Practice Parameters Offer Guidance on Substance Use Disorders in Children, Adolescents

After a teenager's suicide attempt, her desperate and bewildered parents dragged her to a mental health clinic. The 16-year-old admitted to drinking nearly every day and using an assortment of other illicit drugs. Only after a month in treatment did the clinician learn that the teenager had been molested when she was 8 years old by an uncle and threatened with death if she ever told her parents.

Oscar Bukstein, M.D., associate professor of psychiatry at the University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, and principal author of Practice Parameters for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders, explained that often there is a high rate of anxiety disorders, including posttraumatic stress disorder, among adolescent substance abusers.

"While there may be other factors operating in the individual adolescent [that] promote substance use, exposure to trauma may be a component," he said.

The practice parameters that Bukstein developed with the Work Group on Quality Issues for the American Academy of Child and Adolescent Psychiatry emphasize that comorbidity is the rule, rather than the exception, in adolescents.

"We know that many children and adolescents have comorbidity, be it depression or disruptive behavior disorders, such as attention-deficit/hyperactivity disorder or conduct disorder," Bukstein said. "Many adolescents have ADHD, plus depression, plus substance abuse problems. Oftentimes, you need poly-pharmacy to help these kids. But clearly you need other treatments as well, and a multimodal approach...should be considered a standard of care."

The substance use disorders parameters, which were published with nine other practice parameters as a supplement to the Journal of the American Academy of Child and Adolescent Psychiatry (October 1997), are designed to orient clinicians, including child and adolescent psychiatrists, as to what substance use disorders in children and adolescents are all about.

"That, of course, includes their presentation, appropriate assessment procedures and appropriate treatment strategies," said Bukstein.

Few adolescents will volunteer that they may have a substance use problem.

"With any disorder dealing with deviant behavior, whether it be substance abuse or conduct disorder, the kids are usually trying to hide that behavior or get away with it. Very few have a reasonable amount of insight into the destructive nature of their problem. They rarely seek treatment on their own," Bukstein said. "Oftentimes, parents and others need to be tough and use whatever leverage they have to compel adolescents into treatment. To be honest, that is commonly the case with adults as well-only pressure and leverage from bosses, family and friends compels them into treatment."

With the University of Michigan's Monitoring the Future Study (1995) reporting that 30% of high school seniors have more than five drinks in a row in a two-week period and that an estimated 40% of high school students have tried an illicit drug (mostly marijuana), Bukstein was asked how clinicians could differentiate young people who use alcohol and other drugs experimentally from those who have a problem.

"About 90% of kids will have had at least one experience with alcohol before they leave high school, which makes some experimental use of alcohol pretty normative. What happens developmentally is that many of them mature and find they no longer enjoy drinking at that level. It is the kids who begin to have problems in one or more areas of their lives who should be targeted for assessment," Bukstein said. "In order to have any psychiatric disorder, you have to display either a clinically significant level of dysfunction or distress. So kids have to show difficulty in dealing with their families, their friends, functioning in school. If an adolescent by all counts seems to be all right, but is caught and acknowledges some substance use, it is substance use and not necessarily a substance use disorder. That is not to say that people should not be vigilant. Obviously, you have to use substances to have a substance use disorder. Therefore, it is something for parents and others to watch."

Risk Factors

An assessment of risk factors for substance use or abuse often can contribute to the index of suspicion.

"The clinician should inquire, with both the adolescent and his or her parents, about individual, family, peer and community risk factors," according to the substance use disorders parameters.

Individual risk factors include psychiatric disorders, specific temperament traits and favorable attitudes about substance use.

"Attention-deficit/hyperactivity disorder, particularly in the presence of other disruptive behavior disorders such as conduct disorder, makes a child a very high risk," Bukstein said. And certain temperamental traits, such as irritability, high motor activity, impulsivity, and a few others that we may not [have] had a chance to recognize in our research, may place a child at higher risk for substance use."

