Psychological outpatient follow-up after hospitalization for adolescent acute alcohol intoxication

Psychological outpatient follow-up after hospitalization for adolescent acute alcohol intoxication | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological outpatient follow-up after hospitalization for adolescent acute alcohol intoxication Louise Pigeaud, Loes de Veld, Amy van Blitterswijk, Nico van der Lely This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4667985/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Nov, 2024 Read the published version in European Journal of Pediatrics → Version 1 posted 8 You are reading this latest preprint version Abstract Introduction: Alcohol-related emergency department attendance in adolescents should be considered as a valuable opportunity to address and mitigate future alcohol consumption. Therefore, a paediatric department of a major district hospital in the Netherlands developed an outpatient preventive program targeting adolescents admitted for acute alcohol intoxication. The primary aim of this study is to evaluate how adolescent drinking patterns participating in the preventive program developed over time. Methods This retrospective observational study was conducted in the Reinier de Graaf hospital, Delft, the Netherlands. The outpatient preventive program consists of three main components: an initial intervention, subsequent an extended counselling session and psychological interventions. The alcohol consumption was compared at three time points: before the admission for acute alcohol intoxication(T = 0), 4–6 weeks after hospital admission(T = 1) and 6–12 months after the hospital admission(T = 2). Moreover, sociodemographic variables, adolescent risk-taking behaviour and family and pedagogical factors were included in secondary analysis. Results In total, 310 patients underwent the outpatient preventive program from 2014–2022. Adolescents who experienced an alcohol intoxication hospital admittance exhibited more adolescent risk-taking behaviour compared to the Dutch average. Initially, these adolescents had significantly higher rates of alcohol consumption and drunkenness. Alcohol use decreased significantly in the month following intoxication, even below the Dutch average. Though, 6–12 months later, their alcohol consumption increased but remained statistically lower and involved less binge drinking than the Dutch average. Conclusions The findings of this study demonstrate that a preventive program following acute alcohol intoxication contributes to the reduction of adolescent alcohol use and associated risk-taking behaviours. Acute Alcohol intoxication adolescents alcohol out-patient clinic prevention psychologic follow-up What is Known Earlier studies showed that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in a motivational interviewing intervention compared to standard care. During the follow-up assessment of adolescents with acute alcohol intoxication it is possible to signalize mental disorders and to determine whether the patient requires referral to specialized mental healthcare. What is New : These findings suggest that the preventive program had a short-term impact in reducing alcohol consumption among adolescents with acute alcohol intoxication, as well as a long-term impact in reducing binge-drinking behaviours. The program's success in mitigating binge-drinking behaviours aligns with its goals of promoting safer drinking habits among adolescents. 1. Introduction Increasing numbers of youth in need of emergency medical treatment following acute alcohol intoxication (AAI) have been a major public health concern in Europe ( 1 ). This while alcohol consumption between the age of 10 and 24 is the most important risk factor to disability-adjusted life years ( 2 ). Moreover, AAI can result in a variety of immediate medical complications, including decreased consciousness, hypothermia, electrolyte disturbances, and secondary injuries ( 3 ). Also, alcohol in adolescences impacts brain development and leads to impairment of the brain and cognitive and behavioural dysfunctions ( 4 ). Negative effects on social well-being and behaviour can encompass various aspects, such as susceptibility to peer influence, engaging in risky sexual behaviour, participation in criminal activities and decline in academic achievement ( 5 – 7 ). Common mental health issues in adolescents, including anxiety, depression, impulsive behaviour, feelings of shame or guilt, can serve as a trigger for alcohol consumption or emerge as a consequent of alcohol consumption ( 8 – 10 ). Disadvantaged and especially vulnerable populations have higher rates of alcohol-related hospitalization and even death ( 11 ). Thus, excessive alcohol use in adolescents continues to be a major public health problem ( 12 ) and indicated preventive interventions as early as in adolescence are essential ( 13 , 14 ). Alcohol-related emergency department attendance should be considered as a valuable opportunity to address and mitigate future alcohol consumption ( 1 ). Earlier studies showed that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in a motivational interviewing intervention compared to standard care ( 15 – 17 ). Follow-up assessment of adolescents who were admitted for AAI demonstrate a brief period of reduced alcohol consumption shortly after the incident ( 18 ). Moreover, during the follow-up assessment of adolescents with AAI it is possible to signalize mental disorders and to determine whether the patient requires referral to specialized mental healthcare ( 19 ). In 2007, the paediatric department of a major district hospital in the Netherlands developed an outpatient preventive program targeting adolescents admitted for AAI. The program consists of three main components: an initial intervention, subsequent an extended counselling session and a psychological interventions. The primary aim of this retrospective cohort study is to evaluate how drinking patterns of adolescents participating in the preventive program developed over time. Secondary aims were to evaluate risk factors of adolescent alcohol use: substance use patterns, development, positive family history of substance use disorders, parental awareness and alcohol-specific parental rule-setting. 2. Materials and Methods 2.1. Study design and setting This retrospective observational study was conducted in the Reinier de Graaf hospital, Delft, the Netherlands, whereas prevention-intervention program at the ‘Outpatient Department for Adolescents and Alcohol’ was implemented in 2007. Adolescents < 18 years of age were invited to the follow-up program after emergency department presentation or hospital admission related to alcohol consumption. Alcohol consumption was defined as reported alcohol use or a blood alcohol concentration > 0.0 gram/litre. Both the psychological follow-up program and the paediatric alcohol questionnaire are standard care for this population, no additional intervention was conducted because of this study. The program consists of three main components: an initial intervention, subsequent an extended counselling session and a psychological interventions. The initial intervention is conducted on the next day following admission by a nurse or pedagogical worker and aims to raise awareness. The extended counselling session with the paediatrician occurring 3 to 6 weeks after hospital admission focuses on providing a detailed understanding of how alcohol affects adolescents. The psychological interventions consist of a screening consultation aiming to identify psychological risk factors for the continuation of binge drinking, signalizes mental disorders or psychosocial problems and incorporates motivational interviewing. The final consultation takes place 6 to 12 months after the emergency department attendance. Prior research demonstrated follow-up rates of this out-patient clinic were 91% for the consultation at the paediatrician and 67% at the follow-up by a child psychologist ( 19 ). This specific study targets the adolescents that completed the consultation(s) with the child psychologist. The psychological consultation was split in three different sections: one with the adolescent alone, one with the parents and one with all the family members together. 2.2 Data collection Cases were identified using a search engine in the hospital’s electronic health record (Chipsoft HiX, Amsterdam, the Netherlands). The files were extracted by the hospital’s data warehouse based on the presence of a diagnosis and treatment combination code ‘intake alcohol intoxication’, which is used by the child medical psychology department to register all initial consultations related to alcohol intoxication. This registration format at the psychological outpatient clinic was used from 2014 onwards, and therefore data was extracted since 2014. Demographical data were extracted from the health record. All other data were extracted from the medical records of the semi-structured intake consultation with the child psychologist. Pseudonymized data was stored in an online database (Castor Electronic Data Capture, Ciwit BV, Amsterdam, the Netherlands). 