Newsletter

Overview

Throughout human history alcohol has been used in many festivities, celebrations and social occasions. Teens My purpose in writing this article is to encourage parents whose adolescents have CAH to develop a healthy and informed view about teenagers’ alcohol use so they can assist them to intelligently negotiate the risks associated with adrenal insufficiency and alcohol use.

The normalization of binge drinking in our culture is well recognized and, in this regard, youth receive more than their fair share of criticism in the media. It should be noted however that many teens either do not drink or drink within sensible limits and engage in safe practices such as nominating “safe drivers.” It is also true that, due to teens’ increased autonomy and time spent with peers, some get caught up with others who misuse or abuse alcohol. This presents difficulties for parents who, on one hand, acknowledge the need for teens’ increased independence and, on the other, are hard-wired to keep them safe. Shifts in the parenting role also occur during this period, from a strongly directive to more consultative position. This can be frustrating at times for parents when well-meaning information or support is offered, but neither wanted nor accepted.

Alcohol & New Zealanders

Many use alcohol responsibly and have healthy attitudes and practices around drinking. However, a significant proportion (about 20%) in our country misuse it regularly through binge drinking. Mixing alcohol with other substances e.g. party pills, cannabis, creates additional health risks.

Alcohol, it can be said, is a great servant but a poor master. Along with nicotine and cannabis, it has been New Zealanders favorite drug of choice for many decades. The use and misuse of alcohol raises some special issues for parents of teenagers and young adults who have CAH. Many argue alcohol use among youth has become an area of increased concern. Why is this?

Since WW2, alcohol consumption has increased throughout the Western world, reflecting increased levels of personal autonomy and discretionary income (especially among youth), marketing & media pressures, a rise in more liberal or democratic styles of parenting and an ncrease in availability. For a variety of reasons, teenagers today are also less likely today to spend time in the company of adults, reducing opportunities for modeling healthy drinking behavior and decreasing the monitoring of alcohol consumption in general. Research suggests around 60% of alcohol partaken by underage adolescents is obtained from parents.

Our attitude on drinking differs from some other countries. Our “binge” mentality has widespread repercussions for personal health, family life and our lives in the wider community and the workplace. According to one recent estimate, alcohol costs our country $1.17 billion annually in lost productivity, is linked with 70% of accident and emergency admissions at hospitals and is blamed for approximately 90% of weekend crime. When alcohol is teamed with access to fast cars and other illicit drugs, our high rates of teen pregnancy, sexually-transmitted infections and date-rape, along with recent research linking long term binge drinking with brain damage, it is clear this is a social issue that affects us all.

Parenting Guidelines Around Teen Alcohol Use: The Basics

According to renowned family therapist, Virginia Satir, parents are responsible for training children in four main areas: communication, limits and boundaries, self-esteem and links with the outside world. When it comes to communicating about and setting limits around alcohol use, effective parents recognize there is no “one size fits all” way of risk-proofing their teen. There are however, some principles that can assist them in negotiating this territory.

The first is to enable children from an early age to make good choices. In early childhood, decision-making skills are flexed through allowing choices within limits, e.g. cheese or peanut butter; red or blue shoes; which nighttime story to read. Responsibility for choices expands from here into areas such as managing pocket money, household chores or caring for pets.

Decision-making improves when children have opportunities to make choices and learn from their mistakes without being judged or shamed. They need support and encouragement, but not lectures or moralizing when things do not work out. Neither should they be rescued. When consequences are not life-threatening or physically harmful, children should bear at least some of the weight of the consequences of poor choices. This learning from natural consequences is a critical part of learning independence and developing good judgment. Unfortunately, parents often must watch patiently while their children go “round the mountain” more than once. Learning self-responsibility is seldom a linear process!

