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	Substance Abuse Additional information about child and adolescent substance abuse is available from: National Institute on Drug Abuse Substance Abuse Treatment for Children and Adolescents: Questions to Ask, an excellent resource from the American Academy of Child & Adolescent Psychiatry. For information on treatments for substance abuse that are available through CARE-NET, see Studies.	What is Substance Abuse? Substance Abuse Substance Dependence Incidence Symptoms Treatment Abstinence Harm Reduction Rehabilitation Characteristics of Successful Treatment Group Treatment Factors Affecting the Choice of Treatment Setting Family Interventions What is Substance Abuse? Substance use and abuse by children and adolescents remains a critical problem for modern developed countries. Although tolerance and public policy for substance use varies among Western countries, the use of psychoactive substances and other harmful of abuse is common among adolescents. The use of such psychoactive agents can lead to a variety of negative consequences for youth. The term “substance use disorders” encompasses both *substance abuse* and *substance dependence, under the DSM-IV category of substance–related disorders. Substance use disorders are defined for alcohol* amphetamine amphetamine-like caffeine cannabis cocaine hallucinogens inhalants nicotine opioids phencyclidine (or phencyclidine-like) sedative-hypnotic anxiolytics Although these symptoms apply to both children and adolescents, adolescents are most frequently referred to due to the less frequent occurrence of SUDs in prepubertal children. back to top Substance Abuse The diagnosis of substance abuse requires evidence of a maladaptive pattern of substance use with clinically significant levels of impairment or distress. Substance Abuse is characterized by a maladaptive pattern of substance use. Recurrent use in adolescents who abuse substances results in an inability to meet major role obligations, leading to impaired functioning in one or more major areas of their life, and an increase in the likelihood of legal problems due to possession, risk-taking behavior, and exposure to hazardous situations. back to top Substance Dependence Substance Dependence requires a substantial degree of involvement with a substance as evidenced by the adolescent meeting at least 3 criteria: withdrawal tolerance loss of control over use Adolescents commonly exhibit tolerance (i.e., requiring increasing amounts of a substance to achieve the same effect), which is one criterion for dependence, but show withdrawal or other symptoms of physiological dependence much less frequently. Tolerance, in the case of adolescent alcohol use, appears to have a low specificity for a diagnosis of alcohol dependence among adolescents, while withdrawal symptoms and medical problems as a consequence of use are much less common than in adults. However, increasing research points to a high prevalence of withdrawal symptoms in adolescents with cannabis and opiate use disorders. Preoccupation with use is often demonstrated by giving up previously important activities, increasing the time spent in activities related to substance use, and using more frequently or for longer amounts of time than planned. The adolescent may use despite the continued existence or worsening of problems caused by substance use. For adolescents, it is important to include criteria such as alcohol-related blackouts, craving, and impulsive sexual behavior when determining if criteria are met. Polysubstance use by adolescents appears to be the rule rather than the exception; therefore, adolescents often present with multiple SUD diagnoses back to top Incidence In the United States, substances such as opiates, LSD, inhalants, and steroids have shown periodic epidemics among youth in the past several decades. In 2000: nearly a quarter of eighth graders report having taken an alcoholic beverage in the past 30 days. half of 12^th graders report having done so. A third of 12^th graders report having been drunk in the past 30 days. Almost 12 per cent of eighth graders and almost a quarter of high school seniors report having used any illicit drug in the preceding 30 days. In community studies, lifetime diagnosis of DSM-IV alcohol abuse range from 0.4% to 9.6%. Lifetime diagnoses of alcohol dependence range from 0.6% to 4.3% in the Oregon Adolescent Depression Project. The lifetime prevalence of drug abuse or dependence has ranged from 3.3% in 15 year olds to 9.8% in 17 to 19 year olds. Other than alcohol, 54 percent of 12 graders and almost 27 percent (26.8%) of eighth graders report ever having used any illicit drug. Marijuana is the most widely used of the illicit drugs with about a third of high school students indicating some use in the preceding 12-month period. Six percent of high school seniors report daily marijuana use. Overall, school surveys show that the lifetime prevalence of illicit drug use is highest in the USA and Australia (>40%) and high in Canada (>35%), but less than 20%-25% in Europe. As of 2000, cigarette smoking among adolescents in the U.S. has continued a decline from a peak in the mid-90s. An almost 50 percent increase in the rate of smoking among younger adolescents (8^th and 10^th graders) in the early 1990s. In 2000, 14.6 percent of 8^th graders reported current smoking (defined as smoking at least once in the preceding 30 days) while 23.9 percent of 10 graders and 31.4 percent of 12^th graders reported current cigarette use. Approximately a quarter (24.7 percent) of students nationwide reported having smoked a cigarette before the age of 13 years. back to top Symptoms Patients who present with substance use, and frequently resulting intoxication, often manifest significant levels of acute change in mood, cognition, and behavior. The manifestations of substance use and intoxication vary with: the type of substance(s) used. the amount used during a given time period. the setting and context of use. a host of characteristics of the individual such as: experience with the substance expectations the presence or