Foreword

As we seek to understand the behavioral problems of childhood, parents often disclose family secrets. One of the commonest of these is a family history of alcoholism, sometimes previously unacknowledged. In addition to that issue, when we consider the enormous tragedies that result from “driving under the influence,” the prevention of alcohol abuse or, at least, diagnosing the young people who are at risk, becomes a critical task for the pediatrician. Dr. Ranna Parekh has summarized the subject of alcohol abuse in a very comprehensive way. My comments are included in the text, in italics.

Dr. Parekh is a child and adolescent psychiatrist and is the attending psychiatrist on the Adolescent Assessment Unit at Cambridge Health Alliance.

- Dr. Howard King

Motor vehicle accidents are the leading cause of adolescent mortality. Why?

In the United States, accidents are the leading cause of mortality among adolescents. A major contributor of adolescent motor vehicle accidents is alcohol and drugs. In part because of this public health statistic, alcohol and drug use in adolescents is a major concern for health care providers, parents, teachers and public officials. The most frequently asked questions include: what are the leading drugs of abuse, when does alcohol and drug use become problematic, which adolescents are most vulnerable and how does one prevent and treat adolescent substance abuse?

Alcohol is the number one drug of choice

While many blame the wide variety of illicit substances tempting today’s youth, the findings may be shocking. It is not ecstasy, oxycontin or heroin. Rather, the number one drug of choice for adolescents every year consistently is alcohol. The number two drug is always cannabis. The University of Michigan’s Monitoring the Future project, that began in 1975 among high school seniors, annually reports trends in substance use and abuse. Previously known as the National High School Senior Survey, it administers questionnaires to eighth, tenth and twelfth graders, college students and young adults yearly. Monitoring the Future is one of the most frequently cited sources of information for adolescent alcohol and drug use. A quick glance at the website may clue one in on the beliefs, values and other trends espoused by current generations in addition to drugs of abuse.

Gateway drugs: The experimental stage

In addition to being drugs of abuse, alcohol and cannabis are two of the leading “gateway drugs.” This term refers to drugs, which open the door for other drugs to be used and for potential problematic use. Contrary to belief, most adolescents will not progress beyond the first and second stages of use: experimentation and recreational or misuse, respectively. The experimentation stage is fueled by curiosity and peer pressure. By definition, it is a one-time event and does not include intoxication.

The recreational stage

The recreational or misuse stage is characterized by use of a drug during the weekend or weekday without any consistency or set pattern. It is often used on “social” occasions such as school dances, dates or parties with the hope of enhancing the experience or activity. This stage does not preclude intoxication and may involve trouble at school or with the law. A first sign may include a change in peer group.

Stage three: substance abuse

Stage three is substance abuse. Here, there is a pattern of use; for example, it is used on weekends or weekdays or both. Despite negative consequences, the substance continues to be used. This stage is often manifested as a disruption across the three domains of adolescent life: school, home, and social/friendship circle. There is the forming of a habit, a preoccupation with the drug or alcohol at the cost of school grades, relationships and often, the law.

The final stage

The fourth and final stage is the use of drugs to feel OK. Drugs or alcohol no longer are used for positive effects; instead, they shield from withdrawal or negative feelings associated with no use. At this point, most relationships are fractured and replaced with a monogamous relationship with alcohol and drugs.

The importance of individual assessment

These four stages provide a helpful description of drug intensity. It is important to note that there can be variations within each stage and even overlap of symptoms. For example, an adolescent can use alcohol or the drug every night without problems in his school grades. Or there can be use in social situations only which leads to trouble with the law, with parents and with teachers. Hence, adolescents are a culturally diverse group and individual assessments are most valuable.

Risk factors

All evaluations should include drugs of choice, stage of use and assessment of risk factors for abuse. There are several factors that can make an adolescent more vulnerable to abuse and dependence. Twin and family studies have suggested a genetic link in alcoholism and genetic predispositions are suspected in other drug addictions. The implications of these observations remain to be clarified. There has also been research showing an increased incidence of drug use and abuse in households where the availability and sub-cultural acceptance of drugs plays a factor in the lower threshold of use. Another important risk factor is the age of onset of use. The younger one is when he uses drugs, the higher likelihood of drug abuse and dependence later on in life.