Ability to make sound decisions becomes most important for adolescents because issues are weightier, e.g. dating, driving and career choices. As our culture makes it almost impossible to keep children completely away from alcohol, parents must accept that all young adults contend with alcohol at some stage, and many do so before the legal drinking age. Good decision-making and ability to take personal responsibility are both key factors here.
Values are caught, not taught. The best way to teach healthy attitudes and habits around the use of alcohol is to be a good role model. Teenagers in particular hate hypocrisy, and “do as I say but not as I do” is not tolerated by modern youth. Teenagers want adults to be authentic, which means actions speak louder than words.
Parents are the first, and continue to be children’s most important teachers! From an early age they need to create and grab “teachable moments, e.g.
(i) using movies or TV news to initiate conversations about alcohol and drinking,
(ii) playing games to improve awareness and sharpen good thinking skills e.g. “What if”… “What if you were home here with a friend and they said ‘Let’s drink some of your dad’s gin and then top it up with water?’ What choices do you have? What might be the consequences for each?” This has the dual advantage of giving you insight into their decision-making capabilities and also subtly lets them know you’re one step ahead!
Parents need accurate information. Other than hypocrisy, nothing turns away teenagers more than hyperbole or exaggeration. Today’s youth are generally well-informed. From an early age they access information through the web and school-based health and drug education programs like DARE. Parents need to be clear about facts before they talk to teens about alcohol and other drugs. There are lots of helpful resources—pamphlets, library books, websites such as www.faceproject.org and www.teens.drugabuse.gov.
Parents also need to be realistic. Adolescents are on the threshold of adult life. They are working out what they believe and who they are and experimentation is normal. They will make some good and some poor decisions and make some mistakes. While it’s important not to minimize alcohol misuse or abuse, neither should parents “sweat the small stuff.” One drunken episode is not a precursor to a life on the streets!
There are some things parents can do to actively build resiliency. A large international study on youth wellbeing (ADD Health, 1996) outlines four things that help “risk proof” children:
(i) Having high parental expectations along with provision of support;
(ii) Providing homes that are drug and firearms-free;
(iii) Being home at critical times of the day—when children are getting up and coming home from school & bed times;
(iv) Having family meals together (This is considered particularly important.)
Despite the fact that parents today are often extremely busy, they must continue to show interest in their teens’ lives and work at keeping communication open. There is truth in the saying that children spell “L.O.V.E.” as “T.I.M.E.” The New Zealand Youth 2000 report showed 40% of teens want to spend more time with at least one parent. The research is clear: teenagers are less at-risk when strong family bonds are maintained.
When kids approach adolescence, parents must consider some strategies for alcohol-related incidents. Usually, natural and logical consequences work well, but the first and foremost step is active, open communication. For a “first offense” (e.g. teenager arriving home intoxicated) parents should wait until they are sober and calmly and non-accusingly talk with them about it. It may be the teen got out of their depth and made a poor decision. Parents can be understanding and perhaps share an early (repeatable) mistake they also made with alcohol. This will help teens feel that parents are for, rather than against, them and that they understand. Feeling upset/ashamed/distressed about this episode may be the only consequence the teen needs for a first offense along with some guided discussion about what could be done differently next time. Family strategies might need to be put in place e.g. “Call us any time and we’ll come and collect you with no questions asked” (that is, until a calmer, more-rested stage.)
Finally, even for a first or uncharacteristic lapse, parents must kindly, but firmly, follow through with logical consequences. This is not punishment, but about providing a learning opportunity, one which requires the teen to take responsibility for his/her actions. If the incident has involved vomiting and their bed has needed changing, parents should raise this with them on the next day and say “John, there are sheets that need washing from last night. Please make it a priority to rinse them and put them in the machine. I’d like this done before you go to Jack’s this afternoon. Thank you.” Note the importance of neutral, non-accusatory or shaming language, and the power of delivering this with calm, positive body language. Mini-lectures, interrogation, blaming, shaming especially when delivered in a highly emotive manner are always counterproductive.