2.3. Variables primary outcomes The primary aim was to determine how alcohol consumption patterns developed during the follow-up program. Alcohol consumption before the admission for AAI (T = 0) was assessed during the intake consultation with the adolescent alone by the child psychologist. Secondly, alcohol consumption 4–6 weeks after hospital admission was assessed during the psychological intake at that time point (T = 1). Lastly, alcohol consumption 6–12 months after the hospital admission was reassessed during the follow-up session at that time point with the child psychologist (T = 2). At T = 0, alcohol consumption before the hospital admission, was assessed by three different outcome measures: lifetime prevalence, lifetime drunkenness, and lifetime binge drinking. At T = 1 and T = 2 assessed last month alcohol use and binge drinking. Lifetime prevalence was assessed by asking whether the adolescent had ever consumed alcohol before the hospital admission. Last month prevalence was assessed by asking if the adolescent consumed alcohol in the last month. Binge drinking was assessed by asking if the adolescent consumed more than 4 (for girls) or more than 5 drinks (for boys) on a single occasion. The results of these specific outcome measures were compared to a reference group from a nationally representative sample based on year of admission, sex and age ( 20 – 25 ). Detailed comparisons are provided in Table A and B in the appendix. The reference group were sourced from the Health Behaviour in School-aged Children (HBSC) and Peilstations research project, who performed validated questionnaires in the Dutch school-going children in the years 2013, 2015, 2017, 2019 and 2021. The values used for matching study to reference group data includes adolescents’ alcohol use parameters ( Lifetime alcohol use, lifetime drunkenness, last month alcohol use, last month binge drinking ) and risk-taking behaviour parameters ( lifetime prevalence smoking, last month smoking, lifetime cannabis use, lifetime sexual intercourse ). Patients in the study were matched based on their year of admission to the same or previous year of the reference group. If exact matching was not possible due to missing information in the reference group, the closest available year was used. 2.4 Measures Sociodemographic variables such as year of hospital admission, age, and sex were extracted from the electronic health records. Adolescent risk-taking behaviour was assessed by the following measures: age at first alcohol use, lifetime prevalence of smoking, lifetime prevalence of substance use and lifetime prevalence of sexual intercourse. Smoking was defined as a categorical variables with three categories: never smoked, stopped smoking, currently smoking. Furthermore, internalizing and externalizing behaviour were assessed using the validated Child Behaviour Checklist (CBCL), which includes thee questionnaires: CBCL/6–18 by parents, the Teacher’s Report Form (TRF) and the Youth Self Report (YSR). The CBCL evaluates two scales: internalizing problems (including anxious/depressed, withdrawn-depressed, and somatic complaints) and externalizing problems (including rule-breaking and aggressive behaviour). This outcome measure is expressed as the percentage of adolescents clinical score on one of the two scales or total score. Family and pedagogical factors were assessed using the semi-structured intake consultation, conducted separately with the adolescent and with the parents. Family history was assessed by determining the prevalence of alcohol or substance use disorder among first, second or third degree family members. Exposure to parental alcohol use was assessed by asking whether the adolescent had ever seen a parent drunk. Alcohol-specific parental rule-setting was assessed during the session with the adolescent alone and during the session with parents alone. Alcohol-specific parental rule-setting was defined as a categorical variable ranging from 1–3: no rules or approval ( 1 ), rules ( 2 ), strict alcohol-specific parental rule-setting/not allowed ( 3 ) and was asked to the parents and adolescent separately. Parental awareness was assessed by comparing the adolescent's self-reported lifetime prevalence and last month prevalence of alcohol use with those reported by the parents. Details are provided in Table 3 . 2.5. Data analyses Descriptive statistics were used to present baseline characteristics of the study population. Categorical variables were expressed as proportions. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Continuous variables were reported as medians with interquartile range (IQR) for non-normally distributed data or as means with standard deviation (SD) for normally distributed data. Development in drinking patterns were assessed using McNemar test for two-category paired data and the Wilcoxon Signed Ranks test for paired ordinal data. Adolescent risk-taking behaviour and alcohol use parameters from the study population were compared to the reference population using a Chi-square goodness of fit test. The significance level for all statistical tests was set at α = 0.05. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (Armonk, NY, USA: IBM Corp). 2.6. Ethics Only patients who gave consent to the Youth and Alcohol department (data ≥ 2018) or to the former the Dutch Paediatric Surveillance System (data < 2017) for data collection for research purposes using the Paediatric alcohol questionnaire were included in this study. The data collection procedure was approved by the Medical Ethics Committee Leiden The Hague Delft, as well as by the research committee and board of directors of the Reinier de Graaf Hospital. 3. Results 3.1. Study population Between 2014 and 2022, a total of 310 adolescents presented to the emergency department due to AAI and subsequently received outpatient follow-up care from a child psychologist. The characteristics of these patients are summarized in Table 1 . The median age of the cohort was 16 years (interquartile range [IQR] 1.0 year), with no patients younger than 11 years. There was a slight female predominance, accounting for 57.7% of the cohort. Table 1 Population characteristics for total sample Sociodemographic characteristics Study population (n = 310) Year of emergency department presentation 2014–2016 160 (51.6%) 2017–2019 98 (31.6%) 2020–2022 52 (16.8%) Sex Female 179 (57.7%) Male 131 (42.3%) Age ≤ 14 years 67 (21.6%) 15 years 83 (26.8%) 16 years 98 (31.6%) 17 years 62 (20.0%) Adolescent risk-taking behaviour Age at first alcohol use 14 (IQR 2) Lifetime prevalence smoking 47.6% Current smoking status Never smoked 52.3% Former smoker 24.0% Current smoker 23.6% Lifetime prevalence cannabis use 38.1% Lifetime prevalence sexual intercourse 25.7% Psychological factors Psychological disorders 43.9% AD(H)D 20.6% Clinical score CBCL 1,2 15.1% Family and pedagogical factors Family history of alcohol- and substance use disorders Positive in first degree 14.2% Positive in second or third degree 31.1% Exposure to parental alcohol use Seen parents drunk 41.5% 1 CBCL = child behaviour checklist 2 Clinical score as a proportion of adolescents without history of psychological disorders 3.1.1 Adolescent risk taking behaviour, Family and pedagogical factors and psychological disorders The median age at first alcohol use was 14.0 years (IQR 2.0 years). The lifetime prevalence of smoking was 47.6%, with 23.6% classified as current smokers at baseline. The lifetime prevalence of cannabis use was 38.1%. Additionally, 25.7% had engaged in sexual intercourse. A first-degree relative with a history of alcohol or substance use disorders was reported by 14.2% of the adolescents, while 31.1% reported a second or third-degree relative with such a history. Exposure to parental drunkenness was noted in 41.5% of cases. A confirmed psychological disorder before the AAI was present in 43.9% of the adolescents, with Attention-deficit/hyperactivity disorder (ADHD) being the most common diagnosis. Among those without a prior psychological disorder, 15.1% had clinical scores on the CBCL indicative of undiagnosed psychological disorders. The chi-square goodness-of-fit test indicated that the lifetime prevalence of smoking was significantly higher in the study population (47.7%) compared to the general Dutch adolescent population (32.1%, X²( 2 ) = 28.7, p < 0.001). The lifetime prevalence of sexual intercourse in the study population (22.1%) did also differ significantly from that of the general Dutch adolescent population (16.3%, X²( 2 ) = 15.5, p < 0.001). Furthermore, the lifetime prevalence of cannabis use was significantly higher in the study population (38.1%) than in the general Dutch adolescent population (20.0%, X²( 2 ) = 54.6, p < 0.001). 3.2 Alcohol use parameters at baseline The alcohol use parameters at baseline are presented in Table 2 . At the initial assessment (t = 0), the majority of adolescents (89.2%) reported alcohol consumption prior to their alcohol-related emergency department visit. In 10.8% of cases, the emergency department visit was due to first-time alcohol use. The lifetime prevalence of alcohol use in the study population (89.2%) was significantly higher compared to the general Dutch adolescent population (65.8%, X²( 2 ) = 72.0, p < 0.001). Additionally, nearly two-thirds of the adolescents (64.7%) had experienced drunkenness at least once. The prevalence of drunkenness was significantly higher in the study population than in the general Dutch adolescent population (41.8%, X²( 2 ) = 64.5, p < 0.001). However, among those who had consumed alcohol prior to the emergency department visit, the prevalence of binge drinking was significantly lower in the study population (49.2%) compared to the general Dutch adolescent population (75.5%, X²( 2 ) = 98.4, p < 0.001). Table 2 Prevalence of alcohol use during the outpatient follow-up program Sex Age Total Male Female ≤ 14 15 16 17 Lifetime prevalence alcohol use 1 T = 0 90.4% 88.3% 77.4% 84.1% 96.8% 96.6% 89.2%* Lifetime prevalence drunkenness T = 0 63.3% 65.7% 46.9% 56.1% 74.2% 80.3% 64.7%* Last month alcohol use T = 1 36.0% 28.1% 18.0% 24.4% 36.6% 46.7% 31.4%* T = 2 49.5% 33.1% 26.7% 41.0% 38.7% 55.1% 40.4%* Last month binge drinking 2 T = 0 52.2% 47.0% 31.3% 40.6% 57.8% 61.4% 49.2%* T = 2 25.5% 25.0% 36.4% 25.0% 18.5% 28.0% 25.3%* 1 Lifetime prevalence of alcohol use before the emergency department presentation for AAI 2 Last month binge drinking as a proportion of last month alcohol use * Significantly different than reference population based on chi-square goodness-of-fit test, p < 0.05 3.3 Alcohol use parameters over time At the intake assessment (t = 1), two-thirds of the adolescents (68.6%) reported not consuming alcohol between the alcohol-related emergency department visit and the intake with the child psychologist. The last month prevalence of alcohol use at t = 1 was significantly lower in the study population (31.4%) than in the general Dutch adolescent population (47.7%, X²( 2 ) = 31.5, p < 0.001). An exact McNemar test was conducted to determine whether the proportion of alcohol abstinence was sustained over time. During the follow-up period, the prevalence of alcohol use in the last month significantly increased to 43.9% at t = 2 (McNemar p = .023). However, the last month prevalence of alcohol use at t = 2 (40.4%) remained significantly lower than that in the general Dutch adolescent population (47.7%, X²( 2 ) = 4.9, p = 0.027). Conversely, the proportion of binge drinking significantly decreased during the outpatient follow-up program (McNemar p < 0.001). Table 3: Alcohol-specific parental rule-setting and parental awareness T=0 T=1 Alcohol-specific parental rule-setting Strict alcohol-specific parental rule-setting 34.6% 67.6% Permission with rule-setting 25.3% 15.2% Approval or absent rule-setting 40.1% 17.2% Perceived rule-setting Rule-setting concordant 71.7% 82.0% Parental awareness Alcohol use concordant 76.7% Child Parent Lifetime prevalence alcohol use 89.2% 70.7% Last month prevalence alcohol use (T=1) 31.4% 23.3% 3.4. Development of alcohol-specific parental rule-setting and parental awareness Prior to the alcohol-related emergency department visit, a substantial proportion of parents either approved of alcohol use or did not have specific rules regarding it (40.1%). One-third of the adolescents (34.6%) reported having strict alcohol-specific parental rules. Following the emergency department visit, 37.6% of parents adopted stricter alcohol-specific rules (Wilcoxon p < 0.001). The outpatient follow-up program led to an increase in the concordance of perceived parental rule-setting, from 71.7–82.0%. Parental awareness of lifetime and last month alcohol use (at t = 1) indicated that parents underestimated their children's alcohol consumption by 23.3%, as shown in Table 3 . 