Adolescent Substance Abuse and Other High-Risk Behaviors
Richard B. Heyman
Within the inner city and suburbia, among the poor and the affluent, in the white and nonwhite populations, among the educated and illiterate alike, virtually all children are exposed to the influence of tobacco, alcohol, and other drugs (TAOD). “Exposure” takes many forms: one out of four children grows up in a home with an alcoholic relative; the average child is exposed to many forms of protobacco and alcohol media messages on a daily basis (including movies, television and radio, magazines and newspapers, billboards, logo clothing, point-of-sale displays, the World Wide Web), and virtually all movies and 75% of television dramas contain references to TAOD use; drinking is seen as universal in many places frequented by children, including restaurants, sports venues, concerts, festivals, adult parties, and picnics; and, in fact, four out of five students have consumed alcohol by the time they graduate from high school, 80% to the point of intoxication.
Ongoing monitoring of the use of TAOD by children suggests that the youth of the United States will continue to use substances at alarming rates. When asked about usage in the previous 12 months, nearly 40% of high school seniors report marijuana use, 20% report use of other illegal drugs, and one-third are smoking and binge drinking on a regular basis. Actual use is underestimated in studies such as these because they survey only those who are in school. It is thus crucial to consider tobacco, alcohol, and marijuana use to be nearly the norm and to assess every older child and adolescent for this problem.
AT-RISK YOUTH
It is clear that there is a subset of children and adolescents who are at increased risk of substance abuse and for whom extra time should be spent on screening. It is convenient to divide these risk factors into three domains: genetic/family, personal, and community.
Genetic/Family Factors
Numerous studies have documented the role of heredity, especially for so-called type I alcoholism (the kind most common among boys and men and associated with delinquency and antisocial behavior), in which the inheritance from father to son is striking. Genetic evidence is accruing that implicates a role for abnormal dopamine receptors among those who develop alcoholism as well, and researchers continue to find clues to the biologic nature of addictive disorders in general. A family history of alcoholism increases the risk in children by a factor of 4, although fewer than one-third go on to develop the disease. Epidemiologic studies of families also suggest that family structure (disorganized versus organized) and conflict, parenting style (authoritarian or passive versus the authoritative style with its careful limit-setting), family use of TAOD, poverty, lack of religiosity or affinity with organized groups, and significant blocks of unsupervised time (“latchkey” arrangements) all represent risk factors.
Personal Factors
Children with difficult temperaments are at increased risk for the later development of substance use disorders. This is not to say that every irritable and moody child will go on to use TAOD, but children who are aggressive, oppositional, and provocative, as well as those who are risk takers and thrill–seekers, may have inborn susceptibility to drug use and may elicit parental responses that are controlling and negative. Mental health problems, including depression, anxiety, bipolar disorder, and attention deficit-hyperactivity disorder (ADHD), increase the likelihood of subsequent TAOD use. Appropriate treatment may minimize this risk, especially if these problems are identified at an early age. Distorted body image, including the feeling of being overweight or looking older or younger
than one’s actual age (associated with early or delayed puberty), is a risk factor. Low innate intelligence, disability or poor health, low sense of self-esteem and self-efficacy (the ability to affect and control one’s life), and low achievement levels promote a sense of helplessness that may lead to self-medicating with alcohol and other drugs. At the other end of the spectrum, one survey suggested that “more than half of the nation’s 12 to 17 year olds are at greater risk of substance abuse because of high stress, frequent boredom, too much spending money, or some combination of these characteristics.”
than one’s actual age (associated with early or delayed puberty), is a risk factor. Low innate intelligence, disability or poor health, low sense of self-esteem and self-efficacy (the ability to affect and control one’s life), and low achievement levels promote a sense of helplessness that may lead to self-medicating with alcohol and other drugs. At the other end of the spectrum, one survey suggested that “more than half of the nation’s 12 to 17 year olds are at greater risk of substance abuse because of high stress, frequent boredom, too much spending money, or some combination of these characteristics.”
Community Factors
Youth living in neighborhoods where tobacco and alcohol laws are not regularly enforced, where drugs are freely bought and sold, and where users inhabit doorways and parks will be exposed to more opportunities to use as well as the sense that such use is, in fact, normal and acceptable. Where recreational facilities are not available or are not safe, youth will congregate without organized activities. Schools riddled with drugs may not provide appropriate educational and extracurricular opportunities, and the youngster who is not well motivated may founder in such an environment.
ROUTINE SCREENING IN THE OFFICE SETTING
The topic of TAOD use must be addressed as pediatricians interact with families. Prenatal visits should review the impact of maternal TAOD use on the fetus, and visits throughout childhood should stress to the parents the importance of avoiding tobacco smoke exposure, being steadfastly opposed to the use of drugs, and modeling appropriate use of alcohol.
