Evidence-Based Reviews

Emerging clues: Is this teen at risk for substance abuse?

Current Psychiatry. 2009 January;8(1):19-27

References

1. Vanyukov MM, Tarter RE, Kirisci L, et al. Liability to substance use disorders: 1. Common mechanisms and manifestations. Neurosci Biobehav Rev. 2003;27(6):507-515.

2. Karpyak VM, Hall-Flavin DK, Mrazek DA. Can genetics predict risk for alcohol dependence? Current Psychiatry. 2008;7(3):57-73.

3. Kuo PH, Kalsi G, Prescott CA, et al. Association of ADH and ALDH genes with alcohol dependence in the Irish Affected Sib Pair Study of alcohol dependence (IASPSAD) sample. Alcohol Clin Exp Res. 2008;32(5):785-795.

4. Vanyukov MM, Maher BS, Devlin B, et al. The MAOA promoter polymorphism, disruptive behavior disorders, and early onset substance use disorder: gene-environment interaction. Psychiatr Genet. 2007;17(6):323-332.

5. Clark DB, Thatcher DL, Tapert S. Alcohol, psychological dysregulation and adolescent brain development. Alcohol Clin Exp Res. 2008;32(3):375-385.

6. Kendler KS, Schmitt E, Aggen SH, et al. Genetic and environmental influences on alcohol, caffeine, cannabis, and nicotine use from early adolescence to middle adulthood. Arch Gen Psychiatry. 2008;65(6):674-682.

7. Sher KJ, Gershuny BS, Peterson L, et al. The role of childhood stressors in the intergenerational transmission of alcohol use disorders. J Stud Alcohol. 1997;58:414-427.

8. Clark DB, De Bellis MD, Lynch KG, et al. Physical and sexual abuse, depression and alcohol use disorders in adolescents. Drug Alcohol Depend. 2003;69(1):51-60.

9. Clark DB, Thatcher DL, Maisto S. Adolescent neglect and alcohol use disorders in two-parent families. Child Maltreat. 2004;9(4):357-370.

10. Clark DB, Kirisci L, Mezzich A, et al. Parental supervision and alcohol use in early adolescence: developmentally specific interactions. J Dev Behav Pediatr. 2008;29(4):285-292.

11. Clark DB, Kirisci L, Moss HB. Early adolescent gateway drug use in sons of fathers with substance use disorders. Addict Behav. 1998;23:561-566.

12. Clark DB, Winters KC. Measuring risks and outcomes in substance use disorders prevention research. J Consult Clin Psychol. 2002;70(6):1207-1223.

13. Clark DB, Cornelius JR, Wood DS, et al. Psychopathology risk transmission in children of parents with substance use disorders. Am J Psychiatry. 2004;161(4):685-691.

14. Guy SC, Isquith PK, Gioia GA. Behavior rating inventory of executive function—self-report version professional manual. Lutz, FL: Psychological Assessment Resources; 2004.

15. Clark DB, Cornelius JR, Kirisci L, et al. Childhood risk categories for adolescent substance involvement: a general liability typology. Drug Alcohol Depend. 2005;77(1):13-21.

16. Clark DB. The natural history of adolescent alcohol use disorders. Addiction. 2004;99(suppl 2):5-22.

17. Donovan JE, Molina BS. Children’s introduction to alcohol use: sips and tastes. Alcohol Clin Exp Res. 2008;32(1):108-119.

18. Clark DB, Chung T, Martin CS. Alcohol use frequency as a screen for alcohol use disorders in adolescents. Int J Adolesc Med Health. 2006;18(1):181-187.

19. Tarter RE, Kirisci L, Mezzich A, et al. Neurobehavioral disinhibition in childhood predicts early age onset substance use disorder. Am J Psychiatry. 2003;160(6):1078-1085.

20. Tarter RE, Vanyukov M, Kirisci L, et al. Predictors of marijuana use in adolescents before and after licit drug use: examination of the gateway hypothesis. Am J Psychiatry. 2006;163(12):2134-2140.

21. Clark DB, Bukstein OG, Smith MG, et al. Identifying anxiety disorders in adolescents hospitalized for alcohol abuse or dependence. Psychiatr Serv. 1995;46:618-620.

22. Spoth R, Greenberg M, Turrisi R. Preventive interventions addressing underage drinking: state of the evidence and steps toward public health impact. Pediatrics. 2008;121(suppl 4):S311-336.

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ADHD in childhood
CD and accelerated substance use initiation in early adolescence
SUDs involving alcohol and cannabis in late adolescence.⁵

Early substance use initiation. It is rare for a person to begin clinically notable substance use in childhood (age 5 to 12), but adolescence (age 13 to 18) is characterized by substance use experimentation. Experimental substance use during adolescence is near universal and typically does not progress to SUDs.¹⁶ However, the type, extent, developmental timing, and context of substance use in early adolescence provide predictive information.

