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Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.)

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Treatment of Adolescents with Substance Use Disorders.

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Chapter 1--Substance Use Among Adolescents

Substance use by young people is on the rise, and initiation of use is occurring at ever-younger ages. Patterns of substance use over the past 20 years have been documented by two surveys--the National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Monitoring the Future Study conducted by the National Institute on Drug Abuse (NIDA). Data released in 1996 indicated that in the early to mid-1990s, the percentage of 8th graders who reported using illicit drugs (i.e., drugs illegal for Americans of all ages) in the past year almost doubled, from 11.3 percent in 1991 to 21.4 percent in 1995 (NIDA, 1996a). Drug use by high school students also has risen steadily since 1992. The survey also indicates that 33 percent of 10th graders and 39 percent of 12th graders reported the use of an illicit drug within the preceding 12 months (NIDA, 1996a). These estimates are probably low because the statistics are gathered in schools and do not include the high-risk group of dropouts. Most of the recent increase is attributed to marijuana use, which rose significantly during this period.

An estimated 15 percent of 8th graders, 24 percent of 10th graders, and 30 percent of 12th graders reported having had five or more drinks within the preceding 2 weeks (Johnston et al., 1995). Slightly more than half of high school students (grades 9 through 12) reported having had at least one drink of alcohol during the 30 days preceding a 1995 Centers for Disease Control and Prevention (CDC) survey (CDC, 1996). It is further estimated that 9 percent of adolescent girls and up to 20 percent of adolescent boys meet adult diagnostic criteria for an alcohol use disorder (Cohen et al., 1993). Furthermore, the proportion of daily smokers among American high school seniors remains disturbingly high at about 20 percent.

The surveys have found that the perceived risk of harm from drug involvement has been declining while the availability of drugs has been rising (NIDA, 1996a; SAMHSA, 1998a). Particularly in the case of marijuana, sharp declines in harm perception have been observed among 8th, 10th, and 12th graders (see Figure 1-1). This shift has occurred at the same time that marijuana use has spread (NIDA, 1996a). Since 1991, the percentage of students who thought that regular marijuana use carries a "great risk" of harm has dropped from 79 percent to 61 percent among 12th graders, from 82 percent to 68 percent among 10th graders, and from 84 percent to 73 percent among 8th graders (NIDA, 1996a). During the same period, reported use of marijuana within the preceding year rose for all these grades by an average of 11 percent (NIDA, 1996a).

Figure 1-1: Perceived Risk of Harm From and Use of Marijuana Among High School Students, 1991 and 1995.

Figure 1-1: Perceived Risk of Harm From and Use of Marijuana Among High School Students, 1991 and 1995

Household products are abused as well as illegal drugs: The percentage of youths 12 to 17 years old who tried inhalants rose from 1.1 percent in 1991 to 2.2 in 1994 (NIDA, 1996a). "Heroin chic" as exemplified by rock stars and fashion models has boosted the popularity of that drug among young people. Panel members reported that in some areas, the adolescent use of heroin mixed with water and then inhaled has increased. Clearly, drug use trends among young people are a major national concern. Within the context of national surveys of frequency of use, the prevalence of those meeting criteria for a diagnosis is becoming clearer. A 1996 statewide Minnesota survey provided the first systematic look at the rate of substance use disorders in a large student population: 11 percent of 9th grade students and 23 percent of 12th grade students met formal diagnostic criteria as established in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) for drug abuse or drug dependence disorder (Harrison and Fulkerson, 1996).

The Consequences

In terms of public health, adolescent substance use disorders have far-reaching social and economic ramifications. The numerous adverse consequences associated with teenage drinking and substance use disorders include fatal and nonfatal injuries from alcohol- and drug-related motor vehicle accidents, suicides, homicides, violence, delinquency (Dembo et al., 1991), psychiatric disorders, and risky sexual practices (Jainchill et al., in press). Longitudinal studies have established associations between adolescent substance use disorders and (1) impulsivity, alienation, and psychological distress (Hansell and White, 1991; Shedler and Block, 1990), (2) delinquency and criminal behavior (National Institute of Justice, 1994), (3) irresponsible sexual activity that increases susceptibility to HIV infection (DiClemente, 1990), and (4) psychiatric or neurological impairments associated with drug use, especially inhalants, and other medical complications (SAMHSA, 1996).

