There are many reasons for studying how adolescents misuse alcohol, and which empirically tested interventions seem to prevent and treat alcohol use disorders during adolescence:
- Some adolescent substance abusers grow up to be adult substance abusers (Duncan & Petosa, 1995). As a society, we hope to protect young people from the negative health and welfare consequences of drinking. Social workers who help adults with alcohol use disorders often consider ways to intervene earlier, which means working with at-risk individuals during their childhood, adolescent and early adulthood years.
- Adolescence is a period of the lifecycle when individuals are managing multiple, complex developmental tasks. These involve significant changes in biological/physical, social, psychological/emotional, and community-relatedness domains. Mastery of these developmental demands is challenging with lifelong consequences. Attempting to master them while under the influence of alcohol or other substances can become unfeasible. Therefore, it is important to address the problems of adolescents and to facilitate their future development in all arenas.
- Adolescence is a period when individuals may begin to engage in highly risky behaviors. They may be experimenting with sexual activity, criminal and/or delinquent acts, and driving automobiles. Combining these already risky behaviors with the effects of alcohol can increase the adolescent's vulnerability to permanent and irreversible consequences (disability, death, legal entanglements, etc.).
This module addresses the ways in which working with adolescents to prevent and treat alcohol use problems differs from work with adults. The module also discusses how social work practice with adolescents must be tailored to the specific characteristics of the target groups-adolescents differ markedly by ethnic, gender, social class, regional, and age characteristics.
By the end of this module, learners should be able to:
A. Recognize the significance and import of adolescent alcohol use problems.
B. Discuss risk, vulnerability, resilience, and protective factors for adolescents.
C. Understand adolescent assessment issues and concerns.
D. Understand treatment and prevention issues related to adolescent alcohol use problems.
Prevalence Among Teenagers
The use and abuse of alcohol and other drugs by adolescents are pressing social problems in America. The Monitoring the Future Study (Johnston, O'Malley, & Bachman, 2000) is a large, representative annual survey of American teenagers. Data from 2000-2001 found that 43.1% of eighth graders reported some alcohol use during the past year, 14.6% reported cigarette smoking in the past month, and 19.5% reported illicit drug use during the past year.
Among tenth graders, 63.7% reported some alcohol use during the past year, 57.6% reported trying cigarettes, and 46.2% reported trying at least one illicit drug.
Data from the 2001 Monitoring the Future Study indicate that large proportions of high school seniors reported using substances in their lifetime: 80% had tried alcohol, 64.6% had tried cigarettes, and 54.7% had tried at least one illicit drug.
Use in the past 12 months was high for alcohol (73.8%) and other illicit drugs (41.4%). The 30-day prevalence for cigarette use was 29.5% (Johnston, O'Malley, & Bachman, 2001).
A small but significant proportion of adolescents who try alcohol or other drugs will develop substance use problems. Monitoring the Future data indicate 5.8% of high school seniors reported daily marijuana use, 3.6% reported daily alcohol use, 29.7% reported one or more binge drinking episodes in the past two weeks, and 13.2% reported smoking at least half a pack of cigarettes daily. Clearly, a majority of U S. teenagers, regardless of gender or race/ ethnicity, is exposed to, and uses, alcohol and other drugs by the final year of high school.
Psychoactive Substance Use Disorders: Oregon (Lewinsohn et al 1993)
- Lifetime prevalence 8.30%
- Point prevalence 2.34%
- Annual incidence rate 4.00%
DSM-IV Criteria Met- Substance
Use Problems in Past Year:
Minnesota (Harrison et al 1998)
- 13.8% of ninth graders
- 22.7% of twelfth graders
Lewinsohn, Hops, Roberts, Seeley, & Andrews (1993) found that 4% of randomly selected high school students in Oregon developed DSM-III-R-defined substance use problems during the course of a single year. Harrison, Fulkerson, & Beebe (1998) found that 13.8% of ninth graders and 22.7% of twelfth graders in Minnesota met DSM-IV criteria for substance use problems at some point during the previous year. However, it is worth noting that studies using high school samples underestimate the level of alcohol problems because heavy alcohol use is associated with truancy, school expulsion, and dropout. Among more highly selected adolescent samples (e.g., emotionally disturbed adolescents or juvenile offenders), much higher rates of alcohol and other drug problems have been documented.