Imposing rules vs. open communication

While there are adolescents who are particularly at risk for drug abuse and addiction, most will try alcohol or some drug during their teens. The key then is to keep adolescents safe and healthy and to help them make good choices. From peer pressure and identity diffusion to separation, individuation and independence, adolescents is often defined as a period in flux. In this challenging time, adolescents continue to need guidance and in order to provide this, it is important to keep lines of communication open. Imposing adult rules, particularly ones motivated by power and not understanding, will close the doors of communication and, in the end, may lead adults to not know what their adolescents are doing.

Encourage dialogue

One of the television commercials today shows a young male adolescent ready to leave for a party. He is dressed in black and is wearing chains. He has tattoos and piercings, and his hair is spiked and colored. Just as he leaves the home for the night out, he says good-bye to his mother who in turn, wishes him a good time. He calls back to her and says he’ll see her later. The public health announcer at the end of the commercial tells viewer to “Talk with your kids.” The scene depicts open communication and a healthy relationship. The adolescent is allowed to express his individuality and is allowed to go out. He also abides to mom’s rules and is expected to return at a certain time. The implication is that there was a dialogue and negotiations prior to the event that included drugs, responsibility and safety.

We care by letting them be who they are

The take home message is that by letting adolescents be who they are, we tell them that we care about them. The lingering hope is that they will then talk with us and come to trust us with their feelings. Only then can we begin a dialogue and negotiations about tough choices including drugs, alcohol and safety.

The role of the pediatrician

Like parents, the role physicians and clinicians play in the lives of adolescents is important. In fact, they can be critical when families have stopped communicating. Many times, using drugs and alcohol are not only a catalyst to but also a by-product of communication breakdowns in families. Hence, parents may call pediatricians or clinicians stating that they believe that their son or daughter is using alcohol or drugs. Building an alliance is central and a prerequisite to communications with adolescents.

… and the role of the drug counselor

So what does one do when a parent calls and says they want their child drug tested? What do you do when they want you to refer their child to a drug counselor?

Give the family credit for coming in.

First, with adolescents, trust is extremely important to win and even harder if it has been lost. Remember, if an adolescent comes to your office with his parent(s), that alone indicates that this family has some strengths and is still intact. There should be recognition and credit to the family, including the adolescent, for just coming to your office.

Gaining the trust of the adolescent

At later stages of drug abuse and in troubled family dynamics, entry into treatment may not be voluntary and may not involve the family. On the other hand, while the adolescent may physically come to the office, he may not want to be there. It is important to proceed in a way that acknowledges the parental concerns but also gains the trust of the adolescent. Start the assessment by meeting with the adolescent first. If there is resistance by anyone, you can meet the whole family with the adolescent for a few minutes initially.

In order to make the adolescent feel that you are not siding with his parent(s), you should try not to meet with the parents or guardians without first speaking with the adolescent. While meeting with the adolescent, begin with areas of his/her interest. Comment on the sports team on the t-shirt that he or she is wearing. Or ask about the book in his or her hand. Be sincere in your questioning of who they are and ask questions about things that you don’t know. Adolescents are perceptive about the level of interest you have in them. After a period of engagement, you can ease into the chief complaint. Ask them why they believe they have come to your office and why their parents feel they should come to see you. Noting that there might be some discrepancy, it is important to validate both reasons for seeing you.

Assessing alcohol use: the CAGE tool

As one is listening to the adolescent, there should be an assessment of drug use, its purpose, risky behaviors and also, the need for treatment. One of the most popular screening tools to assess problematic alcohol abuse and dependence is the acronym CAGE. Each letter represents a question and two or more “yes” answers suggests problematic use of alcohol in adults.

C = Have you ever felt you should Cut down on your drinking?

A = Have people Annoyed you by criticizing your drinking?