Substance use disorders that begin at an early age, especially when there is no remission of the disorder, exact substantial economic costs to society (Children's Defense Fund, 1991). The trend toward early onset of substance use disorders has increasingly resulted in adolescents who enter treatment with greater developmental deficits and perhaps much greater neurological deficits than have been previously observed. Moreover, the risks of traumatic injury, unintended pregnancy, and sexually transmitted diseases (STDs) are high in adolescents in general. Drug involvement that is superimposed on these already high risks has numerous potentially adverse consequences that have not yet been the subject of indepth study beyond basic population studies.

Mortality

Alcohol-related motor vehicle accidents exact a heavy toll on society in terms of economic costs and lost productivity. Nearly half (45.1 percent) of all traffic fatalities are alcohol-related, and it is estimated that 18 percent of drivers 16 to 20 years old--a total of 2.5 million adolescents--drive under the influence of alcohol. According to the Youth Risk Behavior Surveillance System conducted by the CDC, which monitors health risk behaviors among youths and young adults, unintentional injuries, including motor vehicle accidents, are by far the leading cause of death in adolescents, causing 29 percent of all deaths. An estimated 50 percent of these deaths are related to the consumption of alcohol (CDC, 1998).

Sexually Risky Practices

Adolescents are at higher risk than adults for acquiring STDs for a number of reasons. They are more likely to have multiple (sequential or concurrent) sexual partners and to engage in unprotected sexual intercourse. They are also more likely to select partners who are at higher risk for STDs. Among females, those 15 to 19 years old have the highest rates of gonorrhea, while 20- to 24-year-olds have the highest rate of primary and secondary syphilis (CDC, 1996).

Adolescents who use alcohol and illicit drugs are more likely than others to engage in sexual intercourse and other sexually risky behaviors. A positive correlation has been demonstrated between alcohol use and frequency of sexual activity. In a 1990 Massachusetts survey of adolescents 16 to 19 years old, two-thirds reported having had sexual intercourse, 64 percent reported having sex after using alcohol, and 15 percent reported having sex after using drugs (MacKenzie, 1993).

Substance use among adolescents is associated with early sexual activity, an important factor in the prevalence of STDs and HIV infection. The use of substances combined with sexual activity significantly decreases the likelihood that a condom will be used during sex. Substance use also can decrease an individual's discrimination in the selection of sexual partners and can increase the number of partners and the likelihood of risky sexual practices (including anal intercourse), thereby heightening the risk of STDs (MacKenzie, 1993).

The CDC conducted its school-based Youth Risk Behavior Survey among a representative sample of 10,904 high school students in grades 9 through 12. Among the survey's findings were the following:

  • More than half--53.1 percent--of the students had sexual intercourse at some time. Of these, 9 percent had initiated sexual intercourse before the age of 13.
  • An estimated 17.8 percent of students had sexual intercourse with four or more sexual partners during their lifetimes.
  • Among the students, 6.9 percent reported that they had been pregnant or impregnated someone.
  • Of the currently sexually active students, 24.8 percent reported that they had used alcohol or drugs prior to their last sexual intercourse (CDC, 1994).

Another drug use consequence related to sexual behavior is unwanted pregnancy. Each year, an estimated 4.9 percent of females under age 18--nearly 200,000 young women--give birth to a live infant (NIDA, 1996b). The live birth rate among 18- to 24-year-olds is 34.7 percent (1.4 million women). Among both of these age groups, an estimated 12.4 percent used alcohol, and 21.9 percent smoked cigarettes during their pregnancies (NIDA, 1996b). Some 5.7 percent used illicit drugs (marijuana or cocaine) while they were pregnant. The risks of fetal alcohol syndrome, miscarriage, and restricted fetal growth that accompany substance use during pregnancy result in substantial economic and health costs each year.

The prevalence of early sexual activity among adolescents emphasizes the need for treatment programs to gather sexual histories and to perform HIV and STD testing in this population. Adolescents should be appropriately counseled about these tests, especially the implications of positive test results. They should be assured that the results will remain strictly confidential (see Chapter 8 for confidentiality issues).

