Adolescent Substance Abuse Case Study

 Adolescent Substance Abuse Case Study

question 1

ake a look at Case Study 1: Sally on page 144 (Steiner & Hall, 2015).

Discuss the factors that led to the development of Sally’s substance use.

Also, discuss what severity level you think her substance use is at and how you assessed it. Use specific examples from the case study.

question 2

ake a look at Case Study 2: Charles on page 147 (Steiner & Hall, 2015).

The case describes symptoms of disordered mood and symptoms of disordered drug use. Please describe the symptoms, the difficulty in diagnosis this presents, and ultimately how you would go about clarifying the diagnostic picture so that you can begin treatment.

 

 

5
Substance Use Disorders in Adolescence
Rebecca Hall and Anna Lembke
“ ‘Crash Kills  Contra Costa Youths. Two injured as pickup, -wheeldrive vehicle collide; beer containers found at accident scene.’ ” Eight
young teenagers and adults from the age of  to  were killed in a
head-on collision when they swerved into oncoming traffic while
traveling about  mph, none of them wearing seat belts. One victim’s
brother was stunned: “ ‘I don’t know how it happened. We always have
a designated driver. It was a freak accident. I love my brother, man. I
loved all of them. They were good people.’ ”
Adolescent alcohol and drug use is a major public health
problem in the United States. Drugs and alcohol contribute to a range of
negative developmental outcomes, including mental health disorders,
dropping out of school, delinquency, and incarceration. In , %
of drivers who were involved in a fatal car crash between the ages of  and
 had been drinking alcohol, with motor vehicle fatalities comprising over

Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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one-third of all deaths age  to . Substance use is also associated with
attempted and completed suicide—the third leading cause of death in this
age group.
Health care providers play a key role in the prevention and treatment of
adolescent substance use problems. In this chapter we provide a brief
overview of the epidemiology, risk factors, natural history, screening,
diagnosis, and treatment of substance use disorders. We define substances
as any and all drugs of abuse, including alcohol.
ADAPTIVE SIGNIFICANCE
Humans are well versed in learning what behaviors improve their odds of
survival. By activating neuroreceptors in the brain, these survival behaviors
become associated with emotions that motivate us to either repeat or avoid
them. In addition to the basic human necessities that stimulate this reward
system—food, sex, warmth, positive social interactions—certain plants
and chemicals have the same neurologic effect, causing the brain to develop
a need so strong for these substances that it can eclipse all else. Chemicals
that can “hijack” the brain in this way are considered substances of abuse.
EPIDEMIOLOGY
For most adults with substance use disorders, the problem began as
teenagers or young adults. Approximately .% of people in the United
States are addicted to drugs or alcohol, and % of adolescents aged  to 
have a substance use disorder. Forty-nine percent of graduating high school
seniors have used an illicit drug at some time in their lives.
Between ages  to , American Indian and Alaska Native youths have
the highest rate of substance use, followed by mixed race youths, white
youths, Hispanic youths, black youths, and Asian youths.
Alcohol is the most commonly used substance by adolescents—% of
graduating high school seniors have had at least one alcoholic drink, and
% of seniors have been drunk at least once. Those enrolled in college full
time are more likely to drink alcohol and binge drink than those not in
college. Though cigarette use has declined since the mid-s, it is also
 TREATING ADOLESCENTS
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still an area of concern: % of adolescents have smoked a cigarette by their
senior year, and % of seniors report being current smokers.
Marijuana is the most commonly used drug among youth. In  one
in  high school seniors reported using marijuana every day, or nearly every
day. Synthetic marijuana (Spice or K-) is created in the laboratory to
mimic chemicals in the cannabinoid family, and is used by .% of eighth
graders, .% of th graders, and .% of th graders.
Choice of substance typically varies by demographic and age. College
students, for example, most commonly present with alcohol use disorders,
marijuana use disorders, nicotine use disorders, and/or cocaine use disorders, while the top three substances of abuse for eighth graders are
marijuana, inhalants, and synthetic marijuana. As teens get older they are
more likely to use all categories of substances except for inhalants, which is
the only category with a reverse pattern, declining in use after eighth grade.
This may reflect the availability of inhalants for younger teens, which are
often over the counter household products like nail polish remover, glue,
gasoline, whipped cream dispensers, butane, and solvents.
In the past decade, nonmedical use of prescription drugs was the fastest
rising category of abused drugs among youth, particularly the nonmedical
use of pain relievers, such as hydrocodone products (e.g., Vicodin) and
oxycodone products (e.g., Percocet). In , .% percent of high school
seniors misused a prescription drug. Adolescents most often get these drugs
from a friend or family member’s prescription.
CARDINAL SYMPTOMS
Drug use typically progresses in stages, from less serious substances to more
serious, and from legal to illegal. Experimentation is the first stage of use. A
teen experimenting with a substance does so in a recreational circumstance to
learn what intoxication feels like, but without the intention of continuing.
