people (Frontier Economics 2010). Young people are most likely to require psychosocial, harm reduction and family interventions, opposed to treatment for addiction, which most adults but only a small minority of young people require (Frontier Economics 2010). Psychosocial interventions are known as ‘non-pharmacological’ interventions typically involving ‘structured counselling, motivational enhancement, case management, and care-coordination, psychotherapy, and relapse prevention’. The intention is to encourage behavioural and emotional change, with the support of lifestyle adjustments and the enhancement of coping skills (Frontier economics 2011).
The most common form of therapy offered for substance misuse is some form of counselling; this may take the form of counselling for the drug problem itself, for example thoughts about using, coping strategies for reducing or counselling concerning the surrounding issues that impact on drug use (Lewis et al 2009). Counselling is a flexible approach and can be used to respond to a wide variety of circumstances surrounding misuse (Rounsaville & Carroll 1992). It is possible to identify two general approaches to counselling in use in community drug services, the first being, counselling to tackle the personal problems, underlying drug misuse and the second being that of support and advice to help manage the consequences of drug misuse (Bryant- Jeffries 2001). The vast majority of young people accessing specialist treatment need and receive counselling, sometimes alongside their families to address the underlying causes and consequences of substance misuse. Such ‘psychosocial’ interventions are the most common form of support accessed by under-18s (Frontier Economics 2011).
The National Institute for Health and Clinical Excellence (NICE) coincides with the idea of the counselling theory, and has recommended that offering brief, one-to-one advice on the harmful effects of alcohol use, and how to reduce the risks and find sources of support, is an effective approach for tackling harmful drinking amongst children and young people (NICE 2007).
The most common counselling approach to drug treatment has been cognitive behavioural approaches. The cognitive behavioural approach relies greatly on getting the user to focus on identifying problems and solutions. Cognitive behavioural counselling can be used to promote abstinence or gradual control of drug use, with an emphasis on teaching cognitive and behavioural techniques to resist drug use and related behaviours. The cognitive element of CBT is concerned with getting users to identify the reasons why they misuse, and in particular getting them to identify ‘maladaptive thought patterns’ that lead them to engage in ‘destructive behaviour’ (Jarvis 1995). The behavioural aspect of CBT is about helping people to look at the signs that encourage them to misuse drugs and to help them develop alternative ways of behaving (Jarvis 1995).
NICE has recommended cognitive behavioural therapy (CBT) as an effective intervention for treating young people’s substance misuse (NICE 2007). Providing CBT in a group setting may help young people to role-play and practice coping with ‘high-risk experiences’. The group setting allows young people to share similar problems, develop social skills, model, rehearse and gain peer feedback (NICE 2007). NICE also recommends that brief interventions using motivational interview techniques can be used as one-off interventions, or to facilitate engagement with more structured specialist substance misuse treatment (NICE 2007). Implying that individuals with social networks supportive of drinking will benefit especially from a programme that encourages attendance at AA meetings, because it is ‘the most effective means of eliminating heavy drinking friends and acquaintances from the social network’ (Connors, Tonigan and Miller, 2001).
Although NICE states that a group setting is beneficial in helping young people overcome their alcohol abuse it may in fact be criticised, as young people, especially ‘troubled’ young people may be ‘overwhelmed by group influences’, either in treatment among peers who are also recovering from chemical dependence or else after leaving treatment, in the form of familiar drug-using groups’ (Peele 1987). And so the most successful types of counselling approach used for young people needs to take into account their age, as being amongst adult’s with alcohol issues would not be beneficial to a young person as adults are often described as ‘dependent’ requiring more intensive forms of treatment; young people will have often not reached this stage of ‘dependence’ and so these adult influences may cause further negative impacts on the impressionable ‘young’ (Geldard 2010). Type of personality needs to be taken into account in order to discover which counselling approach would be most appropriate and successful for them as an individual, as some individuals may respond best to a one-to-one approach, being able to fully open up to one person (the counsellor). Whereas some may find it easier to speak within a group setting with peers, learning from others experiences. Counselling is often described as a ‘flexible approach’ (Rounsaville & Carroll, 1992) and therefore can be adopted to meet the needs of individual cases and respond to a wide variety of circumstances surrounding misuse; in addition utilising ‘a flexible approach’ suggests that it allows for the young person to access this service around other commitments such as school, so as to not jeopardise other important aspects and influences within their sphere of activity, flexibility of counselling will also allow for the involvement of the family, with evidence to suggest that family involvement enhances assessment and intervention and increases motivation in treatment (Kaufman, 1992). As young people are often depicted as ‘not yet independent’, family interventions are believed especially important in addressing the basis of their drug and alcohol involvement; (Kaufman, 1992). Also important is helping the family initiate and support the person’s involvement in an appropriate treatment program (Kaufman, 1992). Within individual treatment, compared to group therapy it is believed that much more time can be spent on issues that are unique to the individual involved, a trait that needs to be evident when working with young people (Rounsaville & Carroll 1992).
Motivational interviewing has a number of similarities with cognitive behavioural techniques but has a somewhat different emphasis in that the role of the counsellor is less directive and the responsibility is very much on the client to identify ways of changing (Bryant -Jeffries 2001). It aims, through the counselling ‘relationship’, to engage clients in a process of change and assumes that an individual’s level of motivation can be influenced by the interaction between the client and the therapist. Motivational interviewing assumes that behaviour is a prospect that can be worked on and developed (Bryant – Jeffries 2001).