Juvenile Delinquency and Crime

The link between adolescent substance use and juvenile delinquency is complex. There is a strong and consistent association between conduct disorder and substance use among teenagers (Crowley and Riggs, 1995). Many young people entering the juvenile justice system have a host of problems ranging from impaired emotional, psychological, and educational functioning to physical abuse, sexual victimization, and substance use disorders (Dembo, 1996). A growing trend is that most of the teenagers entering residential treatment for substance use disorders have been criminally active and mandated to treatment by the criminal justice system (Jainchill, 1997).

Drug testing data collected on male juvenile arrestees through the National Institute of Justice (NIJ) confirm a strong and continuing relationship between the extent of drug use and juvenile crime (NIJ, 1997). An additional finding from the data is that the median positive rate for marijuana use among male juvenile arrestees increased from 41 percent in 1995 to 52 percent in 1996.

Developmental Problems

Substance use can prevent an adolescent from completing the developmental tasks of adolescence, such as dating, marrying, bearing and raising children, establishing a career, and building rewarding personal relationships (Havighurst, 1972; Baumrind and Moselle, 1985; Newcomb and Bentler, 1989). Because substance use changes the way people approach and experience interactions, the adolescent's psychological and social development is compromised, as is the formation of a strong self-identity. Adolescents' use of alcohol or drugs may also hinder their emotional and intellectual growth. Some adolescents may use substances to compensate for a lack of rewarding personal relationships. Instead of developing a sense of empowerment from healthy personal development, the substance-using adolescent is likely to acquire a superficial and false self-image as he becomes more deeply entrenched in the drug experience (MacKenzie, 1993). Naturally, treating an adolescent with substance use disorders as early as possible maximizes the opportunity to stem these initially short-term, but potentially long-term, ill effects.

Treatment Needs

A recent study conducted by SAMHSA reveals that treatment for substance use disorders significantly reduces substance use and criminal activity (SAMHSA, 1998b). Administering treatment to adolescents, then, could greatly prevent future substance use related-problems as the adolescent transitions into adulthood. Understanding the relationship between substance use and adolescent development is crucial for designing effective interventions and treatment strategies. Treatment efforts that approach young people as "little adults" are bound to fail. Rather, the treatment process must incorporate the nuances of the adolescent's experience--including cognitive, emotional, moral, and social development--so that treatment providers can begin to grasp why substance use becomes a part of the identity of these young people.

Adolescence is a time when interpersonal relationships are transformed and new cognitive abilities emerge. The adolescent is for the first time forming an individual sense of self. The psychosocial changes associated with the passage into adult society occur within the context of the significant physiological changes of puberty. Social relationships move from a predominant attachment to family to an increased bonding and identification with peers. Teenagers also begin joining and identifying with institutions outside the family--schools, churches, Boy and Girl Scouts, political groups, and fan clubs. The extrafamilial bonding often has a very pluralistic character, with peer groups being only a visible and influential part.

Adherence to the family's values evolves into independent thinking and the development of a personal belief and value system. Abstract thinking, propositional logic (the ability to form hypotheses and consider possible solutions), and metacognition (the ability to think about the thought process itself) are essential abilities that develop during the adolescent years. It stands to reason that these cognitive functions are vital to the process of establishing therapeutic relationships between therapist and client, and for the client to gain insight into the adverse course of substance use, as well as to engage in behavioral change strategies.

Not all young people who experiment with substances develop clinical problems. In fact, some degree of experimentation with drugs is technically normative; that is, most adolescents have tried alcohol or illicit drugs at least once by the time they turn 18 (Johnston et al., 1995). The formidable task faced by every adolescent--to become an independent and responsible adult--is undertaken with strategies that may include exploration, experimentation, risk taking, limit testing, and questioning of established rules and sources of authority. Experimentation with substances may be among these usually functional strategies, despite the potential harm and hazard associated with this behavior. However, substance use can lead to an abusive and addictive pattern that requires more active, firm, and constant intervention.