Experimental use should not be condoned or trivialized by adults. Alcohol
and cigarettes are often tried first, followed by marijuana and cocaine,
hallucinogens, heroin, and opioids. The next stage is limited use, during
which a teen uses substances for pleasure when available and in relatively lowrisk, predictable situations, such as on weekends with friends. This stage is
Substance Use Disorders in Adolescence 
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followed by problematic use. A teen using a substance problematically does so
in high-risk situations, for emotional regulation purposes, or his use is
associated with a negative event like being suspended from school or being
arrested. During this stage the teen may begin to have family conflicts,
academic problems, and peer group changes. Next is a substance use disorder.
Once a teen reaches this stage, the substance use has become a significant
problem, interfering with functioning. This stage is characterized by out of
control use, compulsive use, and continued use despite consequences. The
earlier teens begin experimenting with substances and the faster they move
through these stages, the more at risk they are for developing a substance use
disorder. The following case example illustrates this progression.
Case Study : Sally
Fifteen-year-old Sally moved from the Midwest to California with her
mother after her parents divorced. Her mother’s time was consumed
with settling into a new job and a new city, and Sally was often left on
her own. Prior to the move, Sally had been using alcohol and
marijuana on weekends with friends, and she was smoking about a
pack of cigarettes per day. Sally had a difficult time fitting in at her new
school, until she met Joe. They started dating, and she began drinking
with him at parties. They started smoking marijuana together as well.
Joe then introduced her to crack cocaine, and then she experimented
with crank. Along the way she tried PCP and LSD, but did not like
them enough to continue. She was now using cocaine regularly. Her
grades started to drop, and she developed nasal lesions. Despite her
awareness that cocaine was affecting her health and academics, she felt
unable to reduce her use. Sally had progressed to a substance use
disorder.
DIAGNOSIS
If a patient screens positive for risky substance use, how can we differentiate
risky use from a substance use disorder? We use DSM criteria to make this
distinction. The revised edition of the DSM published in  (DSM-)
 TREATING ADOLESCENTS
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combined substance abuse and substance dependence into the single
diagnosis of substance use disorder, which is measured on a continuum,
with the added qualifiers of mild, moderate, and severe. Each substance is
addressed separately, and called a use disorder. For example, addictive
behavior involving alcohol is called an alcohol use disorder (DSM-
diagnostic codes: mild ., moderate ., and severe .).
The DSM- defines a substance use disorder as involving two or more of
the following symptoms within a -month period: () attempting to cut
back on substance use without success, () consuming more of the substance
than planned, () spending a lot of time and energy getting, consuming, and
recovering from using the substance, () experiencing intense desire to
consume the substance, often referred to as craving, () failing to fulfill major
life obligations due to substance use, () continuing to use the substance
despite consequences, () giving up or reducing important activities due to
substance use, () using in dangerous situations, () developing tolerance,
and () experiencing withdrawal.
According to the DSM- guidelines, if the patient endorses two or three
items on the list, then she has a mild substance use disorder, four or five
items and she has a moderate substance use disorder, and six or more items
and she has a severe substance use disorder. Clinically, a more severe
substance use disorder can take a variety of forms depending on which
criteria the patient meets.
Although the DSM does not use specifiers for quantity or frequency of
substance use, there is an ever-growing body of evidence demonstrating
that the higher the quantity and/or frequency of alcohol use, the higher the
risk of poor health outcomes, such as gastrointestinal-related illness,
pancreatic disease, liver disease, trauma, and death.
Developmental differences between adults and children must be taken
into account when applying these diagnostic criteria to young people.
Because alcohol is illegal for those under , when adolescents drink alcohol
it requires a level of energy and effort to obtain that adults do not face. This
factor can skew criteria like “spending a significant amount of time
obtaining the substance.” Adolescents also usually drink less often than
adults, but do more binge drinking. Withdrawal and tolerance can be
problematic diagnostic criteria, because withdrawal typically does not
Substance Use Disorders in Adolescence 
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occur until after years of use, and some adolescents will bypass the tolerance
phase by jumping straight to drinking larger amounts.
We also need to take social and environmental pressures into account
when assessing young people. Rather than compulsive use, substance use in
an adolescent may be more an indicator of an inability to resist social and
peer pressures. This is true for all patients, but adolescents are particularly
vulnerable to social and environmental pressures. Many of the diagnostic
criteria therefore assume a different meaning in this population, and the
particular nuances of this age group should be evaluated when considering
a substance use disorder diagnosis.
