xxAACP Newsletter, Volume 11, Number 2, Spring 1997
Addressing Adolescent Substance Use
As with adult substance use disorders, biology may play a significant role in determining an adolescent's vulnerability to problem substance use. While we have the most evidence for genetic transmission from studies related to alcohol use, there is now good reason to believe that genetic factors may not be substance specific. Clearly, as with adults, some kids seem to respond with greater sensitivity to a given dosage of a substance, showing greater behavioral and physiologic alterations than their peers. Enviornmental factors also play a significant role in the development of substance use disorders. The availabilty of substances and low socio-economic indicators place kids in danger. Social factors, such as gang activity, are frequently an element of the environment making a contribution to increased risk. Peer groups and peer norms play a large role for all kids of this age, and real or perceived peer pressure into drug use and often sustains it. When predominant cultural mores accept or encourage drug or alcohol use, especially if robust use is seen as a right or passage, this external pressure to use is increased. Parental substance use also puts kids at risk for problem use, even beyond whatever biologic contribution it might make. Parents who model uncontrolled and irresponsible use of substances and those who display tacit approval of use by their children, will obviously contribute to their child's chances for developing problematic use. The traumatic impact of family chaos and disruption on a child is well documented and these circumstances often lead to a child to become involved with substance use as a temporary escape from inner turmoil.
An increased incidence of substance use disorders are also found in adolescents who are suffering from psychiatric disturbances. A large number of adolescents entering treatment of substance use disorders have some kind of co-existing psychiatric disorder. As with adults, the primary vs. secondary disorder distinction is often not very helpful. Whether psychiatric problems occur first and are followed by substance use or vice versa, the problems usually become inextricably intertwined and require concurrent attention. Substance use often exacerbates the symptoms and increases the severity of the course of psychiatric illness, and mental illness often makes it more difficult for a kid to recognize the significance of a substance use problem, and to engage productively to get the problem under control. Kids presenting with psychiatric symptoms and concurrent substance use create some real diagnositc difficulties. It is often very difficult to determine whether what we are seeing represents substance induced psychiatric symptoms or whether symptoms represent an independently existing psychiatric disorder. Conduct disorder, attention deficit disorder, depression, and anxiety disorders are the psychiatric disorders which are most commonly associated with adolescent substance misuse. It is important to remember that almost any psychiatric syndrome can be mimicked by the right combination and dosage of substances. Since treatment approaches may be quite distinct for these two groups, it is important to take some care in coming to diagnostic conclusions. We need to recognize that labels may follow a kid around for a long time and can lead to a varietly of misgiuded interventions bases on assumptions that may be faulty.
Identification of adolescents at the greatest risk for substance use problems allows us to design targeted prevention efforts and to identify existing substance use problems before they progress into severity. If we are going to be able to serve these kids efffectively, we need to find ways to engage them and to keep them involved in treatment and prevention programs. We need to design our treatment programs in a manner that can address both substance use and commonly occurring psychiatric problems. To be successful in these endeavors, it i simportant to recognize the potential barriers to accomplishing our goals.
Perhaps the most obvious obstacle are the kids themselves. Many have already developed a healthy contempt for anyone who represents authority. They often see care providers as extensions of an oppressive system. There are often significant peer pressures not to be a "brown nose" and to remain aloof and ostensively in control. Drug use retards development and thereby these kids are overusing immature defenses; denial, minimization, displacement, projection, projective identification, and splitting to name a few. Alienation is a significant experience for many troubled teens, and cultural, class or racial difference between these kids and potential supports may enhance these feelings and be used as an excuse to maintain distance and avoid risking intimacy.
Clinicians may encounter significant internal barriers to engaging thse youngsters. Personal vulnerability and the inability to honestly confront it may be one source of difficulty. Family experiences with substance misuse may also make working with this population difficult, particularly if enabling and denying behaviors were marked responses to these problems in the past. For many, the adolescent's anger is difficult to tolerate and may be easily personalized. For the clinician who wishes "to be liked" and to "fix problems", working with substance using adolescents may be an extremely frustrating experience. Likewise, for those who have low tolerance for uncertaintly and need to feel as if they are in control of circumstances. Power struggles commonly undermine the therapeutic process, and adolescents seem to have considerable expertise in initiating these types of interactions.
Despite these obstacles, and additional institutional barriers that obstruct engagement, there are some principles which may facilitate interactions with substance using adolescents. Programs should provide clear and consistent structure and provide realistic expectations for establishing behavioral changes. Although overly rigid behavioral regulation will tend to alienate these kids further, inconsistent and overly tolerant attitudes will not allow needed discipline to be internalized. Clinicians must be able to enforce expectations without anger and to maintain humility. Adolescents are quite sensitive to negative judgements, disrespect and dishonesty, and it will be quite difficult for them to develop adequate trust if they sense their presence. It is therefore of great importance that clinicians monitor their own reaction and feelings toward their charges and avoid potentially destructive communications. Staff should be able to demonstrate appropriate behavior and values through their own actions. Adolescents must be guided toward developing responsible autonomy and this can best be accomplished by providing reasonable choices and by avoiding authoritarian and defensive attitudes.
Programming a full continuum of services to meet adolescent needs will of course be important ingredient in the quest to reduce destructive substance use in adolescents, but in the absence of an appropriate enviornment to accomplish this work, success will often be elusive.
This article first appeared in the National Council News and is reprinted here by permission.
Back to Spring 1997 Table of Contents