G = Have you ever felt bad or Guilty about your drinking?

E = Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

The CRAFFT screen

While CAGE has been tested over time, it was initially designed for assessing adults or adolescents over age 16years with alcohol issues only. In June, 2002, John Knight, MD a pediatrician at Boston Children’s Hospital published a study evaluating a new screen that is not only developmentally appropriate for adolescents but also it assesses the use of all drugs, not just alcohol. The screen is CRAFFT and like CAGE, it suggests that answering “yes” to two or more questions may indicate problematic use and the need for further evaluation.

C = Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R = Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?

A = Do you ever use alcohol or drugs while you are by yourself, Alone?

F = Do you ever Forget things you did while using alcohol or drugs?

F = Do your family or Friends ever tell you that you should cut down on your drinking or drug use?

T = Have you ever gotten in Trouble while you were using alcohol or drugs?

Is it a mood or anxiety disorder?

Both screens allow for a quick evaluation but note that screens are one part of the adolescent assessment. Many adolescent psychiatrists believe that the adolescent who uses alcohol or drugs, especially those abusing it, are treating symptoms of a mood or anxiety disorder.

The self-medication hypothesis

Much has been made of Dr. Ed Khantzian’s Self-Medication Hypothesis. The key point is to ask adolescents what the drug or alcohol does for them but also ask them what happens if they don’t use it. For example, an adolescent may say that alcohol helps them in a social situation, that is, it helps them with some social anxiety. The follow-up question then might be, “But if you don’t drink, does that mean that you avoid the party or that you behave differently at the party?” Another example might be the adolescent who smokes cannabis because it makes him feel numb but not taking it makes him feel sad or irritable. This may suggest an underlying mood disorder or symptoms of a mood disorder that need to be monitored.

Is it “a dual diagnosis?”

Evaluating an adolescent when he or she is drug free may not be possible; hence, to ask about symptoms of sadness, irritability, mood swings, sleep disturbance, anxiety, concentration and even suicidal ideations is important. Assessing these symptoms while using or not using alcohol and drugs may help rule out a dual diagnosis. The key to all of the questioning is to appear curious and not judgmental. If adolescents feel that you care and are interested in them, they will tell you why they use and the consequences of their alcohol and drug use.

Consequences of alcohol use

There are many consequences of alcohol and drug use. Studies show that alcohol abuse is associated with unsafe and increased sexual activity leading to increased pregnancy and sexually transmitted diseases. For these females who do get pregnant and use alcohol, they are at increased risk of complications and fetal alcohol syndrome. A fifteen year old who uses alcohol is seven times likely to have sexual intercourse than a peer his age. He/she is also likely to have up to four sexual partners. Alcohol use is also associated with one-third to two-thirds of date rapes in adolescent and college populations. In addition to sexual activity, alcohol and drugs are associated with academic difficulties. Research has shown that students with near and failing grades have three times likelihood of drinking as “A” students. However, there are students especially in the college setting who binge drink; in that, they have four (if women) or five (men) drinks in one setting and continue to be “A” or “B” students. In general, however, as the drinking or drug use progresses, academic decline ensues.

What to share with the parents?

During the interview, ask the adolescent if there are parts of the history he/she gave you that is not known by the parents. If there is something that they strongly don’t want the parent to know, ask them why. Also, ask them if it would help if you helped them tell their parents and if not that day, another time.

Issues of safety

(Dr. King’s comment: As the following paragraph indicates, there might be instances when confidentiality would need to be broken. The pediatrician is obligated to inform the adolescent, from the very beginning of the visit, that such exceptions exist, so that the adolescent wouldn’t feel there had been a violation of trust for which he/she had been unprepared.)

If there is any concern about immediate safety; i.e., active suicidal ideations, confidentiality with the adolescent will need to be broken and the parents will need to be told. In addition, arrangements for an emergency evaluation will need to take place.

What to do next?

