Evidence-Based Reviews

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

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

Many adolescents are ‘diagnostic orphans,’ whose behavior falls short of DSM-IV criteria but clearly shows substance use patterns.

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References

1. Johnston LD, O’Malley PM, Bachman JG. Monitoring the Future: national results on adolescent drug use. Overview of key findings, 2002. Bethesda, MD: National Institute on Drug Abuse, 2003 (in press).

2. Martin CS, Kaczynski NA, Maisto SA, et al. Patterns of DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. J Stud Alcohol 1995;56:672-80.

3. Pollock NK, Martin CS. Diagnostic orphans: adolescents with alcohol symptoms who do not qualify for DSM-IV abuse or dependence diagnoses. Am J Psychiatry 1999;156:897-901.

4. Harrison PA, Fulkerson JA, Beebe TJ. DSM-IV substance use disorder criteria for adolescents: a critical examination based on a statewide school survey. Am J Psychiatry 1998;155:486-92.

5. Grant BF, Dawson DA. Age at onset of alcohol use and its association with DSM-IV alcohol abuse/dependence: results from the National Longitudinal Alcohol Epidemiological Survey. J Subst Abuse 1997;9:103-10.

6. Tarter RE, Laird SB, Bukstein O, Kaminer Y. Validation of the adolescent drug use screening inventory: preliminary findings. Psychol Addict Behav 1992;6:322-6.

7. Rahdert E (ed). The adolescent assessment/referral system manual. DHHS pub. no. (ADM) 91-1735. Rockville, MD: U.S. Department of Health and Human Services, 1991.

8. Kaminer Y, Bukstein OG, Tarter RE. The teen addiction severity index (T-ASI): rationale and reliability. Int J Addict 1991;26:219-26.

9. Meyers K, McLellan AT, Jaeger JL, Pettinati A. The development of the Comprehensive Addiction Severity Index for Adolescents (CASI-A): an interview for assessing multiple problems of adolescents. J Subst Abuse Treat 1995;12:181-93.

10. Deas DV, Roberts JS, Randall CL, Anton RF. Adolescent Obsessive-Compulsive Drinking Scale (A-OCDS): an assessment tool for problem drinking. J Natl Med Assoc 2001;93:92-103.

11. Deas D, Randall CL, Thomas S. The utility of the Deas-Marijuana Obsessive-Compulsive Scale (Deas-MOCS) in an inpatient adolescent substance abusing sample. Drug Alcohol Depend 2002;66(June):S43.-

12. Deas-Nesmith D, Campbell S, Brady KT. Substance use disorders in an adolescent inpatient psychiatric population. JAMA 1998;90:233-8.

13. Clark DB, Lesnick L, Hegedus AM. Traumas and other adverse life events in adolescents with alcohol abuse and dependence. Am Acad Child Adolesc Psychiatry 1997;36:1744-51.

14. Kilpatrick DG, Acierno R, Saunders B, et al. Risk factors for adolescent substance abuse and dependence: data from a national sample. J Consult Clin Psychol 2000;68:19-30.

15. Rose RJ. A developmental behavioral-genetic perspective on alcoholism risk. Alcohol Health Res World 1998;22:131-43.

16. Swadi H. Individual risk factors for adolescent substance use. Drug Alcohol Depend 1999;55:209-24.

17. Azrin N, McMahon P, Donohue B, et al. Behavior therapy for drug abuse: a controlled treatment outcome study. Behav Res Ther 1994;32:857-66.

18. Kaminer Y, Burleson JA, Goldberger R. Cognitive-behavioral coping skills and psychoeducation therapies for adolescent substance abuse. J Nerv Ment Dis 2002;190:737-45.

19. Liddle H, Dakof G. Efficacy of family therapy for drug abuse: promising but not definitive. J Marital Fam Ther 1995;21:511-43.

20. Waldron HB. Adolescent substance abuse and family therapy outcome: a review of randomized trials. Adv Clin Child Psychol 1997;19:199-234.

21. Henggeler SW, Melton LA. Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: a progress report from two outcome studies. Family Dynamics of Addiction Quarterly 1991;1:40-51.

22. Jaffe S. Step workbook for adolescent chemical dependency recovery. Washington, DC: American Academy of Child and Adolescent Psychiatry, 1990.

23. Deas DV, Randall C, Roberts J, Anton R. A double-blind, placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study. Human Psychopharmacology Clinical and Experimental 2000;15:461-9.

24. Geller B, Cooper T, Sun K, et al. Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. J Am Acad Child Adolesc Psychiatry 1998;37:171-8.