4. Discussion The findings of this study provide significant insights into the drinking patterns and associated risk behaviours among adolescents participating in a preventive program following AAI. Our results indicate that these adolescents exhibit higher rates of lifetime smoking, substance use, and sexual intercourse compared to national averages, suggesting a broader spectrum of risk-taking behaviours associated with early and excessive alcohol use. Moreover, nearly half of the patients had a positive family history of alcohol or substance use disorders among first, second, or third-degree relatives. This aligns with existing literature indicating that a family history of substance use disorders significantly increases the risk of similar behaviours and psychiatric morbidity in offspring​ ( 26 )​. Additionally, exposure to parental drunkenness was reported in 41.5% of cases, which literature suggests increases the risk of adolescent binge drinking by approximately twofold ( 27 ). Nearly half of the adolescents with AAI had a confirmed psychological disorder, with ADHD being the most prevalent. Prior studies have shown a strong association between alcohol exposure and the development of mental disorders, highlighting the need for comprehensive mental health assessments in this population ​( 19 , 28 ). Among patients without a prior diagnosed psychological disorder, 15.1% had clinical scores on CBCL indicative of undiagnosed psychological disorders. It is crucial to identify these new mental health issues and determine the need for referral to specialized care to prevent recurrent hospital admissions and future regular alcohol consumption​ ( 19 ). 4.1 Initial Alcohol Consumption Patterns At baseline, the data revealed that adolescents with AAI had significantly higher instances of alcohol consumption and episodes of drunkenness before the AAI event compared to their peers. This finding is consistent with previous research indicating that early initiation and frequent alcohol use are predictors of more severe drinking problems and related risk behaviours in adolescence and later life​ ( 29 ). However, the prevalence of binge drinking before alcohol intoxication was reported lower than the Dutch average, which is unexpected since binge drinking is associated with alcohol intoxication ( 29 ). On the other hand, all these patients did eventually perform in binge drinking resulting in their alcohol intoxication. 4.2 Post-Intoxication Changes in Drinking Behaviour Following the acute intoxication event, a notable decline in alcohol use was observed in the subsequent month. This reduction could be attributed to the immediate health scare and the subsequent intervention efforts, reflecting the known short-term efficacy of preventive programs in mitigating risky drinking behaviours ( 18 ). Alcohol consumption rose at 6–12 months post-intoxication, compared to 4–6 weeks after AAI, still remaining to be below the Dutch average. Interestingly, binge drinking did not increased proportionately 6–12 months post-intoxication. This suggests a potential shift in drinking patterns towards less intensive drinking sessions. The prevention programs might therefore also be successful in curbing binge drinking behaviours in the long run, which are often associated with acute health risks and long-term negative outcomes ( 29 ). 4.3 Alcohol-specific parental rule-setting and parental awareness Prior to the alcohol-related emergency department presentation, a substantial proportion of parents either approved of alcohol use or did not have specific rules regarding it. Only one-third of the adolescents reported having strict alcohol-specific parental rules. Following the emergency department visit, more than one-third of parents adopted stricter alcohol-specific rules. This is a positive sign since indulgent and negligent parenting styles are associated with a significant increase in prevalence of adolescent binge drinking with 2.51-, and 2.82-fold, respectively ( 27 ). Additionally, adolescents' perception of high parental disapproval of substance use has been prospectively associated with a non-binge drinking trajectory ( 30 ). Parental awareness of lifetime and last-month alcohol use indicated that parents underestimated the presence of their children's alcohol consumption by 23.3%. This, while research shows that parental monitoring and involvement is a protective factor for alcohol use among adolescents ( 31 , 32 ). 4.4 Strengths and limitations This study has several strengths that enhance the reliability and significance of its findings: the longitudinal design allows for the observation of changes in drinking patterns over time, providing a dynamic view of adolescent behaviour post-intervention. This design helps understand the long-term effects and sustainability of the preventive program. Additionally, by evaluating not only alcohol consumption but also related risk behaviours such as smoking, substance use, sexual activity, psychological disorders and family and pedagogical factors, the study offers a holistic understanding of the adolescent risk profile. The comprehensive assessment helps identify correlations and potential causal relationships between different risk behaviours. Furthermore, comparing the study population's behaviours with Dutch national averages contextualizes the findings, highlighting the extent of risk behaviours in the studied group relative to broader trends. This comparison underscores the specific needs of the targeted population. However, a limitation of this study is the lack of a control group of patients with alcohol intoxication who did not receive follow-up care, making it difficult to determine the extent to which the intervention program or the alcohol intoxication itself resulted in the observed decrease in alcohol use. Though, previous studies have shown that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in motivational interviewing interventions compared to standard care ( 15 – 17 ). Moreover, another limitation is the missing information of patients that were lost to follow-up. Prior research demonstrated follow-up rates of this out-patients clinic was 67% at the child psychologist ( 19 ). During the study period, there might have been a shift in the consultation approach with the child psychologist from universal prevention (where every adolescent was referred) to indicated prevention (where referrals were based on initial assessments and concerns). This potential change was because of personnel shortage at the paediatric medical psychology department and the corona pandemic which made live appointments in the hospital more complex. This change introduced heterogeneity into the lost-to-follow-up population and might have led to a selection bias of the study population, potentially resulting in either overestimation or underestimation of the actual problems among participants. The missing outcome parameters of adolescents who did not visit the paediatric psychology department due to continuation of pre-existing mental health care or direct referral to mental health care likely lead to underestimation of the prevalence of major outcomes in the study. Conversely, adolescents who were not referred to the psychology department due to indicated prevention might lead to overestimation of the prevalence of major outcomes among those that visited that paediatric psychology department. The effect of the adolescents that dropped out before visit to the paediatric psychology department could hypothetically influence the study results in both directions, making it challenging to precisely assess the overall impact (either underestimation or overestimation) of the findings. However, it is hypothesized that the true impact lies somewhere between these extremes. In conclusion, these findings suggest that the preventive program had a short-term impact in reducing alcohol consumption among adolescents with acute alcohol intoxication (AAI), as well as a long-term impact in reducing binge-drinking behaviours. The program's success in mitigating binge-drinking behaviours aligns with its goals of promoting safer drinking habits among adolescents. Abbreviations AAI: Acute alcohol intoxication, ADHD: Attention-deficit/hyperactivity disorder, CBCL: Child Behaviour Checklist, HBSC: Health Behaviour in School-aged Children, TRF: Teacher’s Report Form of Child behaviour checklist, YSR: Youth Self Report of Child behaviour checklist. Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Ethics statement: Only patients who gave consent to the Youth and Alcohol department (data ≥ 2018) or to the former the Dutch Paediatric Surveillance System (data < 2017) for data collection for research purposes using the Paediatric alcohol questionnaire were included in this study. The data collection procedure was approved by the Medical Ethics Committee Leiden The Hague Delft, as well as by the research committee and board of directors of the Reinier de Graaf Hospital. Moreover, this study was performed in line with the principles of the Declaration of Helsinki. Author Contributions: All authors contributed to the study conception and design. Data entry was performed by AB. Data preparation and analysis were performed by LP and LdV. The first draft of the manuscript was written by LP and LdV and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgement: We would like to thank all patients who gave consent for data collection using the Paediatric alcohol questionnaire and participated in this study. Moreover, we would like to thank Rita van de Poel, from the Reinier de Graaf hospital’s data warehouse, for her help with the data extraction. Reference Diestelkamp S, Drechsel M, Baldus C, et al. Brief in Person Interventions for Adolescents and Young Adults Following Alcohol-Related Events in Emergency Care: A Systematic Review and European Evidence Synthesis. 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Preventive Medicine Reports 2016;3:83-89. de Veld L, van Hoof JJ, Wolberink IM, et al. The co-occurrence of mental disorders among Dutch adolescents admitted for acute alcohol intoxication. European Journal of Pediatrics 2020. M. Rombouts SvD, T. Scheffers-van Schayck, M. Tuithof, M. Kleinjan, K. Monshouwer. Jeugd en riskant gedrag 2019. https://www.trimbos.nl/aanbod/webwinkel/af1767-jeugd-en-riskant-gedrag-2019/: Trimbos Institute; 2019. Maartje Boer SvD, Margreet de Looze, Simone de Roos, Hilde Brons, Regina van den Eijnden, Karin Monshouwer, willem huijnk, tom ter bogt, wilma vollebergh en gonneke stevens. HBSC 2021 Health and welbeing of school-going children in the Netherlands; 2021. S. van Dorsselaer MT, J. Verdurmen, M. Spit, M. van Laar, K. Monshouwer. Jeugd en riskant gedrag 2015: Netherlands Institute of Mental Health and Addiction; 2015. Margreet de Looze SvD, Simone de Roos,, Jacqueline Verdurmen GS, Rob Gommans,, Marja van Bon-Martens TtB, Wilma Vollebergh. 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Comorbid psychopathology in adolescents and young adults treated for substance use disorders: a review. Eur Child Adolesc Psychiatry 2006;15:319-328. Ryan SA, Kokotailo P, USE COS, et al. Alcohol Use by Youth. Pediatrics 2019;144. Martino SC, Ellickson PL, McCaffrey DF. Multiple trajectories of peer and parental influence and their association with the development of adolescent heavy drinking. Addictive behaviors 2009;34:693-700. Borawski EA, Ievers-Landis CE, Lovegreen LD, et al. Parental monitoring, negotiated unsupervised time, and parental trust: the role of perceived parenting practices in adolescent health risk behaviors. Journal of Adolescent Health 2003;33:60-70. Ryan SM, Jorm AF, Lubman DI. Parenting Factors Associated with Reduced Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies. Australian & New Zealand Journal of Psychiatry 2010;44:774-783. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Nov, 2024 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 20 Sep, 2024 Reviews received at journal 18 Sep, 2024 Reviewers agreed at journal 09 Sep, 2024 Reviewers agreed at journal 09 Sep, 2024 Reviewers invited by journal 09 Jul, 2024 Editor assigned by journal 09 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 01 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4667985","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333074236,"identity":"156f08d8-e48c-4ce4-94db-80cc0dc7a924","order_by":0,"name":"Louise Pigeaud","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYDACZggpByTYYGKMB4jRYoyshQG/FqjGxAaitZizs1988LPNOr2f/+yxRzcYbBK3N/AewKvFspmn2LC3LT135oy8dOMchrTEOQf4EvBqMTjMkybB23Y4d8MNHjPpHIbDiTMYeAwIaUn/+bftcLr9+TMgLf+J0cJ+jBloS4IBQw5IywHCWoB+YZaWOZduOONGXpp0jkGy8QxmAlrM+Y8//PimzFqev//sMemcCjvZGew9hg/wOgzoDCiTB8yFRS4+LewwI3kIKB0Fo2AUjIIRCwCF90Zo/vLvCQAAAABJRU5ErkJggg==","orcid":"","institution":"Erasmus University Rotterdam","correspondingAuthor":true,"prefix":"","firstName":"Louise","middleName":"","lastName":"Pigeaud","suffix":""},{"id":333074237,"identity":"6b2e93bf-b374-4c44-946a-fc866d7164c6","order_by":1,"name":"Loes de Veld","email":"","orcid":"","institution":"Reinier de Graaf Hospital","correspondingAuthor":false,"prefix":"","firstName":"Loes","middleName":"","lastName":"de Veld","suffix":""},{"id":333074238,"identity":"0c1ff996-48dc-4a4c-950e-830ca0b40b95","order_by":2,"name":"Amy van Blitterswijk","email":"","orcid":"","institution":"Reinier de Graaf Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"van","lastName":"Blitterswijk","suffix":""},{"id":333074239,"identity":"46738308-5b4f-4d08-b1eb-b83d882a664e","order_by":3,"name":"Nico van der Lely","email":"","orcid":"","institution":"University Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Nico","middleName":"van der","lastName":"Lely","suffix":""}],"badges":[],"createdAt":"2024-07-01 12:19:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4667985/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4667985/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-024-05856-1","type":"published","date":"2024-11-15T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69286029,"identity":"1ca3e580-82c3-4b57-8025-563068db9adf","added_by":"auto","created_at":"2024-11-18 19:29:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":826100,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4667985/v1/6c1be0b0-715a-4fba-a518-5663628cb0d5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological outpatient follow-up after hospitalization for adolescent acute alcohol intoxication","fulltext":[{"header":"What is Known","content":"\u003cul\u003e\n \u003cli\u003eEarlier studies showed that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in a motivational interviewing intervention compared to standard care.\u003c/li\u003e\n \u003cli\u003eDuring the follow-up assessment of adolescents with acute alcohol intoxication it is possible to signalize mental disorders and to determine whether the patient requires referral to specialized mental healthcare.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is New\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThese findings suggest that the preventive program had a short-term impact in reducing alcohol consumption among adolescents with acute alcohol intoxication, as well as a long-term impact in reducing binge-drinking behaviours.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe program\u0026apos;s success in mitigating binge-drinking behaviours aligns with its goals of promoting safer drinking habits among adolescents.\u003c/li\u003e\n\u003c/ul\u003e\n\n"},{"header":"1. Introduction","content":"\u003cp\u003eIncreasing numbers of youth in need of emergency medical treatment following acute alcohol intoxication (AAI) have been a major public health concern in Europe (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This while alcohol consumption between the age of 10 and 24 is the most important risk factor to disability-adjusted life years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Moreover, AAI can result in a variety of immediate medical complications, including decreased consciousness, hypothermia, electrolyte disturbances, and secondary injuries (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Also, alcohol in adolescences impacts brain development and leads to impairment of the brain and cognitive and behavioural dysfunctions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Negative effects on social well-being and behaviour can encompass various aspects, such as susceptibility to peer influence, engaging in risky sexual behaviour, participation in criminal activities and decline in academic achievement (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCommon mental health issues in adolescents, including anxiety, depression, impulsive behaviour, feelings of shame or guilt, can serve as a trigger for alcohol consumption or emerge as a consequent of alcohol consumption (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Disadvantaged and especially vulnerable populations have higher rates of alcohol-related hospitalization and even death (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Thus, excessive alcohol use in adolescents continues to be a major public health problem (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and indicated preventive interventions as early as in adolescence are essential (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlcohol-related emergency department attendance should be considered as a valuable opportunity to address and mitigate future alcohol consumption (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Earlier studies showed that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in a motivational interviewing intervention compared to standard care (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Follow-up assessment of adolescents who were admitted for AAI demonstrate a brief period of reduced alcohol consumption shortly after the incident (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moreover, during the follow-up assessment of adolescents with AAI it is possible to signalize mental disorders and to determine whether the patient requires referral to specialized mental healthcare (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2007, the paediatric department of a major district hospital in the Netherlands developed an outpatient preventive program targeting adolescents admitted for AAI. The program consists of three main components: an initial intervention, subsequent an extended counselling session and a psychological interventions.\u003c/p\u003e \u003cp\u003eThe primary aim of this retrospective cohort study is to evaluate how drinking patterns of adolescents participating in the preventive program developed over time. Secondary aims were to evaluate risk factors of adolescent alcohol use: substance use patterns, development, positive family history of substance use disorders, parental awareness and alcohol-specific parental rule-setting.