Alcohol and Teens with CAH: The Extras

Many young people make very good choices around alcohol and, conversely, many adults do not. For parents of teens who have CAH there are a number of additional complicating factors. These are:

Increased risk of electrolyte imbalance caused by vomiting;
Increased risks of being drunk/falling asleep and failing to take their next dose of medication (which should be increased if they’ve vomited);
Drinking buddies may not under- stand their medical needs or may also be “under the influence” reducing the likelihood of them getting appropriate medical intervention.
Increased risk associated with unwillingness to wear Medic Alert disc and the potential of alcohol-related accidents/injury. This is important because a teenager requiring emergency help will need aCAH wallet card or Medic Alert disc to alert ambulance staff. (Also note: should SoluCortef be required, ambulances will not administer it, even when this is supplied by the patient and accompanied by a doctor’s covering letter.

Emotional Hurdles for Parents of CAH Teens

It’s helpful for teens to understand how alcohol affects their bodies, especially with a complex condition like CAH. Alcohol is processed via the liver and the kidneys and anecdotal evidence from CAH adults suggests people with adrenal insufficiency do not process alcohol as well as others. Many adults with CAH feel they have gotten drunk quicker and have been hung-over for longer than their peers.

As do most of us, adolescents learn by doing and working things out for themselves. However it is particularly important that parents with a CAH teen be pro-active about points #1 to #9 as safety issues are magnified for teens with CAH.

One of the big challenges for parents of teens with CAH is to contain their anxiety, so they don’t consciously or unconsciously restrict teens. (This goes for other areas too, not just alcohol). Protectiveness is understandable, but teens will resent it, especially if it’s because of their CAH. As many teenagers with CAH have already grown up with anxieties around health and body issues, it is important that parents act calmly and reasonably. If a parent needs to cry or let off steam, they should do so in private or seek support from a partner or friend. Talking with a GP can be helpful as can talking with other CAH parents who have teenagers the same age or older. It is also very helpful to signal to your teen’s physician in advance that you would like some support with the issue. Depending on the maturity of the individual child, this discussion may need to take place just prior to or during adolescence. As physicians deal regularly with other teens for whom misuse of alcohol can be risky (e.g. diabetics), he or she is in a good position to educate a teen about the risks, as well as offer practical guidelines for healthy drinking habits. They have the advantage of being an independent adult voice, one which a teen may be more willing to listen to or take advice from at this stage.

Another reason for not overstating theperils of drinking is that teens with CAH may worry about upsetting parents, choosing to stay away from home if they have had one drink too many. If teens do get drunk or become under the influence of alcohol or other drugs they need to be where a responsible caregiver can keep an eye on them. Depending on the severity of the episode, they may require SoluCortef and their electrolytes monitored throughout the next day. They may need saline or fluids and will require extra medication as per the usual guidelines for vomiting.

Many CAH teens may feel angry their medical condition puts yet another limit on what they can or can’t do. Peer-acceptance and belonging is so important in adolescence and alcohol is so central in many recreational and sporting events that restriction caused by CAH can be hard for some to bear. For some boys, it might mean they can’t “hold their drink like a man” and thereby lose face with peers. They may be frustrated that friends get drunker, but bounce back quicker than them. This anger needs to be acknowledged and talked about.

Finally, while CAH presents extra challenges for young drinkers, parents must not focus on these to the exclusion of other alcohol-related risks. For young teens especially, the disinhibition caused by alcohol makes good decision-making about driving and dealing with sexual urges or advances very difficult. Use a variety of means to get the message across—older relatives or family friends whom teens like and trust, books or videos, pamphlets or websites designed for teens which discuss these issues.

Spring 2008 Newsletter	CAH Article	CARES Foundation, Inc.