It is concerned essentially with working with clients to address the confluence of factors that drug misusers consistently feel about changing their behaviour and hopefully encouraging them towards reducing or abstaining (Jarvis 1995). The theoretical basis of this approach is ‘Prochaska and Di Clemente’s transtheoretical model of behaviour change or, as it is most frequently referred to, the ‘stages of change’ model’ (Turnbull 2000). The stage of change model is a ‘social cognition model’; focusing upon readiness to change a potentially destructive form of health behaviour i.e. drug misuse. The model has been applied to other health behaviours such as eating disorders as well as to substance misuse (Wilson & Schlam 2004). It refers to a five or six stage process that people go through in their thoughts about their readiness to change. A study of alcohol users found that the number of clients motivated to change was increased by 77% when motivational interviewing was used (Miller & Sanchez 1999). Motivational interviewing is believed to increases the effectiveness of more extensive psychosocial treatments; often the chosen method of treatment used in young people (NTA 2010).
Motivational interviewing although successful, in adult treatment programmes, may not be the best choice of treatment to use when young people are concerned. As previously stated they are unlikely to have used drugs for a prolonged period of time, to develop dependencies (NTA 2010) and so readiness to change, or to contemplate change may not be something they have even thought about and so a ‘pre-occupation’ with lifelong abstinence in a young population may not only be unnecessary but unrealistic, and may actually encourage ‘regular relapse episodes’ (Peele 1987). Young people require guidance and cannot often think about the consequences of their actions, or the harm they are causing themselves by ‘heavy drinking’ (DfES 2004). It is suggested that therapy should encourage the assumption of values toward work, accomplishment, family, and social institutions that facilitate the ‘maturation process’ (Peele 1987).
Harm Reduction is one of the key public health approaches to drug use in recent years (Riley et al 1999). The harm reduction approach attempts to define and discuss drug use in terms of the harm it can be said to cause, and respectively to look at ways of reducing levels of harm (Riley et al 1999). Harm reduction is a term that defines policies, programmes, services and actions that work to reduce the health and social economic harms to the individual, the family, communities or society that are associated with the use of drugs (Newcomb 1992) ‘without necessarily reducing drug consumption’ (Wodak 2011).
A harm reducing approach to illicit drug use focuses on attracting users to services, in the realisation of the fact that many people who have problems with their drug use are not in touch with services (Wodak 2011). Thus, harm reduction policies and programs are offered to those not willing or able to cease their drug use in the short-run; aiming to make services more accessible to drug users as a first step towards treatment; however, this philosophy remains compatible with an ‘eventual goal of abstention’ (CAHM 2009); Programs requiring abstinence as an ‘immediate goal’ cannot therefore be considered harm reduction (CAHM 2009). A ‘goal sequence’ produced by the Aids and Drug Misuse report (ACMD 1988) provides a clear example of a harm reduction approach to drug use; firstly to discourage sharing, encourage the shift from injecting towards oral use, reduce the overall levels of illicit drug use and finally abstinence (ACMD 1988).
Harm reduction accepts that some use of mind-altering substances is inevitable and that some level of drug use in society is normal (CAHM 2009), for young people and alcohol use this is most definitely the case, as most individuals have their first experiences of alcohol during their early teenage years (Marlatt & Witkiewitz 2002). Based on the recent evidence young people would benefit from prevention programmes aimed to reduce the amount of harm experienced by ‘young drinkers’ this may be seen as a more realistic and effective method for educating individuals about the possible consequences associated with alcohol consumption as opposed to abstinence within this particular age group (Marlatt & Witkiewitz 2002). This suggests that Harm reduction in this sense is the best approach when looking at young people and alcohol misuse, as abstinence may be described as ‘unlikely’ within this age group, acknowledging that most ‘adolescents’ will drink, speaking of the possible harms may be enough to reduce harmful levels of drinking by the young person (Marlatt & Witkiewitz 2002).
The Life Skills Training Program and the Alcohol Misuse Prevention Study (AMPS) in the United States and the School Health and Alcohol Harm Reduction Project (SHAHRP) in Australia are described as large scale intervention studies that have been ‘systematically designed’ and ‘evaluated based’ on a ‘harm reduction philosophy’ (Marlatt & Witkiewitz 2002). The life skills training programmes is said to adopt a cognitive behavioural approach to drug abuse prevention; thus providing education on the effects of drugs, teaching skills for resisting social pressure to use drugs, and promoting the development of self-esteem and social skills (Marlatt & Witkiewitz 2002). Whilst SHAHRP combines a harm reduction philosophy with ‘skills training, alcohol education, and activities designed to encourage positive health behaviour change’ (Marlatt & Witkiewitz 2002); Results from a study comparing an intervention group of students who participated in SHAHRP with a control group over a 3-year period, conveyed that students in SHAHRP had significantly lower levels of alcohol consumption and alcohol related harms (Marlatt & Witkiewitz 2002).
In conclusion, harm reduction seems the best approach for young people and alcohol use, it must be stated that they are not as advanced as adults who misuse alcohol thus require harm reduction leading to abstinence. Young people will often ‘eventually “mature out” of harmful drinking behaviour’ (Marlatt & Witkiewitz 2002) and so harm reduction at such a stage should be an appropriate practice in order to highlight the harmful effects to young people enough so that it reduces overall consumption.
‘We need to be able to convince children that life is worth living and that they are capable, not only of avoiding drugs, but of achieving a worthwhile existence (Peele 1987); presenting them with the values of achievement and positive accomplishments; of friendship and community; of health and self-preservation; of fun and adventure; of responsibility for self and contribution to others; of consciousness and intellectual awareness; and of a commitment to life that goes beyond personal protectiveness and fear’ (Peele 1987).
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