Parental abuse of substances, lack of close attachment with parents and lack of parental supervision, including inadequate parental management styles, are among the family risk factors.

"Research indicates that substance use disorders do run in families. According to twin and adoption studies, we know there is a significant genetic component to that. Obviously, though, there are environmental factors that shape that biologic or genetic risk.

"Kids who have early attachment with peers seem to be more at risk for developing substance use disorders, as are kids with friends who abuse substances," Bukstein said.

Community or neighborhood characteristics, such as low socioeconomic status, high population density, physical deterioration of the neighborhood and high crime, are associated with greater adolescent substance use.

Assessment

Beyond reliance on risk factors for screening, the parameters discussed the roles of toxicology testing and medical and physiological issues in assessing substance use disorders.

According to the parameters, clinicians and medical professionals should also maintain a high level of suspicion for substance use or abuse when adolescents present for care following an accident (automobile, bicycle, and even skateboarding). Other possible indicators are being a victim or perpetrator of violent acts, engaging in unprotected and unsafe sexual activity with subsequent pregnancy or sexually transmitted disease, and having human immunodeficiency virus infection, which is a risk factor among some intravenous drug and crack cocaine abusers.

"Toxicological screening is limited by the time needed to obtain results, lack of correlation between drug concentration and observed results, and the risk of false-positive and false-negative results," the parameters warned. "Toxicological methods, however, can provide a check of adolescent truthfulness. A positive drug screen does not prove substance abuse or dependence, but does indicate substance use. Similarly, a negative drug screen is not sufficient to rule out either substance use or SUDs [substance use disorders]. The effectiveness of drug screens may be limited by the brief presence in the body of many substances of abuse and their metabolites. Stimulants are detectable in the urine for up to one or two days. Cocaine and its major metabolite are present for up to several days...Cannabis, which is lipid soluble, may be detected for one month or more when use has been chronic."

In many ways adolescents who use and abuse substances differ from adults. "What we would call physiologic dependence is much less common among adolescents. Adolescent use tends to be more sporadic. The use of multiple substances is more characteristic of adolescents with difficulties than it is with adults with difficulties. By the time individuals are adults, they have settled on one or two favorite drugs and abuse those exclusively," Bukstein said. "Another difference may be that adolescents are more likely to have coexisting psychiatric disorders than adults. For instance, in adults, just having alcoholism is quite common, whereas it is rare to see an alcoholism problem and nothing else in an adolescent."

Treatment Considerations

With regard to treatment, Bukstein said, "If we have learned anything, it is that one size does not fit all. I have treated 10-year-olds who have well-established patterns of substance use. Just as adolescents often need a different approach from that used with adults, 10-year-olds need a different approach from 17-year-olds."

The practice parameters recommend that "treatment services for affected adolescents should be different from services designed for and used by adults," maintaining that "treatment for adolescents should be peer-oriented and should recognize the adolescent's specific developmental tasks [including social development], his or her cognitive developmental level and his or her status as a dependent member of a family system."

While adult treatment is not necessarily the best model or the best type of treatment for adolescents, Bukstein added that there are some components of adult treatment that may be applicable to adolescents, such as cognitive/behavioral approaches, certain aspects of motivational approaches and certain types of pharmacotherapy. But they have to be put in the appropriate developmental context.

"Generally, because adolescents are earlier in their substance use career, the [practice parameter] guidelines suggest a conservative approach. Psychosocial treatments should be tried, [and] medications in mainstream that have been approved by the Food and Drug Administration should be used. Only in the more treatment-resistant cases should drugs that have not been examined systematically, such as naltrexone [ReVia] or disulfiram [Antabuse], be tried in adolescents," Bukstein said.

Treatment modalities cited in the parameters include family therapy, interpersonal or psychodynamic therapy, psychoeducation, cognitive-behavioral therapy, psychopharmacology, 12-step programs and self-help groups, along with treatment for comorbid conditions. However, Bukstein said there are few well-controlled studies of specific treatment modalities for adolescent substance use disorders.