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Alcohol, Teens & Adrenal Insufficiency

By Helen Mann, Coordinator, New Zealand CAH Support Group, Reprinted with permission, CAHNZ

Overview Throughout human history alcohol has been used in many festivities, celebrations and social occasions. My purpose in writing this article is to encourage parents whose adolescents have CAH to develop a healthy and informed view about teenagers’ alcohol use so they can assist them to intelligently negotiate the risks associated with adrenal insufficiency and alcohol use. The normalization of binge drinking in our culture is well recognized and, in this regard, youth receive more than their fair share of criticism in the media. It should be noted however that many teens either do not drink or drink within sensible limits and engage in safe practices such as nominating “safe drivers.” It is also true that, due to teens’ increased autonomy and time spent with peers, some get caught up with others who misuse or abuse alcohol. This presents difficulties for parents who, on one hand, acknowledge the need for teens’ increased independence and, on the other, are hard-wired to keep them safe. Shifts in the parenting role also occur during this period, from a strongly directive to more consultative position. This can be frustrating at times for parents when well-meaning information or support is offered, but neither wanted nor accepted. Alcohol & New Zealanders Many use alcohol responsibly and have healthy attitudes and practices around drinking. However, a significant proportion (about 20%) in our country misuse it regularly through binge drinking. Mixing alcohol with other substances e.g. party pills, cannabis, creates additional health risks. Alcohol, it can be said, is a great servant but a poor master. Along with nicotine and cannabis, it has been New Zealanders favorite drug of choice for many decades. The use and misuse of alcohol raises some special issues for parents of teenagers and young adults who have CAH. Many argue alcohol use among youth has become an area of increased concern. Why is this? Since WW2, alcohol consumption has increased throughout the Western world, reflecting increased levels of personal autonomy and discretionary income (especially among youth), marketing & media pressures, a rise in more liberal or democratic styles of parenting and an ncrease in availability. For a variety of reasons, teenagers today are also less likely today to spend time in the company of adults, reducing opportunities for modeling healthy drinking behavior and decreasing the monitoring of alcohol consumption in general. Research suggests around 60% of alcohol partaken by underage adolescents is obtained from parents. Our attitude on drinking differs from some other countries. Our “binge” mentality has widespread repercussions for personal health, family life and our lives in the wider community and the workplace. According to one recent estimate, alcohol costs our country $1.17 billion annually in lost productivity, is linked with 70% of accident and emergency admissions at hospitals and is blamed for approximately 90% of weekend crime. When alcohol is teamed with access to fast cars and other illicit drugs, our high rates of teen pregnancy, sexually-transmitted infections and date-rape, along with recent research linking long term binge drinking with brain damage, it is clear this is a social issue that affects us all. Parenting Guidelines Around Teen Alcohol Use: The Basics According to renowned family therapist, Virginia Satir, parents are responsible for training children in four main areas: communication, limits and boundaries, self-esteem and links with the outside world. When it comes to communicating about and setting limits around alcohol use, effective parents recognize there is no “one size fits all” way of risk-proofing their teen. There are however, some principles that can assist them in negotiating this territory. The first is to enable children from an early age to make good choices. In early childhood, decision-making skills are flexed through allowing choices within limits, e.g. cheese or peanut butter; red or blue shoes; which nighttime story to read. Responsibility for choices expands from here into areas such as managing pocket money, household chores or caring for pets. Decision-making improves when children have opportunities to make choices and learn from their mistakes without being judged or shamed. They need support and encouragement, but not lectures or moralizing when things do not work out. Neither should they be rescued. When consequences are not life-threatening or physically harmful, children should bear at least some of the weight of the consequences of poor choices. This learning from natural consequences is a critical part of learning independence and developing good judgment. Unfortunately, parents often must watch patiently while their children go “round the mountain” more than once. Learning self-responsibility is seldom a linear process! Ability to make sound decisions becomes most important for adolescents because issues are weightier, e.g. dating, driving and career choices. As our culture makes it almost impossible to keep children completely away from alcohol, parents must accept that all