RELATED DIAGNOSES TO BE RULED OUT
AND CONCURRENT PATHOLOGY
One of the major challenges in diagnosing a substance use disorder is
differentiating it from primary mental disorders. Psychiatric symptoms
caused by substance use can mimic primary mental disorders, which often
do also occur concurrently. Robust scientific evidence also demonstrates
that substances can cause psychiatric disorders. For example, cannabis can
trigger an acute psychotic state, and frequent, heavy cannabis use is
associated with a higher risk of psychosis, such as schizophrenia. However,
it is still unclear if marijuana can induce a psychotic disorder that
would not have developed otherwise. Refer to Chapter , Schizophrenia,
Psychosis, and Autism Spectrum Disorders, for more information.
On the other hand, having amentalillness other than addictionis predictive
of having a co-occurring substance use disorder. In a study of  adolescents in
drug treatment programs, % had at least one comorbid mental disorder,
most often disruptive behavior disorders (Chapter ). Other commonly cooccurring disorders are mood disorders (Chapters  and ), anxiety disorders
(Chapter ), ADHD (Chapter ), bulimia nervosa (Chapter ), and learning
disabilities (Chapter ). Youth with substance use problems are also at greater
risk for suicidal behaviors (Chapter ).
One way to understand the high rates of comorbidity between
substance use disorders and other mental illnesses is the self-medication
hypothesis, which states that efforts to “treat” the underlying psychiatric
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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disorder lead to substance abuse. Although having a mental illness may
indeed be a risk factor for developing a substance use disorder, it is only one
of many risk factors (see later section on lifetime trajectory), and the selfmedication hypothesis should be invoked cautiously in clinical practice.
Encouraging the “self-medication” justification for substance use can
further a patient’s denial and lead to overdiagnosis of primary mental
disorders and undertreatment of substance use disorders. Adolescents are
aware that using substances will elicit disapproval. Presenting their substance use as a reaction to sadness, rather than their sadness as a reaction to
their substance use, can be an effort to avoid judgment or to rationalize
substance use in their own minds. In general, clinical attention should be
paid to both disorders concurrently.
The following case illustrates the dilemma of differentiating a primary
psychiatric disorder from substance-induced symptoms.
Case Study : Charles
Charles, an -year-old Asian American male, began drinking alcohol
and smoking marijuana when he was . Over the next  years his
drinking increased, and he began using cocaine. He entered our clinic
as a college freshman, where he lived in a fraternity and “partying” with
friends represented the majority of his social life. He reported that he
looked forward to little else throughout the week.
At the first visit, Charles stated that his drinking had increased over
the past  months. At times he would intend to drink only one or two
alcoholic beverages, but once he started drinking he was unable to
stop. He often drank until he blacked out. Despite attempts to curtail
his binge drinking, he was not able to cut back. He currently used
marijuana a few times per month. He stopped using cocaine a month
ago, prior to which he had been using heavily on weekends. He
typically smoked a few cigarettes per day, and an entire pack when
drinking alcohol.
Charles was originally referred to us by the campus health center,
where he had presented with complaints of depression, anxiety, and
Substance Use Disorders in Adolescence 
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sleep disturbances that had persisted for the previous  months. He
reported that the past few weeks had been particularly difficult, with
increased levels of sadness and often sleeping until the middle of the
day. He had begun to have academic difficulties and thoughts of
suicide.
Charles also reported mood swings, in which he would feel
energetic and increasingly talkative for a few days at a time. During
these periods he slept very little and engaged in risky behaviors, like
unprotected sex. His last episode like this was  month ago.
When asked about his history of mood swings, Charles reported
that his moodiness began in high school. However, his ups and downs
did not affect his academics or overall functioning at that time. Charles
stated that he believed that he had begun drinking alcohol in order to
“self-medicate” his depressive symptoms.
Charles clearly meets the criteria for alcohol use disorder, nicotine use
disorder, and possibly cocaine use disorder and marijuana use disorder,
reporting symptoms such as craving substances, taking more than intended,
an inability to reduce use, significant amount of time spent using, failing to
fulfill academic obligations, risky behavior while using, and possibly experiencing withdrawal symptoms. The question this case poses is: “Does Charles,
in addition to having a substance use disorder, also have a mood disorder?”
Charles’ history of depression and hypomania suggest a bipolar affective
disorder. However, many teenagers experience some mood fluctuations
during high school, and given that Charles did not experience any
impairment in functioning during that time, these ups and downs may
have been within the normal limits. His substance use history indicates that
these symptoms may actually be substance induced, rather than a primary
mental disorder. For example,  month prior to his first visit with us, he
stopped cocaine and simultaneously began feeling more depressed. Ergo,
withdrawal from the cocaine could be the cause of his current depressive
symptoms. His last use also coincided with feeling hypomanic, suggesting
that intoxication with cocaine or alcohol could be to blame for Charles’
manic symptoms.
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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An observed prospective period of abstinence is the best way to
differentiate a substance-induced psychiatric disorder from an independently occurring psychiatric disorder in the context of substance abuse.
