Substance Abuse and Dependence in Adolescence

Epidemiology, Risk Factors and Treatment

Cecilia A. Essau, Cecilia A. Essau

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317710653
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia dello sviluppo

Recent years have seen a growth in the numbers of studies of substance abuse and dependence in adolescence, focusing on prevalence, risk factors, comorbidity, course and outcome. At the same time, numerous prevention and intervention strategies have been developed. Substance Abuse and Dependence in Adolescence presents a comprehensive review of state-of-the-art empirical and practical information on this topic.
Cecilia A. Essau, along with an eminent group of international researchers and clinicians, summarises the most recent empirical findings and state-of-the-art knowledge on substance abuse and dependence in adolescence and includes comprehensive information on prevention and treatment. Substance Abuse and Dependence in Adolescence contains:
* general issues related to substance use disorders
* epidemiology, comorbidity, course, outcome and risk factors
* the prevention and intervention of substance abuse and dependence
* a discussion of progress and unresolved issues in substance use disorders
* recommendations for future studies in the field.
Substance Abuse and Dependence in Adolescence will be an invaluable resource for students, researchers, and other professionals working in the fields of psychology, psychiatry, paediatrics, social work and other mental health professions.

Chapter 1
Substance use and adolescence

Gerald Adams, Anne-Marie Cantwell, and Shawn Matheis

Adolescence is defined as the life stage between childhood and adulthood; in a hurried society the media pushes images of teenage behaviour at an early age. At the opposite end many adolescents are not sure when they become adults. Gullotta and colleagues (2000) indicate the three essential elements associated with adulthood by many life span theorists are financial independence, gainful employment and marriage. The end of adolescence may require occasional modification of emerging ideas of the age range associated with this period of life. Though this period is often described as including the time from the onset of puberty to the late teen years, Arnett (1992) describes adolescence as puberty to the early 20s because in American culture, adolescence is viewed as the “time from the beginning of puberty until adult responsibilities are taken on” (p. 340). The emphasis of education in our society has resulted in many more youth remaining financially dependent and unemployed while pursuing post-secondary school experiences thus remaining in the stage of adolescence for extended periods (Côté and Allahar, 1994).

Compared to other life stages, adolescence is a period characterized by an amplified capability for behaviours that have potentially dangerous outcomes (Arnett, 1992; Gullone et al., 2000). Bingham and colleagues (1994) have described the period between 14 and 22 as the greatest window of vulnerability for risk consequences across the life span. Such risk-taking, thrill-seeking, and reckless behaviours have received a great deal of attention in research particularly in the last decade (Arnett, 1992, 1996; Gonzalez et al., 1994; Lavery et al., 1993; Levitt et al., 1991). Included in this phenomenon of increased risk-taking are behaviours such as minor criminal activity, sexual activity, reckless driving, problem gambling, alcohol consumption, and drug use. The dramatic outcomes include incarceration, disease, and possibly death. For the purposes of this chapter we will focus on the last two, alcohol consumption and drug use. However, it is important to acknowledge that alcohol and drug use often accompanies the additional behaviours noted above. It is rare that adolescents will engage in only a single risk behaviour; rather adolescents are likely to participate in a variety or composite of such behaviours (Jessor et al., 1991; Jessor and Jessor, 1977).

Related Definitions

The definitions of adolescent substance use and misuse have been the subject of active debate among scholars and clinicians alike, as well as in the media, between various political interests, and in the homes of ordinary families (Bukstein and Kaminer, 1994). As with many definitional concerns, the complexity of defining substance use and abuse in relation to adolescence stems from a variety of sources. Differing beliefs surrounding adolescent use of drugs and alcohol in western cultures is one of the major factors confusing this issue (Gilvarry, 2000). The definition and subsequent diagnosis of substance use disorders is further complicated by the differing effects of various substances on the user (Giancola and Tarter, 1999) and the frequent comorbidity of substance misuse with other mental health disorders (Costello et al., 1999). Accentuating this confusion is the fact that illegal alcohol use is extremely common in adolescence, and in the majority of cases tapers off in early adulthood without the need for intervention (Cole and Weissberg, 1995), a pattern which some have suggested is a normative developmental trend (Baumrind, 1991; Bukstein and Kaminer, 1994; Newcomb and Bentler, 1989).

