Evidence-Based Reviews

Crossing the line: When does teen substance use become abuse or dependence?

Current Psychiatry. 2003 July;2(7):31-41

References

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Table 1

Diagnostic criteria for substance abuse and dependence

Substance abuse	1 of these 4 symptoms in a 12-month period: Role impairment Hazardous use Legal problems associated with use Social problems
Substance dependence	At least 3 of the following: Tolerance Withdrawal Using more or longer than intended Attempting to quit or cut down Much time spent using Activities given up to use Psychological/physical problems resulting from use Subtyped as with or without physiologic features (tolerance or withdrawal symptoms)
Source: DSM-IV-TR

Marijuana may be detected in the urine for 3 days to 4 weeks, depending on level of use. Cocaine can be detected for 2 to 4 days in urine and longer in hair analysis.

Random screening. Adolescents who use drugs usually know how long substances can be detected, so random urine drug screening is important to treatment progress. We inform adolescents at the beginning of treatment that random screening will be performed to corroborate self-report of substance use. To ensure a reliable urine sample, same-gender staff observe while the adolescent gives the sample.

Table 2

Common screening instruments for alcohol and drug use in adolescents

Instrument	Items (#)	How administered	Administration time
Drug Use Screening Inventory (DUSI-R), Revised	159	Self-report	20 to 40 minutes
Problem-Oriented Screening Instrument for Teenagers (POSIT)	139	Self-report	20 to 30 minutes
Teen Addiction Severity Index (T-ASI)	133	Clinician	20 to 45 minutes
Comprehensive Adolescent Severity Inventory (CASI)	245	Clinician	Varies with experience of administrator
Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS)	14	Self-report	About 5 minutes
Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS)	14	Self-report	About 5 minutes

STEP 2: IDENTIFYING PSYCHIATRIC COMORBIDITY

In adolescents, substance use disorder frequently goes hand-in-hand with psychiatric disorders, particularly:

mood and anxiety disorders
disruptive disorders (attention-deficit/hyperactivity, oppositional defiant, and conduct disorders)¹²
and posttraumatic stress disorder.¹³

Uncontrolled psychiatric disorders may sabotage substance abuse treatment. Therefore, assess any adolescent presenting with substance use for psychiatric illness.

Did psychiatric symptoms predate or postdate substance use? The answer may suggest self-medication or a substance-induced phenomenon. This assumption does not always apply, however, as many factors affect the relationship between substance use and psychiatric disorders.

Adolescents who meet DSM-IV criteria for conduct disorder—especially those who are highly aggressive—tend to initiate substance use much earlier than adolescents without conduct disorder, and they continue their use longer.

Most adolescents with comorbid psychiatric and substance use disorders develop the psychiatric disorder first. Some report using various substances to medicate their psychiatric symptoms. Early diagnosis and treatment of the psychiatric disorder may prevent or decrease the adolescent’s substance use.

STEPS 3 AND 4: EVALUATING SOCIAL INFLUENCES AND CONSEQUENCES

Social influences that contribute to adolescent alcohol and drug abuse include family dynamics and peer relationships. Consequences include educational and legal problems. We explore these areas with the adolescents and their parents/guardians. In most cases, adolescents are honest when reporting how their alcohol or drug use has affected their lives.

What is his family like? Assess the adolescent’s family, including its structure and history of substance abuse, psychiatric illness, or trauma (Table 3). Adolescents whose parents or siblings use alcohol or drugs are at increased risk for substance use.¹⁴ To what extent this association is genetic, environmental, or both is undetermined, but the genetic influence increases as adolescents age.¹⁵

Who are her friends? Adolescents who try alcohol or drugs and continue to use them tend to have peers who use these substances.¹⁶ Moreover, the severity of adolescents’ substance use is correlated with the number of substance-using peers. To explore peer relationships, ask about:

peer group composition, including whether peers use alcohol or drugs
peer interactions, including the adolescent’s ability to assert him- or herself in the peer group
markers for risky sexual behaviors related to substance use, including infection with HIV and other sexually transmitted diseases.

How is she doing in school? Inquire about the teen’s academic performance, attendance, disciplinary problems, and motivation. Even a small decline in school performance or an increase in disciplinary problems that result in suspension or expulsion can indicate substance use or other at-risk behaviors.

Poor grades or attendance problems suggest but are not the only clues to substance use. Some adolescents with good school performance engage in substance use and may be impaired in other life domains.

Has he been arrested? Substance-abusing adolescents tend to engage in delinquent behaviors, including shoplifting, vandalism, curfew violations, disorderly conduct, and drunken driving. When assessing for delinquency, ask about behaviors that did or did not result in arrest. The teen who avoided arrest for illegal activities may perceive his/her behaviors as less severe than those involving arrest, and it may help to address this denial in individual or group therapy.

Table 3

Questions to assess family influence on an adolescent’s substance use

Family structure
With whom does the adolescent live? How many people live in the home? What is the quality of the adolescent’s relationship with parents and siblings?
Parenting styles
Are parents authoritative or permissive? What disciplinary methods are used? How is conflict managed?
Substance abuse
Are any family members using alcohol or drugs? Is there a family history of substance abuse or dependence? What has been the extent of treatment?
Psychiatric disorders
Do any family members have psychiatric disorders (diagnosed or not)? What treatments were given? Outcome? What treatment does the family perceive to have been most effective?
Trauma
Has the adolescent experienced physical or sexual abuse or other trauma?