The DSM-IV diagnostic criteria for alcohol use disorders have been widely used for adolescents with drinking problems, though several investigators have questioned the validity for teenagers. Currently, there is much debate as to the appropriateness of these signs and symptoms for detecting drinking problems among youth. For example, Bailey, Martin, Lynch, and Pollock (2000) pointed out that adolescent drinkers are typically binge drinkers who drink in social contexts. Such drinking patterns may make certain symptoms more likely to be seen among adolescents (e.g., social problems) and other symptoms less likely to be seen (e.g., withdrawal) when compared to adults. Moreover, many teenagers appear to demonstrate alcohol tolerance, which may reflect primarily psychological and social responses to alcohol exposure (i.e., "learning how to drink") rather than physiological responses. In fact, the difficulties associated with defining tolerance among adolescents have led one research group to suggest that a diagnostic item reflecting high volume drinking (i.e., five or more drinks at a sitting) be substituted for the current tolerance item (Chung, Colby, Barnett, Rohsenow, Spirito, & Monti, 2000). Finally, adolescents are unlikely to demonstrate the diagnostic symptoms associated with long-term alcohol use such as unsuccessful efforts to quit or reduce drinking, or withdrawal, which has been argued by one group of investigators to be both necessary and sufficient for the diagnosis of alcohol dependence ("the Withdrawal-Gate Model;" Langenbucher, Martin, Labouvie, Sanjuan, Bavly, & Pollock, 2000). These factors contribute to the current lack of consensus on how to define and diagnose adolescent drinking problems (Chung et al., 2000).
In a recent review article, Martin and Winters (1999) identified several specific limitations of the DSM-IV alcohol use disorders criteria when applied to adolescents:
Concerns for Using DSM-IV Diagnostic Criteria with Adolescents 1. The one-symptom threshold for substance abuse produces diagnostic heterogeneity among those who meet the diagnosis Martin and Winters, 1999 2. The three-symptom threshold for alcohol dependence produces diagnostic orphans (i.e., individuals with one or two symptoms necessarily do not receive the diagnosis) (Pollock and Martin, 1999 3. The assumed sequencing of alcohol abuse preceding alcohol dependence may not hold up in adolescent populations Martin and Winters, 1999 4. Lack of knowledge regarding the overall validity of the diagnostic criteria for teens Martin and Winters, 1999 5. Several DSM-IV symptoms are atypical for adolescents with alcohol use problems Martin and Winters, 1999 6. Some symptoms have low specificity in distinguishing adolescents with and without drinking problems Martin and Winters, 1999 7. Some symptoms occur only in particular subgroups of teenagers Martin and Winters, 1999
In addition, Martin and Winters (1999) noted a lack of knowledge about the overall validity of the diagnostic criteria for teenagers, the fact that several DSM-IV symptoms are atypical for adolescents with alcohol use problems (e.g., withdrawal; alcohol-related medical problems), that some symptoms have low specificity in distinguishing adolescents with and without drinking problems (e.g., tolerance), and that some symptoms tend to occur only in particular subgroups of teenagers (e.g., hazardous use and legal problems appear mainly among older conduct disordered males).
In comparison with adult alcohol abusers, adolescent alcohol abusers are less likely to suffer from the progressive nature of the disorder, medical complications, and other consequences of protracted use. Moreover, teens sent for treatment may use a greater number or different types of substances (i.e., polysubstance use) than adults, resulting in more complicated withdrawal and dependency patterns than suggested by the DSM-IV. Polysubstance use among adolescents with alcohol use problems is especially notable because:
- Teens often perceive alcohol to be "safer" than other substances, which can lead to differential motivation regarding abstinence across substances
- The use of alcohol may precipitate relapse to the abuse of other drugs
- Alcohol may interact with, potentiate, or compound the action of other drugs
Another difference between adult and adolescent abusers is that adolescent alcohol use occurs in the context of rapid developmental changes, which may mimic or exacerbate drug effects. In addition, current DSM-based methods of estimating adolescent alcohol and other drug problems result in high percentages of "diagnostic orphans," adolescents who appear to have some substance use problems but do not fully meet diagnostic criteria (Pollock & Martin, 1999). This suggests that the DSM criteria may seriously underestimate substance use problems among teens.
Given the ongoing debate of whether the DSM-IV alcohol disorder symptoms are suitable for identifying alcohol use problems among adolescents, Wagner, Lloyd, and Gil, (in press) explored in depth one of the limitations described by Martin and Winters. Wagner et al. recruited a large, multiethnic sample of adolescents from the community. The goal of this study was to examine putative variation across subgroups of adolescents in the incidence and timing of first occurrence of DSM-IV alcohol abuse and dependence symptoms. Wagner et al. tested whether youths of different sexes or different racial/ethnic backgrounds differentially demonstrate abuse and dependence symptoms, and whether these subgroups vary in the first occurrence of these symptoms. The cumulative incidence of Alcohol Abuse and Alcohol Dependence diagnoses, as well as one alcohol abuse symptom and four dependence symptoms, varied by race/ethnicity. The incidence of both diagnoses, as well as for two alcohol abuse symptoms, varied by gender. Event history analysis revealed no significant subgroup variation in first onset patterns for only three of the eleven symptoms. Racial/ethnic variation, but not gender variation, was significant for three symptoms, and both racial/ethnic variation and gender variation was significant for the remaining five symptoms. Wagner at al. concluded that most of the DSM-IV Alcohol Use Disorder Symptoms, when applied to adolescents, demonstrate significant subgroup variation in incidence and onset age patterns. All of the issues discussed above raise significant concerns about the appropriateness of using the DSM-IV alcohol use disorders diagnostic criteria with teenagers. The DSM diagnostic criteria for alcohol abuse and dependence can be useful, but may not be optimal or sufficient for assessing youth with alcohol problems.