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003e2.1. Study design and setting\u003c/h2\u003e\n \u003cp\u003eThis retrospective observational study was conducted in the Reinier de Graaf hospital, Delft, the Netherlands, whereas prevention-intervention program at the \u0026lsquo;Outpatient Department for Adolescents and Alcohol\u0026rsquo; was implemented in 2007. Adolescents\u0026thinsp;\u0026lt;\u0026thinsp;18 years of age were invited to the follow-up program after emergency department presentation or hospital admission related to alcohol consumption. Alcohol consumption was defined as reported alcohol use or a blood alcohol concentration\u0026thinsp;\u0026gt;\u0026thinsp;0.0 gram/litre. Both the psychological follow-up program and the paediatric alcohol questionnaire are standard care for this population, no additional intervention was conducted because of this study.\u003c/p\u003e\n \u003cp\u003eThe program consists of three main components: an initial intervention, subsequent an extended counselling session and a psychological interventions. The initial intervention is conducted on the next day following admission by a nurse or pedagogical worker and aims to raise awareness. The extended counselling session with the paediatrician occurring 3 to 6 weeks after hospital admission focuses on providing a detailed understanding of how alcohol affects adolescents. The psychological interventions consist of a screening consultation aiming to identify psychological risk factors for the continuation of binge drinking, signalizes mental disorders or psychosocial problems and incorporates motivational interviewing. The final consultation takes place 6 to 12 months after the emergency department attendance. Prior research demonstrated follow-up rates of this out-patient clinic were 91% for the consultation at the paediatrician and 67% at the follow-up by a child psychologist (\u003cspan\u003e19\u003c/span\u003e). This specific study targets the adolescents that completed the consultation(s) with the child psychologist. The psychological consultation was split in three different sections: one with the adolescent alone, one with the parents and one with all the family members together.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003e2.2 Data collection\u003c/h2\u003e\n \u003cp\u003eCases were identified using a search engine in the hospital\u0026rsquo;s electronic health record (Chipsoft HiX, Amsterdam, the Netherlands). The files were extracted by the hospital\u0026rsquo;s data warehouse based on the presence of a diagnosis and treatment combination code \u0026lsquo;intake alcohol intoxication\u0026rsquo;, which is used by the child medical psychology department to register all initial consultations related to alcohol intoxication. This registration format at the psychological outpatient clinic was used from 2014 onwards, and therefore data was extracted since 2014. Demographical data were extracted from the health record. All other data were extracted from the medical records of the semi-structured intake consultation with the child psychologist. Pseudonymized data was stored in an online database (Castor Electronic Data Capture, Ciwit BV, Amsterdam, the Netherlands).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003e2.3. Variables primary outcomes\u003c/h2\u003e\n \u003cp\u003eThe primary aim was to determine how alcohol consumption patterns developed during the follow-up program. Alcohol consumption before the admission for AAI (T\u0026thinsp;=\u0026thinsp;0) was assessed during the intake consultation with the adolescent alone by the child psychologist. Secondly, alcohol consumption 4\u0026ndash;6 weeks after hospital admission was assessed during the psychological intake at that time point (T\u0026thinsp;=\u0026thinsp;1). Lastly, alcohol consumption 6\u0026ndash;12 months after the hospital admission was reassessed during the follow-up session at that time point with the child psychologist (T\u0026thinsp;=\u0026thinsp;2).\u003c/p\u003e\n \u003cp\u003eAt T\u0026thinsp;=\u0026thinsp;0, alcohol consumption before the hospital admission, was assessed by three different outcome measures: lifetime prevalence, lifetime drunkenness, and lifetime binge drinking. At T\u0026thinsp;=\u0026thinsp;1 and T\u0026thinsp;=\u0026thinsp;2 assessed last month alcohol use and binge drinking. Lifetime prevalence was assessed by asking whether the adolescent had ever consumed alcohol before the hospital admission. Last month prevalence was assessed by asking if the adolescent consumed alcohol in the last month. Binge drinking was assessed by asking if the adolescent consumed more than 4 (for girls) or more than 5 drinks (for boys) on a single occasion.\u003c/p\u003e\n \u003cp\u003eThe results of these specific outcome measures were compared to a reference group from a nationally representative sample based on year of admission, sex and age (\u003cspan\u003e20\u003c/span\u003e\u0026ndash;\u003cspan\u003e25\u003c/span\u003e). Detailed comparisons are provided in Table A and B in the appendix. The reference group were sourced from the Health Behaviour in School-aged Children (HBSC) and Peilstations research project, who performed validated questionnaires in the Dutch school-going children in the years 2013, 2015, 2017, 2019 and 2021. The values used for matching study to reference group data includes adolescents\u0026rsquo; alcohol use parameters (\u003cem\u003eLifetime alcohol use, lifetime drunkenness, last month alcohol use, last month binge drinking\u003c/em\u003e) and risk-taking behaviour parameters (\u003cem\u003elifetime prevalence smoking, last month smoking, lifetime cannabis use, lifetime sexual intercourse\u003c/em\u003e). Patients in the study were matched based on their year of admission to the same or previous year of the reference group. If exact matching was not possible due to missing information in the reference group, the closest available year was used.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003e2.4 Measures\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eSociodemographic variables\u003c/em\u003e such as year of hospital admission, age, and sex were extracted from the electronic health records.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAdolescent risk-taking behaviour\u003c/em\u003e was assessed by the following measures: age at first alcohol use, lifetime prevalence of smoking, lifetime prevalence of substance use and lifetime prevalence of sexual intercourse. Smoking was defined as a categorical variables with three categories: never smoked, stopped smoking, currently smoking. Furthermore, internalizing and externalizing behaviour were assessed using the validated Child Behaviour Checklist (CBCL), which includes thee questionnaires: CBCL/6\u0026ndash;18 by parents, the Teacher\u0026rsquo;s Report Form (TRF) and the Youth Self Report (YSR). The CBCL evaluates two scales: internalizing problems (including anxious/depressed, withdrawn-depressed, and somatic complaints) and externalizing problems (including rule-breaking and aggressive behaviour). This outcome measure is expressed as the percentage of adolescents clinical score on one of the two scales or total score.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFamily and pedagogical factors\u003c/em\u003e were assessed using the semi-structured intake consultation, conducted separately with the adolescent and with the parents. Family history was assessed by determining the prevalence of alcohol or substance use disorder among first, second or third degree family members. Exposure to parental alcohol use was assessed by asking whether the adolescent had ever seen a parent drunk. Alcohol-specific parental rule-setting was assessed during the session with the adolescent alone and during the session with parents alone. Alcohol-specific parental rule-setting was defined as a categorical variable ranging from 1\u0026ndash;3: no rules or approval (\u003cspan\u003e1\u003c/span\u003e), rules (\u003cspan\u003e2\u003c/span\u003e), strict alcohol-specific parental rule-setting/not allowed (\u003cspan\u003e3\u003c/span\u003e) and was asked to the parents and adolescent separately. Parental awareness was assessed by comparing the adolescent\u0026apos;s self-reported lifetime prevalence and last month prevalence of alcohol use with those reported by the parents. Details are provided in Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003e2.5. Data analyses\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics were used to present baseline characteristics of the study population. Categorical variables were expressed as proportions. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Continuous variables were reported as medians with interquartile range (IQR) for non-normally distributed data or as means with standard deviation (SD) for normally distributed data. Development in drinking patterns were assessed using McNemar test for two-category paired data and the Wilcoxon Signed Ranks test for paired ordinal data. Adolescent risk-taking behaviour and alcohol use parameters from the study population were compared to the reference population using a Chi-square goodness of fit test. The significance level for all statistical tests was set at \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (Armonk, NY, USA: IBM Corp).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003e2.6. Ethics\u003c/h2\u003e\n \u003cp\u003eOnly patients who gave consent to the Youth and Alcohol department (data\u0026thinsp;\u0026ge;\u0026thinsp;2018) or to the former the Dutch Paediatric Surveillance System (data\u0026thinsp;\u0026lt;\u0026thinsp;2017) for data collection for research purposes using the Paediatric alcohol questionnaire were included in this study. The data collection procedure was approved by the Medical Ethics Committee Leiden The Hague Delft, as well as by the research committee and board of directors of the Reinier de Graaf Hospital.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e3.1. Study population\u003c/h2\u003e\n \u003cp\u003eBetween 2014 and 2022, a total of 310 adolescents presented to the emergency department due to AAI and subsequently received outpatient follow-up care from a child psychologist. The characteristics of these patients are summarized in Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e. The median age of the cohort was 16 years (interquartile range [IQR] 1.0 year), with no patients younger than 11 years. There was a slight female predominance, accounting for 57.7% of the cohort.