"There doesn't seem to be one approach that is clearly better than another. But it is clear from the literature that treatment works; that some treatment is better than no treatment," Bukstein said, referring to a 1990-1991 study by Catalano and colleagues (Int J Addict 25:1085-1140).

Defining treatment success is a dilemma for the experts in the field, according to Bukstein. He pointed to the lack of quality treatment research in adolescent substance use disorders and differences of opinion as to how to measure recovery and treatment success.

"We do know that most adolescents return to some level of substance use after treatment. However, even those who return to use appear to be better. Their level of psychosocial functioning tends to be improved overall...It may not be what we think of as treatment success-obviously we would like adolescents to be abstinent, that is the explicit goal of treatment-but it may be we need to look at other targets for treatment and accept other outcomes in addition to attenuating or stopping substance use," Bukstein said, adding that moving to a harm-reduction model remains controversial.

"I'm ambivalent about it myself. I think mental health professionals have to be willing to accept harm reduction not as an explicit goal, but as an implicit goal," he said.

The practice parameters define harm reduction as a decrease in the use and adverse effects of substances, a reduction in the severity and frequency of relapses, and improvement in one or more areas of the adolescent's functioning, including academic achievement or family functioning.

Although harm reduction as an interim goal for treatment remains controversial, the practice parameters and Bukstein cautioned that "controlled use" of any substance of abuse should never be an explicit statement to a substance abuser.

"They will take it as meaning 'I can get better and not have to quit.' That is not a good message to send," Bukstein said.

More Research Needed

Since the practice parameters were developed to assist clinicians in psychiatric decision-making, Bukstein said they were based on scientific evidence regarding diagnosis and effective treatment as much as possible. The problem is that "in the area of adolescent substance abuse treatment, there is very little scientific literature, so we had to gather what we could from the existing scientific literature as well as from what is considered ideal clinical practice or clinical experience of individuals."

Clinical consensus on the parameters was obtained through extensive review by the members of the Work Group on Quality Issues, child and adolescent psychiatry consultants with expertise on substance use disorders, the entire academy membership and the academy assembly and council.

Plans call for the parameters to be reviewed and updated periodically based upon new scientific evidence.

Among those contributing to the new scientific research will be Bukstein and his colleagues:

"We are looking at both the presentation of children and adolescents with substance use problems, [and] the progression of the disorders. How do these disorders play out? How do they interact with other psychiatric disorders? How do they affect a child's functioning and development?"

They also are following adolescents they treated in primarily inpatient programs.

"In one of the projects where I am involved as a researcher, the National Institute on Alcohol Abuse and Alcoholism-sponsored Pittsburgh Adolescent Alcohol Research Center, we have been following adolescents, many of whom were treated in our treatment program, for more than five years. We found that many have matured out of their substance use," he said. "We also have worked with many adolescents who have had multiple relapses. Initially, we treated them somewhat conservatively. If they relapsed, we gave them more intensive treatment. Often, these adolescents relapsed and returned to some level of drug use. We sometimes considered giving up on treating them. But occasionally, we would have these same very difficult patients come back and tell us that they were maintaining abstinence, that treatment had planted the seed, and that when they were ready, it really helped them."

(Copies of Practice Parameters for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders can be purchased for $10 (members) or $20 (nonmembers) from the academy at AACAP Public Information, P.O. Box 96106, Washington, D.C. 20090-6106, (800)333-7636, or at their Web site: http://www.aacap.org. Copies of the Journal of the American Academy of Child and Adolescent Psychiatry Practice Parameters Supplement containing psychiatric assessment of children and adolescents, psychiatric assessment of infants and toddlers, forensic evaluation, anxiety disorders, ADHD, conduct disorder, bipolar disorder, schizophrenia and substance use disorders, can be purchased for $60 from Williams & Wilkins. Call (800) 638-6423-Ed.)