The DSM- recommends that a patient be abstinent from substances for a
minimum of  weeks in order to determine if psychiatric symptoms are
substance-induced.
Clinicians must often make a treatment plan without knowing if the
symptoms are substance-induced or due to a primary mental disorder. A
lifetime timeline can be helpful in this process, which includes the major
life events, such as academic performance, major family events, trauma, the
onset of substance use, and the onset of psychiatric symptoms. Insurance
limitations can complicate this process, as sometimes treatment for a
substance use disorder is only covered if the patient also has a primary
mental disorder. However, inaccurate diagnoses motivated by these
insurance policies ultimately do not benefit the patient or our understanding of these disorders.
LIFETIME TRAJECTORY OF SUBSTANCE USE DISORDER
Understanding social, environmental, and familial contexts is crucial in
understanding why an adolescent uses substances, and in turn, how to
create an effective treatment plan. For a more complete discussion of
different theories of what contributes to the progression of substance use,
please refer to the Handbook of Developmental Psychiatry (Steiner, ).
Access to substances is the biggest risk factor for adolescents and the
strongest determinant for what substances they choose. Perceived risk is
also an important risk factor. The high prevalence rate of both marijuana
and prescription drug use may be reflective of the belief that these
substances are safer than other drugs. Because these drugs are also used
for medical purposes, many teens use these substances under the false
impression that they are not dangerous.
Age of onset of substance use is another important risk factor for
developing a substance use disorder. Those who use alcohol at age  or
younger are more than  times as likely to develop alcohol use disorder as
an adult. Other risk factors in youth for developing a substance use disorder
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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include early aggressive behavior and impulsivity, lack of emotional
regulation, lack of parental supervision and monitoring, parental and
peer substance use, and poverty.
Protective factors include individual self-control; good parental monitoring; academic competence; school anti-drug use policies; and strong
parental, community, and neighborhood attachment. Charles, who we
introduced earlier in the chapter, illustrates how developmental factors can
contribute to substance use in teens.
Case Study  Coninued: Charles’ Developmental History
Charles grew up in an upper-middle-class home. His home life was
tumultuous, with a father who abused alcohol and a mother who
suffered from an eating disorder. Both worked long hours, and Charles
was often home alone. His parents argued regularly throughout his
childhood and were in the process of separating. School had always
been Charles’ source of relief from the anxiety of his home life. He
excelled academically and had a large peer group, including a girlfriend, with whom he drank alcohol and experimented with drugs.
Now in college, Charles spends as much time as he can in the dorms
with his friends in order to avoid home, including during school
vacations.
A variety of factors contributed to a developmental pathway that
resulted in Charles’ addictive behavior, including limited parental monitoring and a stressful home life that may have impacted his ability to
develop coping skills or regulate his emotions. His primary social support
was a deviant peer group, which in combination with his parents’ addictive
behavior, likely normalized his own substance use. The most notable
protective factor in Charles’ history is his academic achievement. Understanding the factors that may have led to his substance use disorder allows
us to develop a stronger case conceptualization and will help to guide
treatment decisions aimed at getting Charles back on a positive developmental pathway.
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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EVIDENCE-BASED TREATMENT INTERVENTIONS
The adolescent substance use disorders treatment guidelines recommended
by the American Academy of Child and Adolescent Psychiatry in  are
now considered outdated. However, practice parameters can be a useful tool
and providers should keep track of any updated guidelines. (http://www
.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and
_Resource_Centers/Practice_Parameters.aspx)
Prevention Programs
Effective prevention programs should aim to both address the developmental
factors and change long-term problematicenvironmental conditions. Schoolbased prevention programs are a worthwhile endeavor, given that a young
person spends a significant amount of her daily life at school. Addressing
adolescent psychopathology also helps to prevent early onset of substance use.
Despite the billions of dollars that have been spent on substance use
prevention programs, studies have shown that life-skills training and drug
refusal skills programs are not overwhelmingly effective. When the typical
adolescent is bombarded with hours of TV, media, and video games that
promote drugs and alcohol, combined with parental/peer modeling, it is no
wonder that programs that last only a few hours do not exert a significant
effect on his substance use.
Pharmacotherapy and Other Biologically-Based Interventions
Pharmacotherapy has been used to treat substance use disorders in adults,
however, there is a significant lack of pharmacotherapy research on
substance use disorders in adolescents. Our treatment discussion here,
therefore, focuses on behavioral and psychosocial interventions. That being
said, evidence is beginning to show that treating co-occurring psychiatric
disorders pharmacologically improves substance use treatment. Clinicians
should be aware that substance use can increase the chances of overdose
with some psychotropic medications. If there are concerns of potential
abuse of these medications, adult supervision of the medication administration should be considered. The current emphasis on concurrent,
Substance Use Disorders in Adolescence 
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integrated treatment is in contrast to the former widely held belief that
substance use disorders should be treated first, followed by treatment for
any residual disorders, or vice versa.