\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePopulation characteristics for total sample\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSociodemographic characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy population\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;310)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cem\u003eYear of emergency department presentation\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2014\u0026ndash;2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e160 (51.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2017\u0026ndash;2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2020\u0026ndash;2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e179 (57.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (42.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;14 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (21.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdolescent risk-taking behaviour\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at first alcohol use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (IQR 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifetime prevalence smoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent smoking status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNever smoked\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFormer smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCurrent smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifetime prevalence cannabis use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifetime prevalence sexual intercourse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAD(H)D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical score CBCL\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1,2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily and pedagogical factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily history of alcohol- and substance use disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePositive in first degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePositive in second or third degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure to parental alcohol use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSeen parents drunk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eCBCL\u0026thinsp;=\u0026thinsp;child behaviour checklist\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eClinical score as a proportion of adolescents without history of psychological disorders\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3.1.1 Adolescent risk taking behaviour, Family and pedagogical factors and psychological disorders\u003c/h2\u003e\n \u003cp\u003eThe median age at first alcohol use was 14.0 years (IQR 2.0 years). The lifetime prevalence of smoking was 47.6%, with 23.6% classified as current smokers at baseline. The lifetime prevalence of cannabis use was 38.1%. Additionally, 25.7% had engaged in sexual intercourse. A first-degree relative with a history of alcohol or substance use disorders was reported by 14.2% of the adolescents, while 31.1% reported a second or third-degree relative with such a history. Exposure to parental drunkenness was noted in 41.5% of cases. A confirmed psychological disorder before the AAI was present in 43.9% of the adolescents, with Attention-deficit/hyperactivity disorder (ADHD) being the most common diagnosis. Among those without a prior psychological disorder, 15.1% had clinical scores on the CBCL indicative of undiagnosed psychological disorders.\u003c/p\u003e\n \u003cp\u003eThe chi-square goodness-of-fit test indicated that the lifetime prevalence of smoking was significantly higher in the study population (47.7%) compared to the general Dutch adolescent population (32.1%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;28.7, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The lifetime prevalence of sexual intercourse in the study population (22.1%) did also differ significantly from that of the general Dutch adolescent population (16.3%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;15.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the lifetime prevalence of cannabis use was significantly higher in the study population (38.1%) than in the general Dutch adolescent population (20.0%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;54.6, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.2 Alcohol use parameters at baseline\u003c/h2\u003e\n \u003cp\u003eThe alcohol use parameters at baseline are presented in Table \u003cspan\u003e2\u003c/span\u003e. At the initial assessment (t\u0026thinsp;=\u0026thinsp;0), the majority of adolescents (89.2%) reported alcohol consumption prior to their alcohol-related emergency department visit. In 10.8% of cases, the emergency department visit was due to first-time alcohol use. The lifetime prevalence of alcohol use in the study population (89.2%) was significantly higher compared to the general Dutch adolescent population (65.8%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;72.0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, nearly two-thirds of the adolescents (64.7%) had experienced drunkenness at least once. The prevalence of drunkenness was significantly higher in the study population than in the general Dutch adolescent population (41.8%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;64.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, among those who had consumed alcohol prior to the emergency department visit, the prevalence of binge drinking was significantly lower in the study population (49.2%) compared to the general Dutch adolescent population (75.5%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;98.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cdiv\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003ePrevalence of alcohol use during the outpatient follow-up program\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;14\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifetime prevalence alcohol use\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e89.2%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLifetime prevalence drunkenness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e64.7%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLast month alcohol use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e31.4%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e40.4%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLast month binge drinking\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e49.2%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e25.3%*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eLifetime prevalence of alcohol use before the emergency department presentation for AAI\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eLast month binge drinking as a proportion of last month alcohol use\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003cem\u003e* Significantly different than reference population based on chi-square goodness-of-fit test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e3.3 Alcohol use parameters over time\u003c/h2\u003e\n \u003cp\u003eAt the intake assessment (t\u0026thinsp;=\u0026thinsp;1), two-thirds of the adolescents (68.6%) reported not consuming alcohol between the alcohol-related emergency department visit and the intake with the child psychologist. The last month prevalence of alcohol use at t\u0026thinsp;=\u0026thinsp;1 was significantly lower in the study population (31.4%) than in the general Dutch adolescent population (47.7%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;31.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). An exact McNemar test was conducted to determine whether the proportion of alcohol abstinence was sustained over time. During the follow-up period, the prevalence of alcohol use in the last month significantly increased to 43.9% at t\u0026thinsp;=\u0026thinsp;2 (McNemar \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.023). However, the last month prevalence of alcohol use at t\u0026thinsp;=\u0026thinsp;2 (40.4%) remained significantly lower than that in the general Dutch adolescent population (47.7%, X\u0026sup2;(\u003cspan\u003e2\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;4.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027). Conversely, the proportion of binge drinking significantly decreased during the outpatient follow-up program (McNemar \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTable 3: Alcohol-specific parental rule-setting and parental awareness\u003c/em\u003e\u003c/p\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT=0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT=1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol-specific parental rule-setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eStrict alcohol-specific parental rule-setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e34.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e67.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003ePermission with rule-setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e25.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e15.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eApproval or absent rule-setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e40.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e17.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived rule-setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eRule-setting concordant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e71.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e82.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParental awareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.857142857142858%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eAlcohol use concordant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.857142857142858%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e76.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eLifetime prevalence alcohol use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e89.