young adults contend with alcohol at some stage, and many do so before the legal drinking age. Good decision-making and ability to take personal responsibility are both key factors here. Values are caught, not taught. The best way to teach healthy attitudes and habits around the use of alcohol is to be a good role model. Teenagers in particular hate hypocrisy, and “do as I say but not as I do” is not tolerated by modern youth. Teenagers want adults to be authentic, which means actions speak louder than words. Parents are the first, and continue to be children’s most important teachers! From an early age they need to create and grab “teachable moments, e.g. (i) using movies or TV news to initiate conversations about alcohol and drinking, (ii) playing games to improve awareness and sharpen good thinking skills e.g. “What if”… “What if you were home here with a friend and they said ‘Let’s drink some of your dad’s gin and then top it up with water?’ What choices do you have? What might be the consequences for each?” This has the dual advantage of giving you insight into their decision-making capabilities and also subtly lets them know you’re one step ahead! Parents need accurate information. Other than hypocrisy, nothing turns away teenagers more than hyperbole or exaggeration. Today’s youth are generally well-informed. From an early age they access information through the web and school-based health and drug education programs like DARE. Parents need to be clear about facts before they talk to teens about alcohol and other drugs. There are lots of helpful resources—pamphlets, library books, websites such as www.faceproject.org and www.teens.drugabuse.gov. Parents also need to be realistic. Adolescents are on the threshold of adult life. They are working out what they believe and who they are and experimentation is normal. They will make some good and some poor decisions and make some mistakes. While it’s important not to minimize alcohol misuse or abuse, neither should parents “sweat the small stuff.” One drunken episode is not a precursor to a life on the streets! There are some things parents can do to actively build resiliency. A large international study on youth wellbeing (ADD Health, 1996) outlines four things that help “risk proof” children: (i) Having high parental expectations along with provision of support; (ii) Providing homes that are drug and firearms-free; (iii) Being home at critical times of the day—when children are getting up and coming home from school & bed times; (iv) Having family meals together (This is considered particularly important.) Despite the fact that parents today are often extremely busy, they must continue to show interest in their teens’ lives and work at keeping communication open. There is truth in the saying that children spell “L.O.V.E.” as “T.I.M.E.” The New Zealand Youth 2000 report showed 40% of teens want to spend more time with at least one parent. The research is clear: teenagers are less at-risk when strong family bonds are maintained. When kids approach adolescence, parents must consider some strategies for alcohol-related incidents. Usually, natural and logical consequences work well, but the first and foremost step is active, open communication. For a “first offense” (e.g. teenager arriving home intoxicated) parents should wait until they are sober and calmly and non-accusingly talk with them about it. It may be the teen got out of their depth and made a poor decision. Parents can be understanding and perhaps share an early (repeatable) mistake they also made with alcohol. This will help teens feel that parents are for, rather than against, them and that they understand. Feeling upset/ashamed/distressed about this episode may be the only consequence the teen needs for a first offense along with some guided discussion about what could be done differently next time. Family strategies might need to be put in place e.g. “Call us any time and we’ll come and collect you with no questions asked” (that is, until a calmer, more-rested stage.) Finally, even for a first or uncharacteristic lapse, parents must kindly, but firmly, follow through with logical consequences. This is not punishment, but about providing a learning opportunity, one which requires the teen to take responsibility for his/her actions. If the incident has involved vomiting and their bed has needed changing, parents should raise this with them on the next day and say “John, there are sheets that need washing from last night. Please make it a priority to rinse them and put them in the machine. I’d like this done before you go to Jack’s this afternoon. Thank you.” Note the importance of neutral, non-accusatory or shaming language, and the power of delivering this with calm, positive body language. Mini-lectures, interrogation, blaming, shaming especially when delivered in a highly emotive manner are always counterproductive. Alcohol and Teens with CAH: The Extras Many young people make very good choices around alcohol and, conversely, many adults do not. For parents of teens who have CAH there are a number of additional complicating factors. These are: Increased risk of electrolyte imbalance caused by vomiting; Increased risks of being drunk/falling asleep and failing to take their next dose of medication (which