Psychosocial Treatment
A substantial amount of research is currently being undertaken to develop
treatments for alcohol use disorders among adolescents, including guided
self-change therapy, brief motivational therapy, cognitive behavioral therapy, and family therapy. So far, social-based treatments that focus on
family and school environments are the most effective for adolescents with
substance use disorders. Involving the family is crucial—family therapy has
been shown to be more effective than couples therapy, individual therapy,
family psychoeducation, peer counseling, life-skills training, education,
and disciplinary actions. Work with families should be approached with a
“nonblaming” attitude, rather than confrontation. This stance reduces the
chance that families and patients will give up on treatment. Family therapy
that involves the community is also an effective strategy.
Opinions on group treatment programs remain divided, as there is
evidence that group programs can negatively affect outcome by introducing the patient to a deviant peer group. This is especially true in youths
with a co-occurring conduct disorder, which is quite common in this
population. Other studies show that group treatment programs can be
beneficial. With more deviant youth, however, it may be more beneficial to
consider other treatment options, such as family-based treatment.
Motivational interviewing, a nonauthoritarian technique that encourages
an adolescent to assume responsibility for her actions and teaches how to make
positive changes, has shown evidence for reducing problems related to alcohol
use and can be administered in the primary care setting. We provide more
discussion about this technique in the following Clinical Practice section.
CLINICAL PRACTICE: PRACTICE-BASED EVIDENCE
Screening
Screening, brief intervention, and referral to treatment (SBIRT) for substance use is recommended for all adolescents. Many resources exist in
 TREATING ADOLESCENTS
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journals, books, and online for how to conduct SBIRT with adolescents. To
highlight some of those details here, the CRAFFT is a six-item questionnaire
that screens adolescents aged  to for risky alcohol and drug use. It can be a
helpful way for a primary care physician to determine if a more in-depth
conversation about substance use is warranted. Those who have a score of 
or more are high risk and should receive follow-up assessment. Administering the survey on paper or by interview without a parent or guardian present
can maximize honest responses.
Interview and Assessment
Many of our patients arrive at our clinic seeking help for problems other
than substance use, such as depression and/or anxiety. They are most often
referred to us from the inpatient service, student mental health service
providers who suspect a substance use disorder, or they are brought to
the clinic by their parents. Helping these patients to understand that they
have a problem with substance use can be a significant challenge. They can
be resistant to the idea that their symptoms are related to their substance
use, or that their substance use is an issue. This resistance must be managed
carefully, and the first interview is an important step.
We first gather a detailed history, including history of any substance
use, behavioral addictions (gambling/sex), current and past nonaddiction
psychiatric issues, a complete review of medical systems, psychiatric
evaluation, developmental/social history, family substance use, and family
psychiatric history. We use CURES (Controlled Substance Utilization
Review and Evaluation System), which is the California prescription drug
monitoring program, to access a patient’s controlled substance history.
This system allows us to know what controlled substances are being
prescribed to the patient by other providers, as a way of screening for a
possible prescription drug use problem. Also, if the patient reports highrisk sexual behaviors, we offer testing for HIV and other STIs and provide
education on safer sex practices.
The way in which this information is gathered can be quite important.
Due to the tendency for patients to justify their substance use with “selfmedication” language, it can be useful to first focus on the patient’s
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
substance use history and gather a detailed account of age of onset, any
patterns of remission and relapse, past treatments, and any periods of
sobriety before discussing the patient’s psychiatric history. When both
areas have been independently explored, we then discuss any possible
relationship between substance use and psychiatric symptoms. By separating these two lines of questioning, the clinician is able to gain a more
accurate picture.
Confidentiality issues must be addressed at the initial interview.
Adolescents will be more likely to be honest about their substance use
if they know that the information will not be shared. They should be
assured confidentiality except when there is a threat of harm to self or
others. Reporting and informed consent laws vary from state to state, and
the clinician should consider both local and federal laws before initiating
any treatment plan. Adolescents should be encouraged to inform their
parents of their substance use.
Treatment Contracting
Once we have finished the initial assessment, we will involve the patient in
discussing which diagnostic criteria are relevant to her and what treatment
will be agreed on. If the patient is particularly resistant to the idea that she
may have a substance use disorder, we will temporarily withhold any
definitive diagnosis and suggest that the patient try a trial period of
abstinence in order to give us both more information. We then go over
the results together. This maintains a collaborative approach and minimizes the tendency for patients to lie about their substance use.
Treatment
We encourage a therapeutic alliance that emphasizes listening and collaboration, rather than paternalism or blaming. We find that when working
with adolescent patients, it is very important not to re-create the didactic
relationship that they may have with concerned parents or teachers. Rather
than insist that they should not use substances, which can trigger resistance, we ask the patient to think through what the pros and cons of their
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/touromain-ebooks/detail.action?docID=4040196.
Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
substance use are, and adopt a “wondering aloud” approach. We are
looking for the patient to think about what impact his substance use has
had on his life. It is important to listen carefully to what the patient believes
are positive outcomes from his substance use, as this will then open up the
conversation about what may be negative about his substance use.
We then move into a discussion about what factors may be contributing to the substance use. Social factors are often big players in adolescent
substance use. These are important to address in order to maximize the
patient’s chances of recovery. When substance use is a major shared activity
with friends, it can be a frightening thing for a young person to abstain.
Removing the common activity can weaken those relationships. We
encourage having an open conversation with patients about how abstinence would affect their relationships and ask them to think through which
of their friends and/or family might be supportive of stopping or reducing
substance use. This conversation should include suggestions about what
organizations or communities do not emphasize substance use, such as
athletics, study groups, or religious groups.
It is also important to address the issue of normalization. When an
adolescent is embedded in a social network that uses substances, it can
create the feeling that drinking alcohol or using drugs is not a big deal.
Normalization combined with low perceived risk makes marijuana
use disorder an especially tricky problem to address with adolescents—we
often hear patients say, “everyone does it, and it’s not even illegal in some
states.” We handle this situation by educating on the dangers of
marijuana, explaining that although it may be legal in some states,
the bottom line is that it is still an illegal substance in California. We help
the patient to understand that although it may seem like everyone else
uses substances, too, this is not actually the case. Often, a patient is quite
surprised that they consume significantly more than the average adolescent their age.
When initiating a treatment plan, we encourage both abstinence from
substance use and reduction. If a patient is resistant to the idea of stopping
his substance use altogether, we focus on changing behaviors to minimize
harm and the consequences from using substances, like encouraging
cutting back or trying edibles instead of smoking marijuana. In addition
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/touromain-ebooks/detail.action?docID=4040196.
Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
to reducing harm, small steps like these can allow the patient to begin to see
the positive effects of reducing his substance use, which fosters motivation
to take more steps toward the ultimate goal of abstinence. With this
approach, concrete progress points and goals should be discussed.
Withdrawal symptoms, such as delirium tremens and seizures, can be a
real barrier to abstinence for some patients. We warn patients of the
possibility of withdrawal symptoms and use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWAR) to assess a patient’s
risk of developing alcohol withdrawal syndrome. Those who experience
troublesome side effects as they abstain or reduce their substance use may
benefit from medication to ease the process. This can help patients stay
motivated. If outpatient medication is not sufficient, we may recommend
hospitalization during acute withdrawal.
Toxicology screens can be helpful in some circumstances, but the
results should be used as a discussion point, not as a definitive data point
around which decisions are made. An agreement about the confidentiality
of results needs to be made with the adolescent before testing. Some
families will use home toxicology screens as part of a contract to stay sober.
However, if a patient tests positive during treatment, we would use this
information as the beginning of a conversation about what is going on, not
as data for incrimination. These tests give limited information, as they are
not % accurate and do not give any information about when a
substance was taken.
Psychiatric symptoms must be continually monitored throughout
treatment. Patients find it reassuring to learn how substance use can cause
psychiatric symptoms and how abstinence can resolve these symptoms.
Often by providing this education, we are able to avoid prescribing
medication. If psychiatric symptoms persist beyond a -week trial period
of abstinence, a primary mood disorder and the appropriate treatment
should be considered. If a patient enters our clinic already on medications
for a mental disorder but is still experiencing psychiatric symptoms, we will
avoid making any adjustments to medication until after the -week period
of sobriety or reduction.
Let us return to the case of Charles to illustrate how we approach the
treatment process in our clinic.
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/touromain-ebooks/detail.action?docID=4040196.
Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
Case Study  Continued: Charles’ Treatment
The first step in the treatment plan for Charles was a period of
abstinence. This was necessary in order to tease out the causal effects of
his mood problems and substance use on each other. Charles agreed to
abstain from alcohol, nicotine, and drugs for a trial period. We
prescribed him desyrel, a nonaddictive sleep aid, to address his sleeping
problems and to help alleviate withdrawal symptoms. Charles began to
see improvement in his sleep and mood within  weeks. He reported
that he was drinking significantly less alcohol and had stopped using
drugs. He had limited his nicotine use to a few cigarettes per week.
Charles had been surprised to discover that his friends were supportive
of his decision to stop using substances. We encouraged Charles to stay
on his path of substance reduction, with the goal of abstaining from
alcohol, drugs, and nicotine altogether.
