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  • Adolescent Substance Abuse: National Trends, Consequences, and Promising Treatments

  • by Sara J. Becker, PhD

    Adolescents who use alcohol or drugs experience a more complex set of problems than adults who use the same substances. Compared to adult substance users, adolescents who drink alcohol or use drugs have more rapid progression from casual use to substance abuse, longer substance use careers, and a greater number of co-occurring psychiatric problems. Problems related to adolescent substance use tend to persist into adulthood, with the majority of adult substance abusers reporting that they first used during adolescence. Consequently, the early identification and effective treatment of adolescent substance use has been identified as a major public health priority.

    Teen Alcohol Use

    May 2013 Vol. 29, No. 5

    CABL logo

    This article was published in the Brown University Child and Adolescent Behavior Letter
    in cooperation with Bradley Hospital.

    The vast majority of adolescents who use substances report a level of experimentation that does not meet criteria for a diagnosable substance use disorder. Experimentation with alcohol and illicit drugs is becoming increasingly common among all adolescents, and especially among older teenagers. For the past 33 years, the Monitoring the Future survey has annually tracked the rates of alcohol and drug use among adolescents in the United States. In 2011, 47,000 students in the 8th, 10th, and 12th grades from 400 schools participated in the survey. Rates of illicit drug use reported by the adolescents were higher than in 2010, continuing a 4-year trend of steady increases. Among 12th graders, 50% reported having tried illicit drugs at least once, 40% reported using illicit drugs within the past year, and 25% reported using within the past month.

    Rates were somewhat lower among younger adolescents, although still very high. The 10th graders reported the following rates of illicit drug use: 38% lifetime, 31% within the past 12 months, and 19% within the past month. Among the 8th graders, corresponding rates were 20%, 15%, and 8.5%. Survey questions about specific drugs indicated that marijuana was the most commonly used drug, with rates of use on the rise for both natural and synthetic forms of marijuana (e.g., Spice and K-2).

     

    Resources

    The National Institute on Drug Abuse for Teens (NIDA for Teens) website — provides relevant information for teenagers about alcohol and drugs including common myths, how specific drugs affect the body, learning activities, and blogs and videos created by other teenagers. There are also sections for parents and educators: http://teens.drugabuse.gov/

    American Psychological Association Division 53 (Child & Adolescent Psychology) website — contains user-friendly information for professionals and parents on youth mental health and substance use symptoms, specific treatment models, and how to find a local treatment provider: www.effectivechildtherapy.com

    The Adolescent Substance Abuse Knowledge Base (ASK) website — contains information for parents on common drugs, symptoms of specific drugs, and when and how to seek help: www.adolescent-substance-abuse.com/

    The risk of negative outcomes increases significantly for those adolescents who progress from experimentation to a diagnosable substance abuse disorder. Among adolescents between the ages of 12 and 17 years old, about 8% meet full diagnostic criteria for substance abuse or dependence. To be diagnosed with substance abuse, an adolescent’s substance use needs to have reached the level that it is interfering with his/her functioning at home, with friends, or at school or work. A diagnosis of substance dependence is more severe and is often associated with physical symptoms such as requiring more of the substance to get the same high, inability to cut down or stop using, and using more or for longer periods of time than intended.

    Adolescent substance use disorders have been associated with a range of negative outcomes including school dropout, strained family relationships, and delinquency. Of particular concern, adolescent substance use disorders have been linked with leading causes of death among youth: suicide, accidents, and violent crime.

    Fortunately, several therapy models that have been adapted specifically for adolescent substance abusers have been found to be effective in rigorous studies. In 2008, Waldron and Turner reviewed prior studies of adolescent substance abuse treatment. This review found that the treatment models with the most research support were cognitive behavioral therapy (specifically when delivered in group format) and family therapy (specifically “multidimensional family therapy” and “family functional therapy”). Due to the methods used in the review, interventions specifically designed to increase the adolescent’s motivation were not included in the analysis; however, many of the CBT models included in the review contained sessions specifically designed to increase the adolescent’s motivation for change.

    Another 2008 review by Becker and Curry rated the research support for different treatments based on the quality of the methods used in prior studies. In this review, cognitive behavioral therapy, family therapy models (specifically those that used an “ecological” or multi-systems approach) and brief motivation-building interventions were the models supported by the highest quality evidence.

    Taken together, these two reviews provide consistent evidence in support of cognitive behavioral therapy and family therapy, as well as some evidence in support of brief motivation-building treatments. These three intervention models are briefly described in the sections below.