should be increased if they’ve vomited); Drinking buddies may not under- stand their medical needs or may also be “under the influence” reducing the likelihood of them getting appropriate medical intervention. Increased risk associated with unwillingness to wear Medic Alert disc and the potential of alcohol-related accidents/injury. This is important because a teenager requiring emergency help will need aCAH wallet card or Medic Alert disc to alert ambulance staff. (Also note: should SoluCortef be required, ambulances will not administer it, even when this is supplied by the patient and accompanied by a doctor’s covering letter. Emotional Hurdles for Parents of CAH Teens It’s helpful for teens to understand how alcohol affects their bodies, especially with a complex condition like CAH. Alcohol is processed via the liver and the kidneys and anecdotal evidence from CAH adults suggests people with adrenal insufficiency do not process alcohol as well as others. Many adults with CAH feel they have gotten drunk quicker and have been hung-over for longer than their peers. As do most of us, adolescents learn by doing and working things out for themselves. However it is particularly important that parents with a CAH teen be pro-active about points #1 to #9 as safety issues are magnified for teens with CAH. One of the big challenges for parents of teens with CAH is to contain their anxiety, so they don’t consciously or unconsciously restrict teens. (This goes for other areas too, not just alcohol). Protectiveness is understandable, but teens will resent it, especially if it’s because of their CAH. As many teenagers with CAH have already grown up with anxieties around health and body issues, it is important that parents act calmly and reasonably. If a parent needs to cry or let off steam, they should do so in private or seek support from a partner or friend. Talking with a GP can be helpful as can talking with other CAH parents who have teenagers the same age or older. It is also very helpful to signal to your teen’s physician in advance that you would like some support with the issue. Depending on the maturity of the individual child, this discussion may need to take place just prior to or during adolescence. As physicians deal regularly with other teens for whom misuse of alcohol can be risky (e.g. diabetics), he or she is in a good position to educate a teen about the risks, as well as offer practical guidelines for healthy drinking habits. They have the advantage of being an independent adult voice, one which a teen may be more willing to listen to or take advice from at this stage. Another reason for not overstating theperils of drinking is that teens with CAH may worry about upsetting parents, choosing to stay away from home if they have had one drink too many. If teens do get drunk or become under the influence of alcohol or other drugs they need to be where a responsible caregiver can keep an eye on them. Depending on the severity of the episode, they may require SoluCortef and their electrolytes monitored throughout the next day. They may need saline or fluids and will require extra medication as per the usual guidelines for vomiting. Many CAH teens may feel angry their medical condition puts yet another limit on what they can or can’t do. Peer-acceptance and belonging is so important in adolescence and alcohol is so central in many recreational and sporting events that restriction caused by CAH can be hard for some to bear. For some boys, it might mean they can’t “hold their drink like a man” and thereby lose face with peers. They may be frustrated that friends get drunker, but bounce back quicker than them. This anger needs to be acknowledged and talked about. Finally, while CAH presents extra challenges for young drinkers, parents must not focus on these to the exclusion of other alcohol-related risks. For young teens especially, the disinhibition caused by alcohol makes good decision-making about driving and dealing with sexual urges or advances very difficult. Use a variety of means to get the message across—older relatives or family friends whom teens like and trust, books or videos, pamphlets or websites designed for teens which discuss these issues.

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© 2008 CARES Foundation, Inc. All rights reserved. Republication or redistribution of CARES newsletter content, including by framing or similar means, is prohibited without the prior written consent of CARES. Disclaimer: Any communication from CARES Foundation, Inc. is intended for informational and educational purposes only and in no way should be taken to be the provision or practice of medical, nursing or professional healthcare advice or services. The information should not be considered complete or exhaustive and should not be used in place of the visit, call, consultation or advice of your physician or other healthcare provider. You should not us the information in this or any CARES Foundation, Inc. communication to diagnose or treat CAH or any other disorder without first consulting with your physician or healthcare provider. The articles presented in this newsletter are for informational purposes only and do not necessarily reflect the views of CARES Foundation, Inc.

Alcohol, Teens & Adrenal Insufficiency