The discussion with children should begin at an early age. The role of media exposure is incontrovertible, and seemingly trivial things such as having a favorite beer commercial or spokesperson (celebrity or animated) and playing with candy cigarettes predict interest in and later use of beer and cigarettes. With the increase in counteradvertising on television, a forum has been opened up through which pediatricians can encourage discussion between parents and their young children.
By the time children reach middle school (age 10 years at the latest), an inventory of personal psychosocial questions should be incorporated into every visit. A discussion of so-called “risk and protective factors” is a useful framework for identifying those youth at risk for substance abuse, and young people and their parents should become accustomed to the care provider’s discussing these issues in an open and nonjudgmental way each time they come into the office. Asking about whether the family has discussed sensitive topics such as TAOD use, puberty and sexuality, violence, bullying, and illegal activities and whether the child has had a TAOD prevention program in school may be nonconfrontational ways to begin the discussion of the subject. The issue of confidentiality should be addressed as well, and separate, private discussions with the patient and family should begin at an early age.
Parents should be encouraged to discuss behavioral concerns with the care provider. Questions should be asked about mental health issues such as depression and anxiety, and the signs and symptoms of substance abuse should be reviewed (Box 94.1). Identifying young people with conduct and attentional disorders, as well as “difficult temperaments” (characterized by impulsive, defiant, and antisocial behavior) will allow the clinician to pinpoint another group of patients at increased risk of substance abuse.
BOX 94.1 Signs of Substance Abuse
Early Signs of Substance Abuse
Mood changes, secretive and erratic behavior, distancing from the family and family activities
Being away from the home more, spending more time locked away in own room
Abandoning old friends, associating with new friends, having strangers call and visit
Change in appearance, dress, hygiene, taste in music, sleep behavior
Things (perhaps alcohol, prescribed medications, jewelry, electronics) and money missing
Physical signs, including cough (may request cough medicine), red eyes (may use ocular vasoconstrictor), dermatitis (may use lotions), sniffles and congestion (may use nose spray), bruises, changes in mental/neurologic status (including slurred speech, abnormal pupils)
Odor of petrochemicals or alcohol on clothes or in room
Conflicts with teachers, coaches, other young people
Later Signs of Substance Abuse
Decline in school performance, truancy, loss of interest in extracurricular activities
No association with old friends, who may, in fact, express concern
Refusal to participate in family events or even leave own room
Large blocks of unaccounted-for time, breaking curfews
Finding drug paraphernalia in the home, including alcohol containers, pipes, rolling papers, empty containers of volatile substances
Encounters with the police for theft, shoplifting, vagrancy
A semistructured interview may be useful for adolescents because it provides a framework for the clinician to use. Among the orally administered screening questionnaires, few are more user-friendly for the busy pediatrician than the HEADSS schema developed by Mackenzie (Box 94.2). This mnemonic allows the clinician to assess quickly a number of critical areas in a young person’s life and can be used casually to take inventory even when the patient is being seen for an illness, injury, or sports physical examination. Exploring these domains with particular attention to issues related to substance abuse may reveal information about the following: parental use of TAOD; violence, bullying and drug use in school; sense of self-worth and social competence provided by participation in extracurricular activities (a strong protective factor against TAOD use); use of TAOD by friends and at social gatherings; early or inappropriate sexual behavior; and significant mood alterations that could be triggered or alleviated by TAOD use. Any positive answers relating to TAOD use must be investigated further, as described later. Jessor and Jessor did important work in the area of problem behavior theory and identified the association between early substance use and other negative actions such as youthful initiation of sexual activity, delinquency, truancy, and school failure, as well as other signs of rebellion. Thus, when one identifies a single problem behavior, one must look for others.
BOX 94.2 The HEADSS Schema
Home: Safety, stability, support, responsibilities, privileges
Education: Achievement, skills, strengths, plans, employment
Activities: Pastimes, sports; religious, civic and community involvement
Drugs: Tobacco, alcohol, and other drug use by friends, family; personal use
Sexuality: Satisfaction with body and self, involvement and concerns about sexuality, sexual activity and sexual identity
Suicidality: Symptoms of depression, anxiety, mood disorder, thinking problems
Footnote
Adapted from
Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health 1991;12:539.
ADDRESSING THE ISSUE OF THE “POSITIVE SCREEN”
Arguably the greatest barrier to an appropriate assessment for TAOD use is clinician discomfort in knowing what to do when such use is identified. By becoming familiar with the appropriate evaluation and management of substance abuse problems, the physician can initiate appropriate referral and treatment.
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