The complexities in the debate over defining substance use and misuse are belied by the seriousness of the issue. Substance use disorders in adolescence are associated with many problems, including poor academic performance, increased rates of school dropouts, juvenile delinquency, sexual promiscuity, early pregnancy, impaired driving, family difficulties, and mental health concerns including depression and suicide (Gilvarry, 2000). In 1999, emergency rooms in the United States were filled with an estimated 52,783 youths between the ages of 12 and 17, and an estimated 10,580 young adults between the ages of 18 and 25 for medical emergencies related to drug use, marking a steep rise from the same estimates in 1992 (Substance Abuse and Mental Health Services Administration, 2000b). Some authors claim that the problems in defining substance use and misuse have hampered efforts to effectively measure these concepts, and to recommend preventative or treatment strategies concerning substance use based on such outcomes (Bukstein and Kaminer, 1994).

The Two Taxonomies: DSM-IV and ICD-10

The definitions of substance use disorders that are currently the most widely accepted are those identified in the Diagnostic and Statistic Manual of Mental Disorders—IV (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10). These two classification systems are similar in many respects (see also Chapter 2 in this volume). Both systems classify substance abuse into two separate categories, dependence and either abuse (DSM-IV) or harmful use (ICD-10). In both cases, dependence includes a component indicating the presence of tolerance and/or withdrawal, as well as an indication that the user cannot control the use of the substance and that the use of the substance is having a negative and tangible effect on the user’s life. Finally, of particular importance to our discussion is that both systems also adopt the same criteria for diagnosis regardless of the user’s age (Rounsaville et al., 1993).

The most important difference between the DSM-IV and the ICD-10 is in the diagnoses of abuse and harmful use. A diagnosis of substance abuse can be made in the DSM-IV if any of the following criteria are present to a clinically significant degree due to substance use: the user is unable to fulfil major role obligations, encounters legal or interpersonal problems, gives up important activities, or uses substances in situations where they are physically hazardous. By contrast, diagnosis of harmful use in the ICD-10 requires evidence that substance use is causing psychological or physical harm to the user (Rounsaville et al., 1993). Not surprisingly, diagnoses can vary based on which classification system is used. Rounsaville et al. (1993) studied the cross-system agreement in diagnoses of substance use disorders between the DSM-IV, ICD-10, and DSM-III-R. The findings showed a reasonable level of concordance between the DSM-IV and the ICD-10 on dependence, but highly discordant diagnoses of substance abuse as opposed to harmful use. Overall, the sample was much more likely to be diagnosed with substance abuse rather than harmful use. This effect was particularly strong for users of alcohol and marijuana (Rounsaville et al., 1993). The difference between these two definitions is of particular importance in diagnosing substance use disorders in adolescents, given that some of the criteria for substance abuse in the DSM-IV are common experiences for young people. In a recent study of undergraduate students, there was a 24.5% lifetime prevalence of substance abuse or dependence as defined by the DSM-IV, while only 4% of the sample had ever sought out substance abuse treatment (Clements, 1999).

While the DSM-IV and ICD-10 definitions of substance use disorders are the most widely used and accepted, many aspects of these definitions have been criticized, particularly as they apply to adolescents. The current definitions have been derived largely on the basis of clinical and empirical work with adults who have been diagnosed as having substance use disorders, and some researchers have questioned their validity in using such measures when diagnosing such disorders in adolescents (Gilvarry, 2000; Bukstein and Kaminer, 1994). Many studies done to validate the definition provided by the DSM-IV with adolescents were mainly designed to test whether abuse and dependence really were two separate disorders, and much of this research has produced mixed results. A wide body of research has found the DSM-IV criteria to be supported in the diagnosis of substance use disorders in adolescence (Kaminer and Bukstein, 1998). For example, a one-year longitudinal study involving 1,507 Oregon high school students found that DSM-IV criteria were highly effective in differentiating between adolescents with normative and pathological functioning related to substance use (Lewinsohn et al., 1996). However, Fulkerson and colleagues (1999) found in a study using a sample of 18,803 high school students in Minnesota that substance abuse and dependence did not provide major differences in diagnosis. Nelson and colleagues (1999) studied DSM-IV classifications of substance use and abuse on a sample of 1,272 adolescents and adults from eight regions around the world, and found that substance abuse and dependence were valid as separate diagnoses for some substances and not in relation to others.