Continuum versus Categories
The use and abuse of alcohol and other drugs among teens is best conceptualized as lying on a continuum, ranging from nonuse to addiction (Steinberg & Levine, 1990):
- Nonusers are actually a heterogeneous population: some have never tried alcohol and other drugs, and have no intention of doing so; others no longer use but did at some point in history. They also differ markedly in their reasons for not using (e.g., fear of consequences, religious reasons, etc.).
- Experimenters try substances (typically alcohol or marijuana) once or twice but decide they do not like the effects enough to warrant the risks (cost-benefit analysis).
- Recreational users use alcohol and/or other drugs on an occasional basis, but generally can "take or leave" the substance use.
- Regular users actively seek alcohol and/or other drugs, and use substances on a regular, somewhat frequent basis. Such teens tend to prefer friends and activities associated with getting high, yet still care about their reputations and parents' approval (the potential "costs" of use).
- Abusers are frequent substance users who tend to use alcohol and other drugs in multiple situations. These adolescents lose interest in the non-substance related activities they used to enjoy and begin to demonstrate declines and/or problems in areas such as school performance and relationships with parents and other family members.
- The substance dependent are chronic and heavy substance users who use alcohol and other drugs compulsively. Substance dependent adolescents start seeking drugs and routes of administration with the most immediate effects (e.g., high proof alcohol, smoking crack cocaine, shooting up). Procurement occupies a significant portion of their time and energy.
Most teenagers who use alcohol and other substances fall into the experimenter-regular user range. Such adolescents rarely come into contact with social workers in the absence of some acute provoking event (e.g., an intoxication-related accident). The types of alcohol-using teens typically seen in substance abuse treatment settings are abusers or substance dependent, with abusers outnumbering the dependent simply because very few adolescents have a long enough alcohol use history to develop the combination of symptoms that define alcohol dependence.
Risk Factors for Alcohol Use Problems Among Teenagers
"Risk factor" is a term that is used widely, though often incorrectly, by mental health professionals. To qualify as a risk factor for alcohol abuse, a given variable only is required to meet two criteria:
- it must occur temporally prior to the onset of the alcohol use problem, and
- it must be associated statistically with an increased probability of substance use problems.
Risk factors need not:
- "cause" alcohol use problems (i.e., be the direct determinants of alcohol abuse),
- be specifically or uniquely associated with only alcohol use problems
- be necessarily associated with alcohol use problems (i.e., alcohol abuse occurs only, and always, when they are present).
A failure to consider these limits in the definition of risk factors can lead to erroneous decisions about appropriate targets for intervention. An accurate knowledge of risk factors is essential for understanding what types of adolescents, under what types of conditions, are most likely to develop problems with alcohol or other drugs.
A great deal of research has been devoted to documenting the risk factors for alcohol use and abuse among adolescents (for excellent reviews, see Hawkins, Catalano, & Miller 1992, and Petraitis, Flay & Miller, 1995). Risk factors may be divided into three categories: 1) individual factors, 2) social/ interpersonal factors, and 3) contextual/cultural factors.
Table 1. Risk Factors for Alcohol Use and Abuse Among Adolescents
Individual Risk Factors
- Physiological factors (genetic pre-disposition, alcohol sensitivity, etc)
- Impaired cognitive functions, learning difficulties, school failure
- Temperament/personality traits (negative mood states, social withdrawal, irritability, tantrums)
- Emotional distress
- Extraversion and sociability
- Tendencies toward risk taking and thrill seeking
- External locus of control
- Low self-esteem
- Poor coping skills
- Deficient social interaction skills
- Alcohol-specific self-efficacy
- Early and persistent problem behaviors
- Low degree of commitment to school, society, and/or religion
- Oriented toward short-term goals and hedonistic gratification
- Little interest in success or achievement
- Alienation and rebelliousness
- Tolerant or positive attitudes toward deviant behavior
- Attitudes favorable to alcohol use
- Early onset of alcohol use
- Belief that alcohol use is normative
- Alcohol expectancies
- Co-morbid psychiatric problems
- Family alcohol and drug behaviors and attitudes
- Poor and inconsistent family management practices
- Limited parental monitoring
- Family conflict
- Low bonding to family
- Peer rejection in elementary grades
- Association with alcohol-involved peers
- Negative evaluations from parents
- Home strain
- Parent divorce or separation
- Laws and norms favorable (or ambivalent) toward alcohol use; nonenforcement
- Availability of alcohol
- Extreme economic deprivation
- Neighborhood disorganization
While an exhaustive review is beyond the scope of this module, individual risk factors represent physiological and psychological factors within the person, such as current and past use, attitudes and beliefs, personality and temperament traits, and abilities/ disabilities.
