The authors of a review of adolescent substance abuse research over the past 10 years say that despite the fact that the number of studies devoted to youth addiction has increased tremendously in the 1990s, there are still gaps in our knowledge of adolescent substance use. Moreover, we don't know the impact of these 'gaps' on the effectiveness of treatment and prevention strategies for youth.Published in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry, the report offers a comprehensive overview and analysis of adolescent substance use disorders (ASUD) in the areas of epidemiology, etiology, comorbidity, assessment, treatment, and prevention.
Epidemiology
Recent surveys have shown a resurgence in ASUD and rates for some drugs are higher than at any time since the mid-1980s. In addition, alcohol and cigarettes were found to be the most widely used and abused substances.
The 1996 "Monitoring the Future" survey of high school students found that nearly one-third of high school seniors reported being drunk in the past month and 4.9% reported using marijuana daily. These actually may be conservative estimates because these surveys tend to underrepresent youths who are habitually absent from school. Also of note are the lower rates of substance use reported in household surveys, suggesting that researchers need to keep in mind that survey style and setting may yield different results.
Other studies, like the National Household Survey on Drug Abuse, also track drug and alcohol related problems. In 1994, 3.1% of 12- through 17-year-olds reported three or more such problems that they attributed to marijuana use, and 6.6% experienced three or more problems because of alcohol use.
Etiology
An important advance in recent research on ASUD is "a focus on risk and protective factors and multiple etiological pathways." The research team found that while social and peer factors contribute to adolescents' decision to use drugs, their substance abuse disorders are related more to biological and psychological variables. Interestingly, peer influence may be less significant than previously thought, with correlates between individual and peer drug use primarily being due to adolescent drug users "selecting drug-using friends and projecting their own drug use into their reports regarding peers."
Studies also have illuminated the links between familial factors and youth addiction. In particular children with parents who abuse drugs or have psychopathological disorders-such as maternal depression and anxiety-are at greater risk for substance abuse.
Protective factors cited by the authors include intelligence, problem-solving ability, social facility, positive self-esteem, supportive family relationships, positive role models, and affect regulation.
Comorbidity
Several population-based and clinical studies suggest high rates of psychiatric comorbidity with ASUD, particularly for conduct disorder and disruptive behavior disorder. ASUD also has been associated with ADHD (see article on page 1), bipolar disorder, depression, anxiety disorder, and eating disorder, although the relationship is less clear-"complicated in part by the mood-altering effects of many abused substances."
Assessment
The first reliable self-report screens and diagnostic instruments were developed to assess adult use of alcohol and drugs. The research group summarizes several tools that have been validated and proven to be useful for the adolescent population.
Treatment
In the area of treatment, the researchers reviewed several studies that illustrate the effeativeness of family therapy. Based on the theory that youth drug and alcohol abuse are related to dysfunctional family structures and interactions, models such as "structural-strategic family therapy" seek to involve all family members in the therapeutic process and to build a therapeutic alliance among the participants.
Patient-centered approaches to youth addiction treatment have received significantly less research attention. Some of these approaches, including adolescent peer group therapy and cognitive-behavioral models, have shown promise.
In addition, the review found that very little is known about the efficacy of pharmacological interventions-such as naltrexone and methadone-for adolescents. Two controversial treatment topics that merit more research attention are:
1) identifying how restrictive treatment settings for adolescents should be; and
2) addressing the dueling treatment goals of abstinence vs. reduction in drug use.
Prevention
"School-based interventions remain the mainstay of prevention research," the authors say. One 1995 study showed significant reductions in drug use that endured for six years after implementation of a school-based prevention program for adolescents, with the teaching of both social resistance and life skills deemed critical to the program's success.
However, say the researchers, school programs may not reach the youths at greatest risk of substance abuse problems, such as dropouts and students who miss school time because of family crises. This points out the need to establish and evaluate more broad-based programs that involve parents and community leaders as well as schools. Multi-component community drug abuse prevention efforts have been put into effect, but "dissemination and implementation of these programs remain incomplete."
Future directions
The authors recommend several areas for future research:
1) studies of the natural histories, incidence, prevalence, and comorbidity patterns of adolescent substance abuse and dependence;
2) further testing and refinement of nosological systems for categorizing adolescent drug use disorders;
3) study of patient-centered treatment approaches and of pharmacological interventions, in the context of multi-component programs;
4) study of interventions targeted to high-risk groups; and
5) research on barriers to implementation of effective prevention interventions.
Naimah Z. Weinberg, Elizabeth Rahdert, James D Colliver, Meyer D. Glantz. Adolescent substance abuse. A review of the Past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 37:252-261,1998. Reprint requests to: Dr. Weinberg, 5600 Fishers Lane, Room 9A- 53, Rockville, MD 20857.
Courtesy of: Center for Alcohol and Addiction Studies.
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