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e70.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"69.14285714285714%\" valign=\"top\"\u003e\n \u003cp\u003eLast month prevalence alcohol use (T=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.571428571428571%\" valign=\"top\"\u003e\n \u003cp\u003e31.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.285714285714285%\" valign=\"top\"\u003e\n \u003cp\u003e23.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\u003cem\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/em\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003e3.4. Development of alcohol-specific parental rule-setting and parental awareness\u003c/h2\u003e\n \u003cp\u003ePrior to the alcohol-related emergency department visit, a substantial proportion of parents either approved of alcohol use or did not have specific rules regarding it (40.1%). One-third of the adolescents (34.6%) reported having strict alcohol-specific parental rules. Following the emergency department visit, 37.6% of parents adopted stricter alcohol-specific rules (Wilcoxon \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The outpatient follow-up program led to an increase in the concordance of perceived parental rule-setting, from 71.7\u0026ndash;82.0%. Parental awareness of lifetime and last month alcohol use (at t\u0026thinsp;=\u0026thinsp;1) indicated that parents underestimated their children\u0026apos;s alcohol consumption by 23.3%, as shown in Table \u003cspan\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe findings of this study provide significant insights into the drinking patterns and associated risk behaviours among adolescents participating in a preventive program following AAI. Our results indicate that these adolescents exhibit higher rates of lifetime smoking, substance use, and sexual intercourse compared to national averages, suggesting a broader spectrum of risk-taking behaviours associated with early and excessive alcohol use. Moreover, nearly half of the patients had a positive family history of alcohol or substance use disorders among first, second, or third-degree relatives. This aligns with existing literature indicating that a family history of substance use disorders significantly increases the risk of similar behaviours and psychiatric morbidity in offspring​ (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)​.\u003c/p\u003e \u003cp\u003eAdditionally, exposure to parental drunkenness was reported in 41.5% of cases, which literature suggests increases the risk of adolescent binge drinking by approximately twofold (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Nearly half of the adolescents with AAI had a confirmed psychological disorder, with ADHD being the most prevalent. Prior studies have shown a strong association between alcohol exposure and the development of mental disorders, highlighting the need for comprehensive mental health assessments in this population ​(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Among patients without a prior diagnosed psychological disorder, 15.1% had clinical scores on CBCL indicative of undiagnosed psychological disorders. It is crucial to identify these new mental health issues and determine the need for referral to specialized care to prevent recurrent hospital admissions and future regular alcohol consumption​ (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Initial Alcohol Consumption Patterns\u003c/h2\u003e \u003cp\u003eAt baseline, the data revealed that adolescents with AAI had significantly higher instances of alcohol consumption and episodes of drunkenness before the AAI event compared to their peers. This finding is consistent with previous research indicating that early initiation and frequent alcohol use are predictors of more severe drinking problems and related risk behaviours in adolescence and later life​ (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, the prevalence of binge drinking before alcohol intoxication was reported lower than the Dutch average, which is unexpected since binge drinking is associated with alcohol intoxication (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). On the other hand, all these patients did eventually perform in binge drinking resulting in their alcohol intoxication.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Post-Intoxication Changes in Drinking Behaviour\u003c/h2\u003e \u003cp\u003eFollowing the acute intoxication event, a notable decline in alcohol use was observed in the subsequent month. This reduction could be attributed to the immediate health scare and the subsequent intervention efforts, reflecting the known short-term efficacy of preventive programs in mitigating risky drinking behaviours (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Alcohol consumption rose at 6\u0026ndash;12 months post-intoxication, compared to 4\u0026ndash;6 weeks after AAI, still remaining to be below the Dutch average. Interestingly, binge drinking did not increased proportionately 6\u0026ndash;12 months post-intoxication. This suggests a potential shift in drinking patterns towards less intensive drinking sessions. The prevention programs might therefore also be successful in curbing binge drinking behaviours in the long run, which are often associated with acute health risks and long-term negative outcomes (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Alcohol-specific parental rule-setting and parental awareness\u003c/h2\u003e \u003cp\u003ePrior to the alcohol-related emergency department presentation, a substantial proportion of parents either approved of alcohol use or did not have specific rules regarding it. Only one-third of the adolescents reported having strict alcohol-specific parental rules. Following the emergency department visit, more than one-third of parents adopted stricter alcohol-specific rules. This is a positive sign since indulgent and negligent parenting styles are associated with a significant increase in prevalence of adolescent binge drinking with 2.51-, and 2.82-fold, respectively (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Additionally, adolescents' perception of high parental disapproval of substance use has been prospectively associated with a non-binge drinking trajectory (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Parental awareness of lifetime and last-month alcohol use indicated that parents underestimated the presence of their children's alcohol consumption by 23.3%. This, while research shows that parental monitoring and involvement is a protective factor for alcohol use among adolescents (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Strengths and limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths that enhance the reliability and significance of its findings: the longitudinal design allows for the observation of changes in drinking patterns over time, providing a dynamic view of adolescent behaviour post-intervention. This design helps understand the long-term effects and sustainability of the preventive program. Additionally, by evaluating not only alcohol consumption but also related risk behaviours such as smoking, substance use, sexual activity, psychological disorders and family and pedagogical factors, the study offers a holistic understanding of the adolescent risk profile. The comprehensive assessment helps identify correlations and potential causal relationships between different risk behaviours. Furthermore, comparing the study population's behaviours with Dutch national averages contextualizes the findings, highlighting the extent of risk behaviours in the studied group relative to broader trends. This comparison underscores the specific needs of the targeted population.\u003c/p\u003e \u003cp\u003eHowever, a limitation of this study is the lack of a control group of patients with alcohol intoxication who did not receive follow-up care, making it difficult to determine the extent to which the intervention program or the alcohol intoxication itself resulted in the observed decrease in alcohol use. Though, previous studies have shown that adolescents with problematic alcohol use reported reduced alcohol consumption and fewer alcohol-related problems after participating in motivational interviewing interventions compared to standard care (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, another limitation is the missing information of patients that were lost to follow-up. Prior research demonstrated follow-up rates of this out-patients clinic was 67% at the child psychologist (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). During the study period, there might have been a shift in the consultation approach with the child psychologist from universal prevention (where every adolescent was referred) to indicated prevention (where referrals were based on initial assessments and concerns). This potential change was because of personnel shortage at the paediatric medical psychology department and the corona pandemic which made live appointments in the hospital more complex. This change introduced heterogeneity into the lost-to-follow-up population and might have led to a selection bias of the study population, potentially resulting in either overestimation or underestimation of the actual problems among participants. The missing outcome parameters of adolescents who did not visit the paediatric psychology department due to continuation of pre-existing mental health care or direct referral to mental health care likely lead to underestimation of the prevalence of major outcomes in the study. Conversely, adolescents who were not referred to the psychology department due to indicated prevention might lead to overestimation of the prevalence of major outcomes among those that visited that paediatric psychology department. The effect of the adolescents that dropped out before visit to the paediatric psychology department could hypothetically influence the study results in both directions, making it challenging to precisely assess the overall impact (either underestimation or overestimation) of the findings. However, it is hypothesized that the true impact lies somewhere between these extremes.