Four weeks later, Charles again began having problems with
insomnia and low mood. Neither issue was as troublesome as it
had been when he initially came to the clinic, but he was getting
increasingly more depressed. He maintained that he had not been
using alcohol or any substances. Enough time had passed since Charles
began abstaining from substance use that we felt comfortable starting
him on a trial of antidepressant therapy. Charles’ sleep and mood both
improved with the antidepressant, and he continued to limit his
substance use, drinking alcohol occasionally and using nicotine in
moderate amounts. We referred him to psychotherapy and skills
training to further address his problems with mood regulation. Charles
has continued to do well.
-Step Groups
Some patients have a more difficult time reducing their substance use than
Charles did. When a patient makes an effort to reduce use but does not
successfully abstain from substance use during the agreed trial period, we
will begin to introduce the idea of a -step program, such as Alcoholics
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/touromain-ebooks/detail.action?docID=4040196.
Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
Anonymous (AA), SMART Recovery, or Secular Organization for Sobriety. The latter two are self-help groups that do not have spiritual components, which some patients are more comfortable with. We also remind
patients who claim that AA is “too religious” that the program is spiritual
rather than religious, and that those with a variety of beliefs, including
atheists and agnostics, attend. We continue to work with patients as they
go through -step programs, incorporating the language of these programs
into our discussions and monitoring the patient’s progress about how the
program is going. For a more in-depth description of these self-help
groups, please refer to Circles of Recovery.
Levels of Care
Like so many other medical centers and clinics, our clinic does not have a
dedicated substance use disorder program, and in treating substance use we
often utilize external referral services. The Substance Abuse and Mental
Health Services Administration maintains a treatment facility locator on its
website (http://www.samhsa.gov/treatment/index.aspx).
There are varying levels of treatment options depending on the severity
of the case and the patient’s needs. Outpatient treatment is best for those
with mild to moderate substance use who have a supportive home
environment. These patients live at home and may still be able to attend
school or go to work. These services can be delivered from a variety of
different locations, from a physician’s office to a substance use specialty
clinic. Outpatient treatment services are typically provided less than 
hours per week.
The next level of care is intensive outpatient, which is similar to
outpatient treatment, but services are provided  or more hours per week.
This will be appropriate for patients with more complex cases but who
still have a supportive home environment. Patients receiving intensive
outpatient treatment will also continue to live at home and go to school
and/or work.
Partial hospitalization, or day treatment, is a type of outpatient care for
patients who require more services due to the severity of their substance use
or serious comorbid health problems, including mental health. These
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
services are offered  or more hours per week ( to  hours per day, up to
 days per week). These patients have a supportive home environment and
continue to live at home, but they typically spend a significant amount of
daily time in treatment, which can limit the ability to work or go to school.
Inpatient/residential detoxification is a short-term program that provides medical management of withdrawal symptoms. Patients discharged
from a detoxification program then move on to an outpatient or residential
treatment program.
Residential nonhospital treatment offers services that are provided in a
-hour live-in setting. These services are offered at differing levels of care
depending on the severity of substance use disorder and/or other health
problems. Acute residential treatment lasts days to weeks and focuses on
stabilizing patients before they enter a more long-term residential program.
Patients reside at acute or long-term facilities with other people in
treatment and have -hour access to professional support. This option
is best for those with more severe disorders, other serious medical conditions, or for those who require a safe and stable living environment.
Medically managed intensive inpatient treatment offers -hour inhospital treatment by a physician. This will be appropriate for those with
severe medical conditions, including mental health, who need constant
care or supervision. Sometimes this is a consequence of their substance use,
such as injuries from a car accident while driving under the influence;
infections; or heart, lung, or liver disease. Patients receiving this level of
care live at the hospital until they can be transferred safely to a different
treatment setting or until the completion of treatment. Rachel is an
example of a teen who benefited from a medically managed intensive
inpatient program.
Case Study : Rachel
Rachel was an attractive -year-old Caucasian girl. She was admitted
to the hospital for severe knee abscesses, which were a consequence of
daily intravenous use of heroin. She was hospitalized on the medical
unit for treatment of her abscesses, where she also required psychiatric
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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consultation and a one-to-one around the clock sitter due to withdrawals from the heroin. As she improved, she was transported to and
from the medical unit and the psychiatric unit for group treatment.
She was then transferred to the medical/psychiatric unit where she
could receive psychiatric treatment, medical management for withdrawals, and continued care for her abscess.
Finally, therapeutic boarding schools are residential educational programs that offer constant professional support for students. They are highly
structured and provide individual and group therapy for students with
substance use disorders or other mental health problems.
Aftercare
Ongoing assessment and follow-up care after the initial acute treatment
phase is crucial. Substance use disorders are often chronic disorders that
continue to require attention and involve periods of relapse and remission.
Aftercare services can improve the chances that an adolescent remains sober
and provide support if the patient relapses. This often takes the form of an
ongoing -step program. Co-occurring mental health problems should
also be monitored on an ongoing basis.