Risk Behaviors of Adolescents

It is useful to consider substance use during adolescence within the context of the more general spectrum of risk behaviors that mark this developmental period. Problem behavior theory provides a useful conceptual framework for understanding risk behaviors during the adolescent period. Problem behavior theory defines risk behavior as behavior that can interfere with successful psychosocial development (e.g., having deviant peers), whereas problem behaviors are risk behaviors that lead to either formal or informal social responses designed to control them (e.g., substance use) (Jessor and Jessor, 1977). In other words, risk behaviors increase the adolescent's vulnerability to a problem, whereas problem behaviors incur consequences, such as discipline at home or school. As Jessor and his colleagues observed in several investigations, problem behaviors tend to cluster in an individual; for example, those who experiment with substance use also tend to engage in risky sexual practices and illegal behavior (Jessor, 1991).

Risk behaviors can become a "risk behavior syndrome" (DuRant et al., 1995a, 1995b) in that problem behaviors serve a common social or psychological developmental goal, such as separating from parents, achieving adult status, or gaining peer acceptance. These behaviors may also help an adolescent cope with failure, boredom, social anxiety or isolation, unhappiness, rejection, and low self-esteem. One example of a risk behavior syndrome is an adolescent's reported use of substances as a means of gaining social status and acceptance from peers and, at the same time, counteracting dysphoria and feelings of low self-worth.

Tailoring Treatment to Adolescents

As noted above, treatment for adolescents with substance use disorders works best when it is provided and implemented with their particular needs and concerns in mind. In this TIP, the Revision Panel used a broad definition of treatment. Treatment is defined as those activities that might be undertaken to deal with problem(s) associated with substance involvement and with individuals manifesting a substance use disorder. Although the Panel recognizes that primary or secondary prevention of substance use is included in expanded definitions of treatment, the Panel limited the continuum of interventions to what is traditionally viewed as acute intervention, rehabilitation, and maintenance. The elements of the continuum primarily reflect the treatment philosophies of providers, with less emphasis on settings and modalities.

Regardless of which specific model is used in treating young people (e.g., 12-Step-based programs, family therapy, therapeutic communities), there are several points to remember when providing treatment for adolescents.

  • Adolescents must be approached differently than adults because of their unique developmental issues, differences in their values and belief systems, and unique environmental considerations (e.g., strong peer influences).
  • Not all adolescents who use substances are, or will become, dependent. Programs and counselors must be careful not to prematurely diagnose or label adolescents or otherwise pressure them to accept that they have a disease: This may do more harm than good in the long run.
  • Programs should be developed to take into account the different developmental needs based on the age of the adolescent; younger adolescents have different needs than older adolescents.
  • Some delay in normal cognitive and social-emotional development is often associated with substance use during the adolescent period (Newcomb and Bentler, 1989). Treatment for these adolescents should identify such delays and their connections to academic performance, self-esteem, and social considerations.
  • In addition to age, treatment for adolescents must also take into account gender, ethnicity, disability status, stage of readiness to change, and cultural background.
  • Programs should make every effort to involve the adolescent client's family because of its possible role in the origins of the problem and its importance as an agent of change in the adolescent's environment.
  • Although it may be a necessity in certain geographic areas where availability of youth treatment programs is limited, using adult programs for treating adolescents is ill-advised. If this must occur, it should be done only with great caution and with alertness to the inherent complications that may threaten effective treatment for these young people.
  • Many adolescents have explicitly or implicitly been coerced into attending treatment. However, coercive pressure to seek treatment is not readily conducive to the behavior change process. Consequently, treatment providers must be sensitive to motivational barriers to change at the outset of intervention. There are several strategies suggested by Miller and Rollnick for encouraging reluctant clients to consider behavioral change (Miller and Rollnick, 1991). Figure 1-2 provides an overview of several of these strategies.

Figure 1-2: Contrasts Between Confrontation of Denial and Motivational Interviewing.

Table

Figure 1-2: Contrasts Between Confrontation of Denial and Motivational Interviewing.

The rest of this document guides providers through the process of treating adolescents with substance use disorders. Chapter 2 covers factors to consider in making treatment decisions. Chapter 3 details the features of successful programs. Chapters 4, 5, and 6, respectively, introduce and describe the treatment approaches used in 12-Step-based programs, in therapeutic communities, and in family therapy. Chapter 7 discusses adolescents with distinctive treatment needs, such as homeless and runaway youth, youth with coexisting disorders, and youth involved in the juvenile justice system. Chapter 8 describes the legal and ethical issues that relate to diagnosis and treatment of adolescents.

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