Tied to these factors is a set of resiliency factors (Norman, 1994) that warrant exploration (e.g., coping and adaptive skills, absence of physiological vulnerabilities easy temperament, intellectual capacities, self-efficacy, etc.).
Social/interpersonal risk factors reflect social influences deriving from interactions with parents, siblings, and peers. Of particular importance in the understanding of adolescent substance use is the influence of the peer group, an area of considerable misattribution of causality. When detecting an association between adolescent and peer use, the importance of social selection and cognitive bias is often overlooked. In other words, the conclusion that peers cause adolescent substance use ignores the fact that many adolescents who choose to use also choose friends that use. This conclusion also ignores a methodological issue: many of the studies simply ask adolescents to estimate the number of their peers/friends who use. Users are very likely to overestimate their peers' as part of a process to normalize the behavior and in an assumption that their peers are "like" themselves.
Tied to the class of social and interpersonal factors is a set of social context protective factors (Turner, 1995) that play key roles in moderating the effects of individual and contextual factors (e.g., family factors, positive relationship with a caring adult, positive modeling, good supervision, traditions/rituals, extended family support, etc.). A host of variables can either mediate or moderate the relationship between family history of alcohol problems and problem use by adolescents (Begun & Zweben, 1990; Sher, 1991).
Contextual/cultural risk factors are broader, macro-level influences such as economic deprivation, racism, social barriers, or alcohol availability (Duncan & Petosa, 1995). As such, social work professionals need to have a variety of skills in working at multiple levels of influence-individual, microsystems, policy, and macrosystems. Knowing about the influences and their mechanisms of operation facilitate both prevention and treatment. Furthermore, it's critical to remember that correlates are not necessarily causally related! Although very good data exist that enumerate the risk factors for alcohol problems among teens, very little is currently known about which risk factors or combinations of risk factors are most virulent, most modifiable, or most specific in regard to adolescent alcohol abuse.
Assessment of Adolescents
Adolescent alcohol and substance use problems are best conceptualized as developmental, biological, psychological, and social phenomena. Failure to consider the role of any of these dimensions in the emergence and perpetuation of alcohol and substance abuse may result in poor clinical outcomes. Furthermore, multiple sources of data enhance the veracity of the information on which the assessment is based. Whenever possible, assessment also should include information from a variety of sources, including teenager self-reports (gained through self-monitoring, clinical interview, and/or structured reporting forms), significant others' reports (e.g., parents, teachers), psychometric testing, direct observation of the adolescent's behavior, and biological measures.
Thus, assessment of teen substance use problems ideally includes evaluation of:
(1) the substance use behavior itself
(2) the type and severity of psychiatric morbidity that may be present and whether it preceded or developed after the substance use disorder
(3) cognitive processes, with specific attention to neuropsychological functioning
(4) family organization and interaction patterns
(5) social skills
Assessment of adolescent substance use problems should also include an evaluation of:
(6) school and/or vocational adjustment
(7) recreation and leisure activities
(8) temperament and/or personality characteristics
(9) peer affiliations
(10) legal status
(11) physical health status and concerns
In addition, toxicology screens can be helpful for verifying teens' reports of recent alcohol or other drug use, and may indeed be mandatory in some treatment settings or among certain populations (e.g., court-referred juvenile offenders).
Actual assessment should begin with a brief open-ended interview with adolescents and their parents about the presenting problem, specifically its chronicity, severity, and origins. Here, it is important to focus on problems that the teenager may have experienced because of substance use, rather than focusing on the frequency, type, or quantity of substance use. When adolescents and their parents' descriptions of the presenting problems are contradictory, it is usually best to openly acknowledge these contradictions without siding with the adolescent or their parents. Teenagers and/or parents may request a meeting alone with the clinician, and such meetings can be pursued if judged by the clinician to be necessary and helpful. However, issues related to confidentiality should be carefully considered and discussed before such meetings take place.
A valid, standardized, and clinically relevant assessment is essential for effective intervention with adolescent substance abusers (Winters, Latimer, & Stinchfield, 1999). The advantages of standardized assessments are that they:
(1) provide a benchmark against which clinical decisions can be compared and validated;
(2) are less prone to clinician biases and inconsistencies than more traditional assessment methods; and
(3) provide a common language from which improved communication in the field can develop. Standardized scores are emerging for specific age groups of adolescents-youth in early adolescence may perform and behave very differently than in later adolescence.