Assessing an adolescent for a possible substance use disorder can be streamlined by choosing age-appropriate screening tools and asking targeted questions. Based on our experience, we offer a 4-step approach to these at-risk patients¹ (Box) that focuses on:

quantifying alcohol or drug abuse and/or dependence
identifying and treating psychiatric comorbidity
evaluating and addressing social influences that contribute to substance use
assessing negative consequences associated with substance abuse.

Box

Portrait of adolescent substance abuse

Adolescent substance use increases the risk of motor vehicle accidents, suicide, transmission of HIV and other sexual diseases, criminal behaviors, and psychological problems. Alcohol and marijuana are the substances most commonly abused by adolescents.

In 2002, the University of Michigan Institute for Social Research’s annual “Monitoring the Future” study reported:

drunkenness in 7% of 8th graders, 18% of 10th graders, and 30% of 12th graders at least once in the previous 30 days.
illicit drug use by 18% of 8th graders, 35% of 10th graders, and 41% of 12th graders in the previous 12 months.

Boys used substances more frequently than girls, and boys’ use was more severe. Within the previous month, boys reported greater alcohol use, binge drinking (five or more drinks in one sitting), and heavy drinking, as well as greater illicit drug use in the past year.¹

INITIAL EVALUATION

Adolescents generally do not seek substance abuse treatment but are referred because of alcohol- or drug-related legal, school, or family problems. Thus, most present for evaluation with their parents, legal guardians, or officers of the court.

We begin by finding out from parents or guardians the reasons for the evaluation, their perspectives on the adolescent’s behavior, and their expectations of treatment. Then we interview the adolescent alone, assessing for substance use and evaluating peer relationships.

Components. A typical initial evaluation takes 90 minutes to 2 hours and includes:

psychiatric history and symptoms
medical history
previous hospitalizations (medical and psychiatric)
family history
social history.

Specifically, the assessment focuses on the reason for the evaluation, with attention to diagnostic criteria for substance use/dependence.

STEP 1: QUANTIFYING DEPENDENCE

As with adults, clinical diagnosis of substance abuse or dependence in adolescents is based on DSM-IV diagnostic criteria (Table 1). Adolescents, however, differ from adults in diagnostic presentation, risk of dependence, and patterns of substance use.

Diagnostic ‘orphans.’ DSM-IV criteria for alcohol use disorders have limitations in adolescents.² Teens who report one or two dependence symptoms and no abuse symptoms have been described as “diagnostic orphans”³—they fall short of criteria for dependence or abuse but clearly demonstrate substance use patterns. This presentation is common; in a survey of 74,008 high school students, almost 10% of 12th graders reported one or two dependence symptoms and no abuse symptoms.⁴

Risk of dependence. Adolescents who begin using alcohol or drugs develop dependence more rapidly than adults do.⁵

Patterns of use. Adolescents are more likely than adults to binge with alcohol and drugs, which may conceal the severity of their abuse. DSM-IV diagnostic criteria for substance abuse or dependence do not consider quantity of use, such as number of drinks or percent of days drinking or using drugs.

Assessment instruments. Many assessment instruments are available to explore adolescent substance use and its associated consequences. Some are described in detail and are available on the Internet. Common screening instruments that can be used for adolescent substance use are compared in Table 2.

DUSI-A and POSIT. Two self-report instruments—Drug Use Screening Inventory-Adolescents (DUSI-A)⁶ and Problem Oriented Screening Instrument for Teenagers (POSIT)⁷—can help explore alcohol or drug use in teens who admit to substance use. Anyone who endorses at least one DSM-IV abuse or dependence criterion requires further evaluation. Either test is a good starting point, and both have a built-in “lie” scale.

T-ASI and CASI. The Teen Addiction Severity Index (T-ASI)⁸ and Comprehensive Adolescent Severity Inventory (CASI)⁹ are more labor-intensive and require training to administer. These assessments are more appropriate for adolescents with extensive alcohol or drug abuse.

A-OCDS and Deas-MOCS. Our group recently developed the Adolescent Obsessive Compulsive Drinking Scale (A-OCDS)¹⁰ and the Deas-Marijuana Obsessive Compulsive Scale (Deas-MOCS).¹¹

These self-report instruments have been validated in treatment- and nontreatment-seeking adolescents and young adults in inpatient and outpatient populations. They are sensitive and specific in identifying problem drinkers and marijuana users, respectively, and are quick, useful screens to determine need for further assessment.

Toxicology is useful for initial assessment and to monitor substance use patterns during treatment.

Urine samples are used to assess marijuana, sedative/hypnotic, amphetamine, cocaine, opiate, and phencyclidine use. Alcohol may be detected in urine, but alcohol levels detected by blood and breath testing are more accurate.