\u003c/p\u003e \u003cp\u003eIn conclusion, these findings suggest that the preventive program had a short-term impact in reducing alcohol consumption among adolescents with acute alcohol intoxication (AAI), as well as a long-term impact in reducing binge-drinking behaviours. The program's success in mitigating binge-drinking behaviours aligns with its goals of promoting safer drinking habits among adolescents.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAI: Acute alcohol intoxication, ADHD: Attention-deficit/hyperactivity disorder, CBCL: Child Behaviour Checklist, HBSC: Health Behaviour in School-aged Children, TRF: Teacher\u0026rsquo;s Report Form of Child behaviour checklist, YSR: Youth Self Report of Child behaviour checklist.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Ethics statement: Only patients who gave consent to the Youth and Alcohol department (data \u0026ge; 2018) or to the former the Dutch Paediatric Surveillance System (data \u0026lt; 2017) for data collection for research purposes using the Paediatric alcohol questionnaire were included in this study. The data collection procedure was approved by the Medical Ethics Committee Leiden The Hague Delft, as well as by the research committee and board of directors of the Reinier de Graaf Hospital. Moreover, this study was performed in line with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Data entry was performed by AB. Data preparation and analysis were performed by LP and LdV. The first draft of the manuscript was written by LP and LdV and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003eWe would like to thank all patients who gave consent for data collection using the Paediatric alcohol questionnaire and participated in this study. Moreover, we would like to thank Rita van de Poel, from the Reinier de Graaf hospital\u0026rsquo;s data warehouse, for her help with the data extraction.\u0026nbsp;\u003c/p\u003e"},{"header":"Reference","content":"\u003col\u003e\n\u003cli\u003eDiestelkamp S, Drechsel M, Baldus C, et al. Brief in Person Interventions for Adolescents and Young Adults Following Alcohol-Related Events in Emergency Care: A Systematic Review and European Evidence Synthesis. European Addiction Research 2015;22:17-35.\u003c/li\u003e\n\u003cli\u003eGore FM, Bloem PJ, Patton GC, et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. 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A Brief Motivational Interview in a Pediatric Emergency Department, Plus 10-day Telephone Follow-up, Increases Attempts to Quit Drinking Among Youth and Young Adults Who Screen Positive for Problematic Drinking. Academic Emergency Medicine 2010;17:890-902.\u003c/li\u003e\n\u003cli\u003eWurdak M, Wolstein J, Kuntsche E. Effectiveness of a drinking-motive-tailored emergency-room intervention among adolescents admitted to hospital due to acute alcohol intoxication \u0026mdash; A randomized controlled trial. Preventive Medicine Reports 2016;3:83-89.\u003c/li\u003e\n\u003cli\u003ede Veld L, van Hoof JJ, Wolberink IM, et al. The co-occurrence of mental disorders among Dutch adolescents admitted for acute alcohol intoxication. European Journal of Pediatrics 2020.\u003c/li\u003e\n\u003cli\u003eM. Rombouts SvD, T. Scheffers-van Schayck, M. Tuithof, M. Kleinjan, K. Monshouwer. Jeugd en riskant gedrag 2019. https://www.trimbos.nl/aanbod/webwinkel/af1767-jeugd-en-riskant-gedrag-2019/: Trimbos Institute; 2019.\u003c/li\u003e\n\u003cli\u003eMaartje Boer SvD, Margreet de Looze, Simone de Roos, Hilde Brons, Regina van den Eijnden, Karin Monshouwer, willem huijnk, tom ter bogt, wilma vollebergh en gonneke stevens. HBSC 2021 Health and welbeing of school-going children in the Netherlands; 2021.\u003c/li\u003e\n\u003cli\u003eS. van Dorsselaer MT, J. Verdurmen, M. Spit, M. van Laar, K. Monshouwer. Jeugd en riskant gedrag 2015: Netherlands Institute of Mental Health and Addiction; 2015.\u003c/li\u003e\n\u003cli\u003eMargreet de Looze SvD, Simone de Roos,, Jacqueline Verdurmen GS, Rob Gommans,, Marja van Bon-Martens TtB, Wilma Vollebergh. HBSC 2013 health and well-being of young people in The Netherlands. hbscnederland.nl/publicaties/rapporten.\u003c/li\u003e\n\u003cli\u003eGonneke Stevens SvD, Maartje Boer,, Simone de Roos ED, Tom ter Bogt, Regina van den Eijnden,, Lisette Kuyper DV, Wilma Vollebergh en Margreet de Looze. HBSC 2017 health and well-being of young people in the netherlands. https://hbscnederland.nl/publicaties/rapporten/; 2019.\u003c/li\u003e\n\u003cli\u003ePEIL/Leefstijlmonitor, Trimbos Instituut i.s.m. RIVM, 2015/2019 \u0026amp; HBSC/Leefstijlmonitor, UU, Trimbos en SCP i.s.m. RIVM, 2017/2021; 2022.\u003c/li\u003e\n\u003cli\u003eMartikainen P, Korhonen K, Moustgaard H, et al. Substance abuse in parents and subsequent risk of offspring psychiatric morbidity in late adolescence and early adulthood: A longitudinal analysis of siblings and their parents. Social Science \u0026amp; Medicine 2018;217:106-111.\u003c/li\u003e\n\u003cli\u003eZuquetto CR, Opaleye ES, Feij\u0026oacute; MR, et al. Contributions of parenting styles and parental drunkenness to adolescent drinking. Braz J Psychiatry 2019;41:511-517.\u003c/li\u003e\n\u003cli\u003eCouwenbergh C, van den Brink W, Zwart K, et al. Comorbid psychopathology in adolescents and young adults treated for substance use disorders: a review. Eur Child Adolesc Psychiatry 2006;15:319-328.\u003c/li\u003e\n\u003cli\u003eRyan SA, Kokotailo P, USE COS, et al. Alcohol Use by Youth. Pediatrics 2019;144.\u003c/li\u003e\n\u003cli\u003eMartino SC, Ellickson PL, McCaffrey DF. Multiple trajectories of peer and parental influence and their association with the development of adolescent heavy drinking. Addictive behaviors 2009;34:693-700.\u003c/li\u003e\n\u003cli\u003eBorawski EA, Ievers-Landis CE, Lovegreen LD, et al. Parental monitoring, negotiated unsupervised time, and parental trust: the role of perceived parenting practices in adolescent health risk behaviors. Journal of Adolescent Health 2003;33:60-70.\u003c/li\u003e\n\u003cli\u003eRyan SM, Jorm AF, Lubman DI. Parenting Factors Associated with Reduced Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies. Australian \u0026amp; New Zealand Journal of Psychiatry 2010;44:774-783.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Acute Alcohol intoxication, adolescents, alcohol, out-patient clinic, prevention, psychologic follow-up","lastPublishedDoi":"10.21203/rs.3.rs-4667985/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4667985/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAlcohol-related emergency department attendance in adolescents should be considered as a valuable opportunity to address and mitigate future alcohol consumption. Therefore, a paediatric department of a major district hospital in the Netherlands developed an outpatient preventive program targeting adolescents admitted for acute alcohol intoxication. The primary aim of this study is to evaluate how adolescent drinking patterns participating in the preventive program developed over time.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective observational study was conducted in the Reinier de Graaf hospital, Delft, the Netherlands. The outpatient preventive program consists of three main components: an initial intervention, subsequent an extended counselling session and psychological interventions. The alcohol consumption was compared at three time points: before the admission for acute alcohol intoxication(T\u0026thinsp;=\u0026thinsp;0), 4\u0026ndash;6 weeks after hospital admission(T\u0026thinsp;=\u0026thinsp;1) and 6\u0026ndash;12 months after the hospital admission(T\u0026thinsp;=\u0026thinsp;2). Moreover, sociodemographic variables, adolescent risk-taking behaviour and family and pedagogical factors were included in secondary analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 310 patients underwent the outpatient preventive program from 2014\u0026ndash;2022. Adolescents who experienced an alcohol intoxication hospital admittance exhibited more adolescent risk-taking behaviour compared to the Dutch average. Initially, these adolescents had significantly higher rates of alcohol consumption and drunkenness. Alcohol use decreased significantly in the month following intoxication, even below the Dutch average. Though, 6\u0026ndash;12 months later, their alcohol consumption increased but remained statistically lower and involved less binge drinking than the Dutch average.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings of this study demonstrate that a preventive program following acute alcohol intoxication contributes to the reduction of adolescent alcohol use and associated risk-taking behaviours.\u003c/p\u003e","manuscriptTitle":"Psychological outpatient follow-up after hospitalization for adolescent acute alcohol intoxication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-01 06:17:44","doi":"10.21203/rs.3.rs-4667985/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-20T08:53:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-18T08:26:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16941754317632085031222628424832071464","date":"2024-09-09T17:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59610732363503387847939562492660662438","date":"2024-09-09T11:10:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-09T10:35:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-09T06:28:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T06:24:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2024-07-01T12:16:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"42a09602-7807-405b-98db-3ce557727948","owner":[],"postedDate":"August 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T19:24:28+00:00","versionOfRecord":{"articleIdentity":"rs-4667985","link":"https://doi.org/10.1007/s00431-024-05856-1","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2024-11-15 15:57:46","publishedOnDateReadable":"November 15th, 2024"},"versionCreatedAt":"2024-08-01 06:17:44","video":"","vorDoi":"10.1007/s00431-024-05856-1","vorDoiUrl":"https://doi.org/10.1007/s00431-024-05856-1","workflowStages":[]},"version":"v1","identity":"rs-4667985","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4667985","identity":"rs-4667985","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}