Until recently, clinicians have often relied on clinical judgment or locally developed procedures to diagnose adolescent substance use problems. However, this has begun to change as standardized and clinically valid instruments such as the Personal Experiences Inventory (Winters et al., 1999), the Drug Use Screening Inventory (Tarter & Hegedus, 1991), the Customary Drinking and Drug Use Record (Brown, Myers, Lippke, Tapert, Steward, & Vik, 1998), and the Teen-Addiction Severity Index (Kaminer, Wagner, Plummer, & Seifer, 1993) have been introduced into the literature. Developmental appropriateness is critical to the effectiveness of using these instruments in work with adolescents. The instrument must be interpretable by individuals who express the kinds of cognitive abilities and limitations that characterize both younger and older adolescents (e.g., reading level, level of concrete versus abstract reasoning, world experience). This also means that the instrument elicits responses that are relevant to the contexts and lifestyles of adolescents. For example, asking about boyfriends/girlfriends rather than spouses; asking about school and workplace rather than careers; asking about drinking in cars, homes, parks, and locations other than pubs, bars, lounges and restaurants.
Standardized, Validated Instruments to Diagnose Substance Use Problems- Personal Experiences Inventory
- Drug Use Screening Inventory
- Customary Drinking and Drug Use Record
- Teen-Addiction Severity Index
Another relevant domain is adolescent reasoning about the morality of drug and alcohol use. In comparison with adults, adolescents are more likely to focus on the harmfulness to self, rather than on possible effects for others (Berkowitz, Begun, Zweben, et al., 1995; Giese & Berkowitz, 1997; Nucci, Guerra, & Lee, 1991). In other words, adolescents are more likely to view substance use merely as a personal choice issue, not as a decision having wider social and societal implications. It is not clear, however, the extent to which adolescent social and moral cognitions actually influence behavior. A closely related developmental concern is the adolescent tendency toward egocentrism and the "imaginary audience" phenomenon (Berkowitz & Begun, in press). In the eye of the adolescent, many negative behaviors are "rewarded" by the presumed sanctioning and regard of peers, even when the peers are not present (Colwell, Billingham, & Gross, 1995; Montgomery, Haemmerlie, & Zoellner, 1996). Furthermore, adolescents are likely to interpret epidemiological data as "normalizing" substance use, and view it as a common event, whether or not it is right or wrong. In sum, it is important to consider these developmental phenomena when designing prevention and treatment interventions for adolescents.
Assessment Feedback Sessions
Once assessment data have been collected and analyzed, feedback about the assessment is a critical determinant of the adolescent's compliance with treatment recommendations. Miller and Rollnick (1991) have described a particularly useful approach to feedback, which in the case of adolescent substance abuse has the following characteristics:
- avoid trying to prove things to teenagers and their families
- describe each result, along with the information necessary to understand what it means
- avoid a scare tactic tone
- solicit and reflect adolescents and their families' reactions to the assessment information
- remain open to feedback from adolescents and their families
- be prepared to deal with strong emotional reactions
The session should conclude with a summary of what has transpired that includes:
- the risks and problems that have emerged from assessment findings
- teenagers' and their families' own reactions to the feedback, with an emphasis on statements reflecting a willingness and interest to make positive changes
- an invitation for the adolescents and family to add to or correct the summary
- assurance that successful treatments are available.
Treatment with Teenagers
Multiple intervention approaches have been developed in an attempt to address alcohol and other drug problems among adolescents. Knowledge about which of these approaches is most effective for which individuals remains limited. Clinical demand for intervention programs has been overwhelming and has outpaced empirical research evaluating their effectiveness. "Surprisingly, few clinical studies have investigated the effectiveness of treatment programs for adolescents" (Schinke, Botvin, & Orlandi, 1991).
While a small number of investigators are currently conducting controlled clinical trials of various adolescent substance abuse interventions (Wagner, Brown, Monti, Myers, & Waldron, 1999; Wagner & Waldron, 2001), most available substance abuse interventions have not been rigorously evaluated. "There is evidence that treatment is superior to no treatment, but insufficient evidence to compare the effectiveness of treatment types. The exception to this is that outpatient family therapy appears superior to other forms of outpatient therapy" (Williams, Chang, & Addiction Centre Research Group, 2000). Unfortunately, family therapy has relatively high rates of attrition with adolescents.
Intervention options vary widely in terms of their developmental appropriateness and their sensitivity to developmental issues. " multiple psychosocial intervention approaches have been developed during the past two decades. Unfortunately, little is currently known about which of these approaches is most effective for which individuals" (Wagner et al, 1999).
At present, we do know that:
- substance use intervention can succeed with adolescents
- adolescent treatment outcomes are comparable to those found with adults
- improvement varies across domains of functioning (e.g., school, emotional distress, family relations).
However, it generally appears that no particular intervention is superior to any other (Brown, Gleghorn, Schuckit, Myers, & Mott, 1996; Wagner et al., 1999; Williams et al., 2000).