    Cognitive Behavioral Therapy

    Cognitive behavioral therapy (CBT) is short-term intervention built on the premise that thoughts, feelings, and behaviors are all inter-related. According to the cognitive- behavioral model, adolescents use substances as a maladaptive way of coping with environmental circumstances or getting needs met. Treatment aims to help adolescents replace their drinking or drug use with less risky behavior by recognizing triggers of their use, avoiding those circumstances if possible, and coping more effectively with problems that lead to increased use.

    While specific CBT models vary in the extent that they emphasize changing behavior, modifying thoughts, and teaching new coping skills, most models contain two key components: functional analysis and skills building. In a functional analysis, the therapist and adolescent work collaboratively to identify the specific thoughts, feelings, and circumstances the adolescent had before and after drinking or using drugs. This exercise helps the adolescent to identify high-risk situations that lead to increased use, while gaining insight into why s/he drinks or uses drugs in those situations. The therapist applies the information obtained through functional analysis to identify specific areas where the adolescent would benefit from learning or practicing new skills.

    Skills that a CBT therapist would commonly consider include: questioning and testing the adolescent’s assumptions about substance use, practicing assertiveness to resist peer pressure, building a social network supportive of recovery, introducing pleasant activities to replace substance use, problem solving during high risk situations, and coping with cravings. To address the developmental needs of adolescents, CBT therapists might choose to combine these core skills with motivation enhancement, parent education, school outreach, and treatment of comorbid conditions.

    Family Therapy Models

    Family therapy is a type of treatment that targets the entire family system. Families are viewed as interconnected units in which the actions of any one family member can affect each of the other family members and the family unit as a whole. In line with this view, family therapists recognize that the family can play a major role in the onset and maintenance of an adolescent’s problems with substance use, and that the adolescent’s substance use can in turn affect all of the other family members. Family therapists avoid blaming any one individual for problems within the family, and instead work to identify interaction patterns that might be contributing to the problem.

    The family therapy models that have been found to be most effective for substance abuse tend to use an ecological or multi-systemic approach. This approach is based on the belief that substance abuse is determined by the interplay of multiple factors, including the individual, family, school, peer, and community.

    Treatment begins with a comprehensive assessment to identify the specific systems that are contributing to the adolescent’s substance abuse (e.g., peer pressure, family interactions, etc.). The assessment then determines the course of treatment, with the therapist often working to address simultaneously the various systems affecting the adolescent. Several of the ecological family therapy models for adolescent substance abuse call for intensive treatment, with multiple sessions offered each week in the family’s home.

    Brief Motivational Interventions

    Interventions designed to increase an adolescent’s motivation tend to be extremely brief (e.g., 1–2 sessions). These interventions first emerged in the 1980’s and evolved out of the recognition of two basic principles. First, clients enter therapy with varying levels of readiness to change their behaviors. Second, teaching clients new skills to change their behaviors is less likely to be successful if the clients are not sufficiently motivated to make changes. Treatment is therefore designed to help clients build their motivation for change by helping them to acknowledge discrepancies between their goals and current behaviors.

    Brief motivational interventions are both client-centered and semi-directive; while the specific goals and reasons for change come from the client, the therapist takes an active role in encouraging the client to consider making changes in their lives. One of the primary therapeutic techniques used in motivational interventions is the weighing of pros and cons of changing versus not changing. Therapists using this approach are trained to be non-judgmental, nonadversarial, and non-confrontational in their interactions with the adolescent. These interventions can be used as a stand-alone technique or can be combined with other interventions.

    In summary, the early identification and effective treatment of adolescent substance abuse can help to reduce the risk of a range of negative health outcomes. Specific treatment models that have been found to be effective for adolescent substance abusers include cognitive behavioral therapy, family therapy, and brief motivational interventions. Many clinics and agencies in the community offer variants of these treatment models to adolescents with a substance use problem or diagnosis. Treatment providers interested in learning more about adolescent substance abuse and its treatment, or interested in sharing educational materials with families, can access the resources below for additional information.


    Sara J. Becker, PhD, is a staff psychologist at Rhode Island Hospital and assistant professor of psychiatry and human behavior at Brown University.


    References

    Becker SJ, Curry JF: Outpatient interventions for adolescent substance abuse: A quality of evidence review. J Consult Clin Psychol 2008; 76:531–544.

    Johnston LD, O’Malley PM, Bachman JG, et al.: Monitoring the Future national results on drug use: 2012 Overview, Key Findings on Adolescent Drug Use. Ann Arbor: Institute for Social Research, University of Michigan, 2013.

    Waldron HB, Turner CW: Evidence-based psychosocial treatments for adolescent substance abuse. J Consult Clin Psychol 2008; 37:238–261.