The Conduct Disorder–Alcohol Link: Implications for Prevention Strategies: In Reply

Abstract

Identifying and treating conduct disorder (CD), as Dr Modesto-Lowe suggests, may be one strategy for preventing early alcohol initiation by addressing the link between CD and alcohol use.1–3 However, because the prevalence of CD is low (1%–4% of 9- to 17-year-olds)1 relative to early alcohol use, efforts that focus strictly on any single diagnosis will likely miss the majority of youth who are at risk. An estimated 34% of ninth-graders in the United States have reported drinking before 13 years of age4 (35% of the seventh-graders in our study).5 Early alcohol use is clearly a common but preventable problem. More specifically, early alcohol use (defined differently across studies) is associated with risky behaviors and adverse health outcomes.5–9 In our most recent study, early alcohol use initiation was strongly associated with suicide attempts.5 These studies, as well as others, provide evidence that supports the need for increased implementation, enforcement, and funding for evidence-based strategies for preventing and delaying early alcohol use.Several population-based intervention strategies, recommended by the Institute of Medicine, are readily available.10 These evidence-based interventions include increasing alcohol excise taxes, adequate enforcement of minimum legal drinking age laws, and additional reductions in alcohol marketing to youth. Recommendations by the Centers for Disease Control and Prevention include enhanced enforcement of laws that prohibit the sale of alcohol to minors and restrict alcohol outlet density and zoning.11 However, these interventions have not been fully implemented and supported. With respect to clinical services, the American Academy of Pediatrics recommends that pediatricians advise strongly against the use of alcohol and discuss the hazards of alcohol with patients and their families.12 Unfortunately, there is a dearth of information about evidence-based and cost-effective clinical strategies that prevent and delay alcohol initiation among youth. As a consequence, the US Preventive Services Task Force concluded that there is insufficient evidence to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care.13 Preventing and delaying alcohol use among youth needs to be recognized as an important health priority; it will require parents, clinicians/health care providers, schools, law enforcement, policy makers, retailers, and corporations to work together to resourcefully address this issue. Most importantly, additional primary prevention efforts are needed, preferably at the elementary school level, to ensure that we reach our children in time.