" some treatment is better than none; no particular treatment method has emerged as superior to any other" (Catalano, Hawkins, Wells, Miller, & Brewer, 1990-91).
Intervention with adolescents should be informed by developmental theory and sensitivity to developmental processes.
Until very recently, treatment approaches used with substance abusing adolescents have mirrored those used for adults (Wagner & Kassel, 1995). While this was a good place to start, clinicians and researchers have recognized that the behavioral manifestations of, the motives underlying, and the factors associated with adolescent substance use problems may be markedly different from those associated with adult substance use problems (see Table 2 on next page).
Table 2. Differences Between Adult and Adolescent Substance Abusers
Compared to adult substance abusers, adolescent substance abusers
- have a briefer history of substance involvement
- are more likely to demonstrate episodic AOD consumption, and less like to demonstrate chronic, daily use
- are less likely to suffer from the progressive nature of the disorder, medical complications, and other consequences of protracted use
- use a greater number or different types of substances, resulting in more complicated withdrawal and dependency patterns
- are undergoing rapid developmental changes, which may mimic or exacerbate drug effects
- are more likely to present with co-occurring problems such as psychiatric comorbidity, family disruption, academic problems, problem behaviors, deviance, low levels of conventionality, and peer drug use
- may be more likely to "outgrow" patterns of substance use/abuse by early adulthood without formal intervention or treatment
- may be less amenable to confrontation-of-denial approaches to treatment, given developmental issues associated with independence and autonomy
When viewed within this developmental framework, "Drug use may be seen as a way to consolidate with peers, as a way to establish autonomy, as a way to separate from family, and as a way to address the emerging questions and hypotheses adolescents have about themselves" (Murray & Perry, 1985). Such adolescent-specific developmental issues need to be taken into account for treatment to be most effective. For example, compared to adult substance abusers, adolescent substance abusers:
- have a briefer history of substance involvement
- are more likely to demonstrate episodic consumption, and less likely to demonstrate chronic, daily use
- are less likely to suffer from the progressive nature of the disorder, medical complications, and other consequences of protracted use
- tend to use a greater number of different types of substances, resulting in more complicated withdrawal and dependency patterns
- are undergoing rapid developmental changes, which may mimic or exacerbate drug/alcohol effects
- are more likely to present with co-occurring problems, such as depressive symptoms, family disruption, academic problems, problem behaviors, deviance, low levels of conventionality, and peer drug use
- may be more likely to "outgrow" patterns of substance use/abuse by early adulthood, without formal intervention or treatment
- may be less amenable to confrontation-of-denial treatment approaches because of developmental issues associated with independence-seeking and achieving autonomy
Remember that use of multiple drugs should be addressed with adolescents, since the modal alcohol use problems of this age group also involve polysubstance use.
Adolescents with alcohol use problems are a heterogeneous group. They exhibit marked individual differences on factors such as the anticipated effects and consequences of substance use, the context and motivations in which use occurs, and the risk factors that contribute to or accompany substance use (Wagner & Kassel, 1995). These differences may help to explain why some alcohol-abusing adolescents respond to treatment and others do not. Individual difference variables likely to affect treatment response have been labeled "amenability to treatment" or "matching" factors. However, very few studies have examined the differential amenability of adolescents to various treatments, and treatment matching for teenagers is currently in its infancy. Moreover, many teenagers with alcohol use problems demonstrate significant psychiatric comorbidity, and as a result, require intervention that addresses both problems associated with alcohol use and problems associated with the comorbid psychiatric diagnoses. In sum, it remains likely that different substance abusing adolescents may respond differently to different substance abuse treatments.
At present, several evidence-based, developmentally sensitive approaches are emerging for addressing alcohol, nicotine, and other drug use problems among adolescents (Wagner & Waldron, 2001). These include family systems approaches (Liddle & Hogue, 2001; Waldron, 1997), brief motivational interventions (Barnett, Monti, & Wood, 2001), guided personal change programs (Brown, 2001; Gil, Tubman, & Wagner, 2001), cognitive-behavioral skills building treatments (Bry & Attaway, 2001; Donohue & Azrin, 2001; Myers, 2001; Wagner, Myers, & Brown, 1994), and assertive aftercare programs (Harrington, Godley, Godley, & Dennis, 2001). Moreover, there has been increasing attention devoted to community-based treatment models (e.g., treatment provided in neighborhood clinics, schools, and/or the home), which have greater ecological validity and impact, and fewer barriers to treatment access than more traditional treatment models for adolescent substance abuse (Wagner, Swensen, & Henggeler, 2000). Examples of empirically derived, community-based treatments for adolescent alcohol abuse may be found in Brown (2001); Bry and Attaway (2001); Gil, et al. (2001); and Wagner, Kortlander, & Leon Morris (2001). Finally, given the high rates of psychiatric comorbidity among adolescents with alcohol or other drug problems, and the growing availability of pharmacological agents for treating psychiatric and substance use problems, an effective treatment "package" for substance abusing teenagers may include medication (Kaminer, 2001).