Consuming small quantities of alcohol under parental supervision is culturally normative and does not predict problematic drinking.¹⁷ On the other hand, regularly consuming “standard drink” quantities of alcohol in late childhood typically occurs in unsupervised settings and predicts adolescent-onset AUDs.¹⁸

Problem-focused interview methods—including CAGE, TWEAK, and CRAFFT—have been developed and tested to screen adolescents for AUDs. None has been as consistently successful as the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT) questionnaire¹⁸ (see Related Resources).

Childhood cigarette smoking also predicts accelerated substance use and SUDs.¹⁵ Marijuana use predicts both cannabis use disorders and other illicit drug use.¹ This observation supports the controversial “gateway hypothesis,” which proposes that marijuana use accelerates the onset of other illicit drug use.^15,19,20 An alternate hypothesis proposes that use of marijuana and other illicit drugs is a developmentally specific manifestation of a more general liability for SUDs.¹

Identifying those at high risk

Screening for SUD risk factors makes it possible to identify children and adolescents who are very likely to develop problematic substance use. For example, in a study of 560 children age 10 to 12 at recruitment, this author (DBC) identified subjects as high risk if they had 2 parents with SUDs, tobacco or alcohol use by age 12, and high psychological dysregulation as measured by combined assessments of cognitive, emotional, and behavioral regulation. By age 18:

three-quarters of these adolescents used tobacco daily
more than one-half had alcohol problems
nearly one-half had cannabis abuse or dependence.¹⁵

Clinical Point

Conduct disorder, ADHD, mood disorders, and PTSD in children predict adolescent substance use disorders

By contrast, children identified as low risk (parents without SUDs, the absence of significant substance use, and low psychological dysregulation) were unlikely to have substance-related problems by age 18. Less than 10% had daily tobacco use, alcohol problems, or cannabis abuse or dependence.

Recommendations. Children and adolescents receiving health care services—including primary care, ongoing treatment for chronic conditions, and treatment for psychiatric disorders—should be evaluated for SUD risk. Screening ideally occurs at the initial evaluation or early in the course of treatment. Family history determines genetic risk.

Direct questioning is needed because unstructured evaluations often fail to reveal the presence of important SUD risks.²¹ Explore possible child maltreatment by questioning the parent and child about physical abuse, sexual abuse, and neglect. Key mental disorders include CD, ADHD, and PTSD. Ask about use of tobacco, alcohol, cannabis, and other drugs. Follow acknowledgement of use with inquiries on frequency, quantity, and problems.

Clinical Point

Directly question parents and children about physical or sexual abuse, neglect, and use of alcohol, tobacco, and illicit drugs

Prevention and early intervention

By identifying characteristics that confer risk for SUDs, you can target these characteristics in prevention and early treatment efforts. These efforts may involve parents as well as children. Many promising approaches have been developed, including universal or selective interventions based on family, school, community, or multi-component approaches.²²

Because parental SUDs are a prominent risk factor for children, interventions to reduce or eliminate parental substance use may be helpful, particularly for diminishing childhood psychological dysregulation.²³ Early treatment of childhood predictive phenotypes, including CD and ADHD, is another promising approach.¹² Community efforts to limit adolescents’ access to addictive substances have met with some success.²²

Clinical Point

Eliminating or reducing parental substance use may diminish children’s psychological dysregulation

These suggestions logically follow from the literature, but more effective prevention and early treatment approaches are needed. Our increasing ability to distinguish children and adolescents by their risk characteristics suggests that interventions targeted to specific risk characteristics and overall risk level may become more available.

Parents, teachers, and children and adolescents can obtain a wealth of information from the Web sites of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse (Box 2). The Centers for Disease Control and Prevention offers infomation about preventing smoking (see Related Resources.)

Box 2

Web resources for parents, teachers, and teens

Parents/teachers

The National Institute on Drug Abuse (NIDA) provides a Web site for parents and teachers at www.drugabuse.gov/parent-teacher.html. Parents also can find resources at NIDA for teens at http://teens.drugabuse.gov.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides several free booklets for parents at www.niaaa.nih.gov/Publications/PamphletsBrochuresPosters/English.

My Brain, My Body (www.mybrainmybody.com) is an NIAAA-supported educational tool for teaching middle school students. Developmentally specific NIDA Junior Scientist Programs have been developed for kindergarten through grade 5. The Office of Safe and Drug-Free Schools, part of the U.S. Department of Education, also provides relevant resources.

Children and adolescents

An NIAAA-sponsored educational resource (www.thecoolspot.gov) provides education on alcohol designed for young teens (age 11 to 13). The site includes quizzes, suggestions for resisting peer pressure, and activities that encourage refusing drinking opportunities.

NIDA for Teens (http://teens.drugabuse.gov) provides information and activities designed for those age 11 to 15.