absence of other psychopathology Behavioral changes may include: disinhibition lethargy hyperactivity or agitation somnolence hypervigilance Changes in cognition may include: impaired concentration changes in attention span perceptual and overt disturbances in thinking, such as delusion Mood changes can range from depression to euphoria. A hallmark of SUDs in adolescents is impairment in psychosocial and academic functioning. Impairment can include: family conflict or dysfunction interpersonal conflict academic failure Associated characteristics include: deviant and risk-taking behavior comorbid psychiatric disorders such as conduct, attention-deficit/hyperactivity, mood, and anxiety disorders back to top Treatment Many adolescents with SUDs also have co-existing psychiatric conditions that cannot be adequately described within a single DSM-IV diagnostic category. Some conditions, such as disruptive behavior disorders (i.e., oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder [ADHD]) and mood disorders (e.g., major depressive disorder and bipolar disorder), coexist with adolescent SUDs more often than not. Knowledge of the assessment and treatment of these disorders is essential for the adequate management of SUDs. In view of the frequency of comorbidity in adolescents, the clinician should consider, but not be limited by, the practice parameters applicable to both the substance use and the comorbid psychiatric disorder. However, the optimal treatment of adolescents with SUD and psychiatric comorbidity involves an integration of treatment modalities rather than merely concurrent or consecutive treatment with specific modalities for either SUD or psychiatric disorder(s). back to top Abstinence The primary goal for the treatment of adolescents with SUDs is achieving and maintaining abstinence from substance use. While abstinence should remain the explicit, long-term goal for treatment, a realistic view recognizes both the chronicity of SUDs in some populations of adolescents and the self-limited nature of substance use and substance use related problems in other adolescent populations. back to top Harm Reduction Given these considerations, harm reduction, that is, reduction in the use and adverse effects/ consequences of substances a reduction in the severity and frequency of relapses improvement in one or more domains of an adolescent’s functioning may be an acceptable interim, implicit goal for treatment. Included in the concept of harm reduction is a reduction in the use and adverse effects of substances, a reduction in the severity and frequency of relapses, and improvement in one or more domains of the adolescent's functioning (e.g., academic performance or family functioning). Despite an acceptance of harm reduction as an interim goal for treatment, clinicians should discourage "controlled use" of any non-prescribed substance of abuse as an explicit goal in the treatment of adolescents. back to top Rehabilitation Abstinence or decreased substance use should not be the only goal of treatment. The broad concept of rehabilitation involves targeting associated problems and domains of functioning for treatment. Integrated interventions that concurrently deal with coexisting psychiatric and behavioral problems family functioning peer and interpersonal relationships academic/vocational functioning will produce not only general improvements in psychosocial functioning, but will most likely yield improved outcomes in the primary treatment goal of achieving and maintaining abstinence. back to top Characteristics of Successful Treatment The important characteristics of successful treatment are sufficient duration Intensiveness and comprehensiveness The presence of after-care or follow up treatment(s) Sensitivity to cultural, racial and socioeconomic realities of adolescents and their families, family involvement Collaboration with social services agencies Promotion of pro-social activities and a drug-free lifestyle Consideration of involvement in peer-based self-support groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). back to top Group Treatment A controversial element of traditional treatment programs in the widespread use of group treatment. There is substantial evidence that group treatment can have significant negative effects on outcomes. Further emerging data suggests this iatrogenic effect may be limited to more deviant, conduct-disordered youth who nevertheless make up a substantial portion of the adolescent SUD treatment population. Clinicians should take caution when formulating groups for treatment and should consider alternative family-based or other modalities for more deviant youth. back to top Factors Affecting the Choice ofTreatment Setting Treatment of adolescents with SUDs can take place at one of several levels of care, reflecting intensity of treatment and restriction of movement. Factors affecting the choice of treatment setting include: motivation and willingness of the adolescent and his/her family to cooperate with treatment the adolescent’s need for structure and/or limit-setting that cannot be provided in a less restrictive environment the need to provide a safe environment and the ability of the adolescent to care for him/herself the existence of additional medical and/or psychiatric conditions the availability of specific types of treatment settings for adolescents the adolescent’s and his/her family’s preferences for a particular setting treatment failure in a less restrictive setting or level of care. back to top Family Interventions Family Interventions are critical to the success of any treatment approach with adolescents with SUDs, since a number of family-related factors, such as parental substance use or abuse, poor parent-child relationships, low perceived parental support, low emotional bonding, and poor parent supervision and management of the adolescent's behavior, have been identified as risk factors for the development of substance abuse among adolescents. back to top Source: "Substance Abuse Disorders," Oskar Bukstein, M.D., M.P.H., chapter in Clinician's Deskbook of Child and Adolescent Psychiatry.