Evidence-based approaches for adolescent ATOD problems:
- Family systems approach
- Brief motivational interventions
- Guided personal change programs
- Cognitive-behavioral skills building treatments
- Assertive aftercare programs
- Community-based treatment models
- Pharmacotherapy for psychiatric comorbidity
Group therapy and 12-step programs are commonly used with adolescents, but recent reports suggest that these interventions should be approached with caution. While group therapy can be successful for teenagers with substance use problems, it may have iatrogenic effects. Based on developmental and intervention findings, Dishion, McCord, & Poulin (1999) have argued that adolescent peer networks formed on the basis of deviance (e.g., referral to group therapy) may provide a context where problem behaviors are reinforced. Kassel and Jackson (2001) have critically evaluated the utility of Alcoholics Anonymous and other 12-step approaches for teenagers. While the empirical literature regarding the impact of 12-step programs on adolescents is scant, these authors concluded that some adolescents respond positively to AA and its derivatives, primarily because of expanded social support for non-use. This is especially true for teens who have been involved in intensive substance abuse treatment (Brown, 1993). Among adolescents, attendance in such support groups is related to perceived similarity with other group members and age (Brown, 1993; Kelly, Myers, & Brown, 2000; Vik, Grizzle, & Brown, 1992). However, other teenagers do not respond positively to 12-step approaches, primarily because these programs do little to accommodate the developmental and diagnostic issues associated with substance use problems among adolescents. Clearly, more research is needed on the impact of group therapy and 12-step approaches on adolescents with substance use problems. In addition, we need to expand our understanding of how to serve adolescents encountered in a wide variety of settings including mental health centers, schools, hospitals and medical services, child maltreatment services, vocational training, and criminal justice programs.
Ethnicity and culture have an impact on multiple aspects of the alcohol abuse treatment process (Collins, 1993). It appears that cultural sensitivity (or congruency) may enhance the degree to which a specific intervention addresses AOD use problems among clients from specific ethnic/cultural groups (Longshore & Grills, 2000; Longshore, Grills, & Annon, 1999; Pérez-Arce, Carr, & Sorensen, 1993). However, little empirical research has examined:
- the effectiveness of substance abuse treatment for ethnic minorities (Gil & Vega, 2001; Gil et al., 2001)
- how ethnicity and culture may moderate the treatment process and outcome
- how interventions may be modified to improve cultural congruency
Scant research has specifically examined the role of ethnicity/culture in clinical outcomes of psychotherapy trials with children and adolescents. While a few studies support the effectiveness of interventions for adolescent substance use problems, research to date has been plagued by inadequate attention to issues related to ethnicity and culture (Gil & Vega, 2001; Vega & Gil, 1998; Williams et al., 2000). Clearly, adolescents from different ethnic and cultural groups differ in risk factors for, and rates of, substance use/abuse. They also may differ in responsiveness to various treatments. We know very little about the effects of factors such as perceived discrimination, cultural mistrust, and acculturation on treatment effectiveness. In short, whether we need culturally specific interventions for adolescents is not clear. Currently, the important question of whether adolescents from different ethnic and cultural groups respond differently to different types of interventions remains unanswered.
Motivation to Change
Higher levels of pretreatment motivation to change have been shown to predict greater reductions in the frequency of alcohol and other drug use during treatment, and higher likelihood of six-month post treatment abstinence among substance abusing adolescents (Cady, Winters, Jordan, Solberg, & Stinchfield, 1996). Thus, motivation may play a critical role in treatment response. One way to bolster substance abusers' commitment (i.e., motivation) to making changes is to allow them choices in approaches to, and goals for, treatment (Sobell & Sobell, 1993). The Problem Recognition Questionnaire (PRQ) is a 24-item self-report measure of adolescents' perceptions of the seriousness of alcohol/drug involvement and motivation for drug use change and readiness for treatment (Cady et al., 1996). The PRQ has three factor analytically derived scales (i.e., contemplation, contemplation/preparation, and preparation) that are interpreted as representative of the stages of change proposed by Prochaska, DiClemente, and Norcross (1992). In a sample of 234 adolescents admitted to substance abuse treatment, the PRQ showed a high level of internal consistency (alpha = .91). In addition, high scores of the PRQ (i.e., higher motivation) were predictive of some post treatment variables (e.g., abstinence and change in drug use) but not discharge variables. As in the case with adults, a complete assessment would include motivation and readiness factors.
