What is the recommended approach for screening and treating alcohol use disorder in adolescents?

Screening and Treatment for Alcohol Use Disorder in Adolescents

All adolescents aged 12-21 should be universally screened for alcohol use at annual visits and acute care visits as needed, using validated age-appropriate screening tools such as CRAFFT, AUDIT, or S2BI, followed by brief intervention and referral to treatment when indicated. 1

Screening Algorithm

Step 1: Initial Screening

Use one of these validated tools:

1. CRAFFT - Highly recommended by both NIAAA and AAP, with high sensitivity (92%) and specificity (64%), short administration time, and no gender bias 1, 2

2. AUDIT/AUDIT-C - The AUDIT-C (3 questions) is validated for ages 12-19 and identifies quantity/frequency of alcohol consumption 1

3. S2BI (Screening to Brief Intervention) - Uses single frequency-of-use questions per substance, highly sensitive and specific at discerning risk categories 1

4. NIAAA Two-Question Screen - Age-specific questions about personal alcohol use and friends' use, appropriate for ages 9-18 1

Step 2: Ensure Confidentiality

• Create a private space by asking parents/guardians to leave the room during part of the examination 1
• Explain confidentiality and its limits to the adolescent (e.g., disclosure required if immediate risk to self or others) 1

Step 3: Secondary Assessment (for positive screens)

For adolescents with positive initial screens, conduct more detailed assessment using:

• Full AUDIT (10-item version)
• BSTAD (Brief Screener for Tobacco, Alcohol, and Other Drugs)
• Comprehensive psychosocial assessment using HEEADSSS or SSHADESS frameworks 1

Intervention Based on Risk Level

Low Risk (no use or minimal use)

• Positive reinforcement for healthy choices
• Brief education about risks of alcohol use for adolescent brain development 3
• Clear messaging against use of alcohol before age 21 1

Moderate Risk (risky use without disorder)

• Brief intervention using FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) 4
• 5-15 minute motivational interviewing session focusing on:
  • Providing feedback about risks
  • Emphasizing personal responsibility
  • Offering clear advice
  • Discussing alternatives to drinking
  • Expressing empathy
  • Building self-efficacy 4, 5
• Schedule follow-up within 1-3 months

High Risk (alcohol use disorder symptoms)

• More intensive brief intervention using motivational interviewing techniques
• Multiple sessions may be required
• Focus on harm reduction strategies (reducing driving/riding while intoxicated, unplanned sex, alcohol-related injuries) 5
• Consider referral to specialized treatment for further assessment 1

Severe Risk (alcohol dependence)

• Immediate referral to specialized treatment programs 4
• Consider breaking confidentiality if acute safety concerns exist 3
• Involve family in treatment planning when appropriate

Treatment Considerations

Behavioral Approaches

• Cognitive behavioral therapy
• Family therapy
• Group therapy
• Individual psychotherapy 4

Pharmacological Options (for older adolescents)

• Limited evidence for pharmacotherapy in adolescents
• For older adolescents (near 18), consider:
  • Baclofen for achieving abstinence 4
  • Avoid naltrexone in patients with liver disease 4

Implementation Challenges and Solutions

Barriers to Screening

• Time constraints
• Lack of familiarity with screening tools
• Uncertainty about managing positive results
• Limited treatment resources 1

Solutions

• Integrate screening into electronic health records
• Use computer/tablet-based self-administered screening (takes ~49 seconds vs. 74 seconds for physician-administered) 5
• Develop clear protocols for responding to positive screens
• Maintain updated referral resources for specialized treatment

Special Considerations

Vulnerable Populations

• Homeless youth, LGBTQ+ adolescents, and those with comorbid mental health conditions are at higher risk for alcohol misuse 1
• More intensive screening and follow-up may be needed for these groups

Environmental Factors

• Assess family attitudes toward alcohol use
• Parental disapproval of underage drinking is protective 1
• Close alliance with family can reduce risk of alcohol misuse 1

Electronic screening and brief intervention shows promise and should be considered as technology-based approaches may be particularly appealing to adolescents 6. The ultimate goal is to prevent or reduce alcohol-related harm and promote healthy development during this critical period of brain maturation.