PROGNOSIS AND OUTCOMES
We cannot know if an adolescent will stop using substances or learn to
control their use on her own, but we do know that without treatment an
adolescent with a substance use disorder is more at risk for academics
issues, legal problems, health consequences, and more problematic substance use as an adult. We therefore recommend treating these disorders.
Substance use disorders cannot be cured, but with treatment they can
be successfully managed. When determining the definition of success,
abstinence should not be considered the only standard. In comparison with
adults, adolescents have lower rates of total abstinence in the year after
treatment. Learning to limit use, decreasing risky behaviors, and improved
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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Created from touromain-ebooks on 2020-02-17 19:38:48. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.
functioning are all positive outcomes. Factors that improve outcome are
continued attendance at support groups, parental support, and involvement with a peer group that does not use substances.
A LOOK INTO THE FUTURE
Among those who work with adolescents, there is an inherent tension between
viewing substance use as a normal part of growing up and as a problematic
disorder.What is needed is an integrated approach—both an understanding of
the normal developmental spectrum and of symptomatic behavior. Experimenting with substances is a common phase of adolescence, but when it
becomes a habit that interferes with functioning, what began as experimentation has transitioned into a dangerous disorder that puts the adolescent at risk
for a host of negative outcomes. It is therefore crucial for substance use
screening to be incorporated into the routine care of all adolescents.
Looking toward the future, many leaders in the field of addiction are
promoting the conceptualization of addiction as a pediatric disorder, based
on the numerous risk factors that come into play in childhood and
adolescence, and the fact that most addicts began using substances before
the age of . With this new conceptualization, addiction leaders are
recommending much earlier and more aggressive interventions for adolescents who use substances of any kind, even if they do not demonstrate
the stigmata of addiction. Some are even suggesting that intervention
should occur even in the absence of substance use if there is a strong family
history of substance use, in particular if there is a parent or grandparent
with addiction, since data show that having a parent or grandparent with
addiction increases the risk of developing a substance use disorder fourfold.
What would this intervention look like? It might take the form of more
intensive psychoeducation around risk factors for addiction, and cautioning young people to avoid any kind of substance use if they have lots of risk
factors for addiction, for example, a co-occurring mental illness such as
ADHD and a biological relative with addiction.
The danger of this approach is to overpathologize. But perhaps an
overly reductionistic approach to the problem might be warranted to stave
off the loss of more lives to the scourge of addiction.
Substance Use Disorders in Adolescence 
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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CROSS-REFERENCING
Due to the overlap between these disorders, readers interested in adolescent
substance use disorders are encouraged to cross-reference the following
chapters: Bipolar and Mood Disorders in Adolescents; (Chapter ), Anxiety
Disorders, Tics, and Trichotillomania; (Chapter ), and Attention-Deficit
Attention Disorder (ADHD) (Chapter ).
SUGGESTED READINGS
Chung, T., Martin, C. S., & Winters, K.C. (). Diagnosis, course, and
assessment of alcohol abuse and dependence in adolescents. In M.
Galanter (Ed.), Recent developments in alcoholism: Vol. . Alcohol
problems in adolescents and young adults: Epidemiology, neurobiology,
prevention, treatment. New York, NY: Springer.
Hesselbrock, V. M., & Hesselbrock, M. N. (). Developmental
perspectives on the risk for developing substance abuse problems. In
W. R. Miller & H. M. Carroll (Eds.), Rethinking substance abuse: What
the science shows and what we should do about it. New York, NY:
Guilford Press.
Humphreys, K. (). Circles of recovery: Self-help organizations for
addictions. Cambridge, UK: Cambridge University Press.
Kandel, D. (Ed.). (). Stages and pathways of drug involvement:
Examining the gateway hypothesis, Cambridge, UK: Cambridge
University Press.
Sheff, D. (). Clean: Overcoming addiction and ending America’s greatest
tragedy. New York, NY: Houghton Mifflin Harcourt.
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Barnes, G. M., Welte, J. W., Hoffman, J. H., & Dintcheff, B. A. ().
Shared predictors of youthful gambling, substance use, and
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Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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Fitzgerald, J., & Arndt, S. (). Reference group influence on adolescent
alcohol use. Journal of Alcohol and Drug Education, : –.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E.
(). Monitoring the Future national results on drug use:  overview,
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Libby, A. M., & Riggs, P. D. (). Integrated substance use and mental
health treatment for adolescents: Aligning organizational and financial
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incentives. Journal of Child & Adolescent Psychopharmacology, (),
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Riggs, P. D., & Davies, R. D. (). A clinical approach to integrating
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Steiner, H. (Ed.). (). Handbook of developmental psychiatry. Singapore:
World Scientific.
 TREATING ADOLESCENTS
Steiner, Hans, and Rebecca E. Hall. Treating Adolescents, John Wiley & Sons, Incorporated, 2015. ProQuest Ebook Central,
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