In the more probable scenario, there may be risky behaviors, some symptoms of mood or anxiety disturbance and problems with school, the family or the law. When no immediate risk of safety is present, there needs to be an assessment of what to do next. If there is more than one yes on the CRAFFT or CAGE screen, it is recommended that the adolescent have a full evaluation by a substance abuse counselor. If there are symptoms of mood or anxiety, it might be best to refer to an adolescent psychiatrist.

Many times, however, an adolescent may refuse to see a counselor. In this case, the best outcome may be that you have regular follow-ups (once a week or every two to three weeks) where you continue to build alliance and continue to probe about the severity of the abuse and need for an outpatient therapist. It is also important to ask the adolescent for weekly urine toxicology screens and to phrase it as, “I trust you; I don’t trust the alcohol (drug) abuse.” If you can persuade the adolescent to go to AA or NA, in addition to seeing you, that would be great.

(Dr. King’s comment: While I might be willing to follow the adolescent for a while, assuming he/she wanted me to do so, I’d need to think about that. If I thought the adolescent really needed to see someone, I would need to be direct about that with both the parents and the adolescent. I’d also be asking myself, “What is going on with the family? What is the young person telling me, by his/her resistance, about the current functioning of the family?”

I would consider telling the adolescent that I’m thinking of meeting the parents to see how they’re doing, but I would tell him/her I wouldn’t reveal anything about the adolescent to the family, within the legal bounds of confidentiality. (This assumes I’m comfortable meeting with the parents for this purpose.) More often than not, something may be going on with the family, which may be reflected in the adolescent’s resistance to change.

It’s also unlikely I’d get involved with routine urine testing. For me, that is something to be done within a voluntary drug rehab program or at the workplace, not by me, the family pediatrician. But other pediatricians may feel differently.)

Provide a list of options and be willing to have ongoing negotiations with the adolescent about what might work. “So, if you don’t feel that you need to see a counselor or go to AA, how about seeing me in two weeks without your parents?” Or to say, “OK, I understand that you don’t feel like you need to see me and the problem is with your mom. How about some family therapy so you can present your side of the difficulties?” Be creative with your options and weave in contact with a professional – you or some type of therapist or therapy. Each time, you will need to assess safety and increasing risks.

(Dr. King’s comment: My personal approach is to be proactive by having someone (it could be myself or a social worker or a therapist) work in an on-going way with the parent(s), so I wouldn’t have to frame the issue as a family conflict.)

There are many places for treatment

Inpatient units are locked and, usually, admitted based on acute safety issues or acute detoxification issues. There are few Acute Residential Treatment units, which are like inpatient units, except they are unlocked and hence don’t require acute safety issues. There are many partial hospitalizations and day treatment programs. Most are for 6 to 8 hours a day.

All of these types of treatments except inpatient units require a level of motivation on the part of the adolescent because they are voluntary units. Insurance companies often prefer to use day treatment programs over inpatient units especially if there is no acute safety concern. While an adolescent may not agree that he/she has a substance abuse problem, many attend day treatment programs and upon discharge, are offered outpatient supports and treatments. A major piece of work at day treatment programs is psycho-education about drugs and the effect it has on one’s life. For many, it is the beginning step in understanding their problem, even if they don’t successfully complete the program.

Outpatient therapy

While some adolescents may accept day treatments, there are those who will not go. In this situation, it is very important to encourage outpatient therapy and hope that this outpatient clinician will then assess the need for group therapy work, family therapy, psychiatric evaluations, legal involvement (i.e., filing of a CHINS, Children In Need of Services, through the court systems leading to an assigned probation officer). This person will also be able to work with a pediatrician and parents and continue to assess level of abuse and treatment progress.

Summary

The trajectory of substance use to abuse or dependence and recovery can be less than linear. It is an area of mental health that is one of the least well understood, despite its overall significance on individuals, family units and our society. It is important to know that treatment is a process, not a one-time thing, and that the goal is to educate, to build positive relationships with and to motivate our adolescents.

Web sites

Below are some helpful websites for anyone interested in substance abuse:

www.monitoringthefuture.org

www.aap.org

www.samhsa.gov

www.madd.org

www.al-anon.alateen.org

www.ceasar-boston.org