Prevention and Early Intervention
Primary prevention of, and early intervention with, adolescent alcohol use problems is intended to reduce the number of new cases, enhance positive functioning, promote protective and resilience factors in adolescents' social contexts and themselves, encourage healthy behaviors that are inconsistent with substance abuse, and minimize risk and vulnerability factors. There is considerable debate as to the long-term effectiveness of alcohol abuse prevention programs (Meyer, 1994), although many programs have clearly documented short-term impact and a capacity to at least delay the onset of the problems. More personal and environmental resources can be employed to prevent the emergence of future abuse the longer first use is delayed (Norman, 1997).
Prevention effectiveness is enhanced when the targeted adolescents encounter social contexts and environments that continue to support the prevention mission (i.e., social disapproval for the behavior), multiple-year "booster" inoculations are delivered, and multiple contexts are involved in the change effort (i.e., school, work, family, community, media, and peers). While it is not likely that intensive, systematic, community-wide prevention interventions will be economically feasible or efficacious in preventing alcohol use problems from emerging among the relatively few users who eventually convert to patterns of abuse (Rickel & Becker-Lausen, 1997), these interventions do represent an important part of an overall package. Intervening at the level of the individual is not sufficient (Meyer, 1994), and the potential as well as realized impacts of social policy must be considered (Nicholson, 1994). Developmentally sensitive prevention strategies begin prior to the emergence of the criterion behavior. In other words, these programs initiate efforts prior to the middle school years and continue throughout the vulnerable periods of early and late adolescence.
Social policies should be considered. Intervening at the level of the individual is not sufficient.
Summary and Conclusions
Several issues, debates, and strains related to the treatment of adolescent alcohol use problems exist. The first is the ongoing debate as to whether controlled use of substances is a desirable, or even possible, outcome. A second, related topic, is what actually constitutes a "successful" treatment outcome with adolescents? A third issue of concern and strain on the service system is the high rate of coexisting psychopathology and polydrug use. Fourth, many adolescent substance abusers are estranged from their families, making treatment difficult when social supports and family history are expected to facilitate the assessment and intervention processes. A fifth challenge relates to the various aspects and concerns involved with appropriate client-treatment matching. Sixth is the observation that many adolescents with alcohol use problems will no longer demonstrate the problematic behaviors as young adults (i.e., after about age 22 years). The final issue is the ongoing debate concerning diagnostic criteria and instruments that are most appropriate for application in work with adolescents.
WHAT WE KNOW WHAT WE DON'T KNOW A majority of adolescents have tried alcohol, and many have tried other drugs, by 12th grade.
Which factors are most important and how do they interact with one another?
Some of these adolescent substance users will develop diagnosable substance use disorders. Which interventions are best for which adolescents? The vulnerability, risk, resilience, and protective factors associated with adolescent alcohol use problems have been identified. The vulnerability, risk, resilience, and protective factors associated with adolescent alcohol use problems have been identified. How does the interaction between individuals and treatment factors affect outcomes? Intervention of some type is usually better than no intervention What diagnostic criteria and instruments are most appropriate for adolescents?
RECOMMENDED CLASSROOM ACTIVITIES
- Watch one week of "teen market" television programming, or three video/DVD rentals targeted to this age group. Critique the messages related to alcohol that are conveyed in these media devices.
- Access one of the adolescent-tested assessment instruments and conduct a role-play of its use with adolescent characters who are:
- a) at intake to an alcohol treatment program
b) at intake to a non-substance specialized program (e.g., teen pregnancy program, school social work intervention, adolescent criminal justice facility).
Be sure that you include in your role-play the assessment feedback session!
- Develop a training poster for social work professionals (not specifically drug and alcohol clinicians) to teach them about the continuum of adolescent alcohol use problems.
- Develop a program evaluation plan that will systematically examine the effectiveness of a treatment approach specific to adolescents with alcohol use problems. Make sure that your evaluation research is developmentally sensitive and addresses the key adolescents' issues, and uses instruments that are appropriate for use with this population.
- Have each student conduct a single component of a media content analysis related to alcohol use. Focus on aspects of the media that are likely to be accessed by different groups of adolescents (e.g., video games, rock/popular music, movies and video rentals, magazines, clothing logos, etc.). Compile the images and messages and discuss their cumulative impact on adolescents (positive and negative messages).
- Discuss ways that social workers might overcome their "adult-centric" perspectives that might interfere with their effectiveness in working with adolescent alcohol users/abusers.
- Discuss the ethical issues that arise in social work practice with alcohol using/abusing adolescents-vis a vis their families, schools/work, peers/friends, and their legal status.
- Seek out data that describe alcohol use problems among youth/adolescents in another culture. (You might want to consider the data that are presented for Project Hope youths in Russia as an appendix to the presentation.) What are the implications related to your comparison? What are the limitations of the comparison? What does this comparison tell us about risk/protective factors and how we might develop and implement better prevention and treatment programs in our own country?
- Discuss ways to evaluate the effectiveness of different types of intervention for different types of adolescents.
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Updated: March 2005