Critical Issues in Defining Adolescent Substance Use and Misuse

Beyond issues regarding the utility of the DSM-IV and ICD-10 in defining and diagnosing substance use disorders in adolescence, there are also several critical issues that have been raised concerning substance use and misuse in adolescence that impact on the nature of definitions. These issues include whether features of substance use and misuse are unique to adolescence, and contrasting ideas over what constitutes substance misuse in adolescence.

There is a fairly active debate regarding whether substance use and misuse can be defined by the same criteria in adolescence and adulthood. Those who are in favour of the idea that substance use and misuse are unique in adolescence usually argue that many adolescents exhibiting characteristics of substance use disorder are going through an exploratory period during which ideas and behaviours consistent with appropriate substance use are developing (Bukstein and Kaminer, 1994). Research on general populations of adolescents has shown that the vast majority of the symptoms of substance use disorder spontaneously remit as adolescents move into adulthood (Bukstein and Kaminer, 1994; Warner et al., 1995), and that of those who show evidence of problem substance use behaviour in adolescence, only a small fraction will show continued problems with substance abuse in adulthood (Gilvarry, 2000).

However, others argue that while there are developmental and contextual factors unique to adolescence that should be considered, the overall definitions of substance use disorder that apply to adults also apply to adolescents. Proponents of this point of view point out that assessments of substance misuse based on definitions in the DSM-IV, which was based on disorders in adults, have been also shown to reliably diagnose substance use disorders in adolescents as well (Lewinsohn et al., 1996). Diagnoses of substance use disorders in adolescence have also been shown to be predictive of the same disorder in adulthood. For example, in the Epidemiological Catchment Area study, 35% of adults with lifetime diagnoses of alcohol abuse/dependence had shown their first symptoms between the ages of 15 and 19 years (Helzer et al., 1991). Overall, the literature suggests that while many adolescents engage in substance use behaviours who do not develop disorders, there is still considerable overlap between substance misuse in adolescence and adulthood.

A second and very important issue is what criteria should be used in determining substance use and misuse in adolescence. One criterion used has been amount or frequency of the substance used, with the main distinction made being between occasional use and abuse (e.g., Hillman and Sawilowsky, 1992; Tarter et al., 1997). However, concerns have been raised about both of these methods. It has been argued convincingly that while information regarding the quantity of a substance consumed is useful, it does not give reliable information regarding substance abuse since individual variation is probable both in the effects of various substances and in the adolescents’ reactions to them (Giancola and Tarter, 1999).

Another criterion has been the extent to which substance use has had a harmful effect on the functioning of the adolescent (e.g., Hillman and Sawilowsky, 1992; Tarter et al., 1997). Some concerns have been raised about this approach as well, even though it forms the backbone of the DSM-IV system. Bukstein and Kaminer (1994) pointed out that, because substance use disorder is usually comorbid with other disorders, it is often difficult to tell whether the substance use is indeed the source of many problems faced by the adolescent. Recent studies have suggested that effects normally attributed to substance use disorder might be more accurately viewed as part of an interconnected set of relationships involving other disorders, personal traits of the adolescent, and environmental factors (Windle et al., 2000).

Recent literature has suggested looking more closely at the contexts in which substance use and misuse occur in order to clarify distinctions between them. Bukstein (1998) suggests considering substance use in the context of other psychiatric diagnoses, family and peer relationships, and the surrounding community when diagnosing substance abuse disorder. Similarly, McWhirter and colleagues (1998) suggest using the following factors in determinations of substance abuse: the frequency of use, quantity typically used, variety of substances used at the same time, social context in which substances are used, and emotional state of the adolescent when using the substances. While both are examples of considerations made during clinical diagnoses, they could also be used to inform research intended to distinguish more clearly between substance use and abuse.

Prevalence

In order to present a complete picture of the variation evident in substance use, the following section will describe the prevalence rates for a variety of substances that are commonly used among adolescents (see also Chapter 3 in this volume). It is necessary to remember that it has been suggested that the definitions of substance use and abuse vary depending on the substance. It will also become evident that there are some differences in usage patterns for different age groups within the stage of adolescence.

Overall trends

The Monitoring the Future Study (MFS) has been collecting a nationally representative sample of the United States grade 12 population since 1975, and grades 8, 10, and 12 since 1991 (Johnston et al., 200...