DSM-IV-TR Diagnostic Criteria

Substance Abuse

1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

   1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

   2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

   3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

   4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of Intoxication, physical fights)

2. The symptoms have never met the criteria for Substance Dependence for this class of substance.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 American Psychiatric Association.)

DSM-IV-TR diagnostic criteria for substance abuse and dependence are the same for adolescents and adults. Empirical data generally support the validity of the DSM-IV-TR diagnosis for substance abuse and dependence in adolescents. However, compared with adults adolescents are polysubstance users, context of use in social setting is more common than using alone, have a more rapid transition from use to dependence, are less likely to experience blackouts and have alcohol withdrawal less often. It is important to differentiate between substance abuse and dependence and not assume a natural continuity between the two. Abuse is not always a prodrome for dependence and in most instances abuse does not progress into dependence which may also develop without having gone through an abuse phase. Abuse which includes all criteria possible of abuse plus two of the dependence criteria might present a clinical situation that is more severe of dependence that is composed of merely the minimum required (i.e., 3 criteria).

Some symptoms of the dependence category may often be developmentally limited (e.g., impaired control and tolerance which is associated with the changing body mass of the individual adolescent). Another important nosological entity in youth is entitled orphan diagnoses, including subthreshold alcohol or other substance dependence (i.e., one or two symptoms only). A 3-year follow-up study demonstrated that this entity has a trajectory dissimilar to those of abuse and dependence. Nevertheless, adolescents who fall into this category may manifest impairment that deserves an intervention. It is expected that the development of DSM-V will take these findings into consideration and that symptom count will generate a better developmentally sound diagnostic profile for youth.

The use of alcohol and other drugs are associated with the three leading causes of mortality among adolescents as a result of motor vehicle accidents, homicide and suicide. Additional morbidity under the influence of substances have contributed to violent behavior, rape, and unprotected sexual activity including unplanned pregnancy and sexually transmitted diseases.

Epidemiology

Lifetime diagnoses of alcohol and drug abuse among adolescents in different states in the US range from 3–10%. Six percent and 5.4% of youths aged between 12 and 17 were classified as needing treatment for alcohol use and illicit drug use respectively. Due to lack of motivation, limited resources, insufficient age-appropriate quality programs, and lack of a broad consensus on preferred treatment strategies, only 10–15% of adolescents in need of treatment end up receiving services.

Although any nonmedical use of drugs (including tobacco and alcohol) by adolescents is illegal and can be regarded as a form of abuse, this viewpoint ignores some key epidemiological findings. Specifically, the high prevalence of alcohol and tobacco use underscores the fact that use of alcohol and tobacco is normative, or at least not exceptionally deviant. By age 18 years, approximately 80% of youth in the United States have drunk alcohol, two thirds have smoked cigarettes, and 50% have used at least once an illicit drug. Four percent drink alcohol daily and 13% smoke half a pack of cigarettes a day. Substance use (marijuana in particular) among American youth rose alarmingly rates between 1992 and 1997. Since then, it has decreased significantly until 2002 and has since then leveled off for alcohol, tobacco, and most drug classes except for prescription opiates, the use of which continues to increase.

Most adolescents who engage in substance use do not develop substance use disorder (SUD) as defined by DSM-IV-TR criteria. It is thus imperative to understand adolescent substance use in the context of changing patterns of behavior and to distinguish normative behavior from a SUD.

Etiology

Adolescent neurodevelopment occurs in brain regions associated with motivation, impulsivity, executive functioning and addiction. Adolescent impulsivity and novelty seeking can be explained in part by maturational changes in the prefrontal cortex. These developmental processes may promote for adaptation to adulthood but also confer greater vulnerability to the drug addiction. A number of behavioral dispositions and environmental influences predict age at initiation of drug use, drug use intensity, and the experience of negative consequences during adolescence. These behavioral characteristics are impulsivity, aggression, sensation seeking, low levels of harm avoidance, inability to delay gratification, low achievement motivation, lack of a religious orientation, and psychopathology, especially conduct disorder. The most common contextual or environmental factors are stressful life events, lack of parental support, absence of prosocial peers, perception of high availability of drugs, social norms that encourage drug use, and relaxed laws and regulatory policies. Clearly, manifold risk factors, with different salience, determine overall risk. In aggregate, these risk factors determine the slope and momentum of the developmental trajectory into adulthood, culminating in substance use, abuse, or dependence. Psychiatric disorders, and temperamental precursors such as impulsivity and novelty seeking tend to peak in late adolescence or early adulthood and are predictive of SUDs.

Young adults who become problem drinkers are likely to be rebellious, nonconforming and deviant during high school. Research using difficult-temperament index to classify adolescent alcoholic patients resulted in clusters that were similar to the adult subtypes reported by Cloninger and Babor. The smaller subset of adolescents manifesting behavioral dyscontrol and hypophoria were included in Cluster 2, whereas those with primarily negative affect were included in Cluster 1. Compared with Cluster 1 subjects, Cluster 2 patients were younger at the time of first substance use, first substance abuse diagnosis, and first psychiatric diagnosis. Moreover, adolescents with difficult temperament had a high probability of having psychiatric disorders such as conduct disorder, attention-deficit/hyperactivity disorder (ADHD), anxiety and mood disorders. Cluster 1 and Cluster 2 were identified in both genders.

Genetics

Vulnerability to engage in the use and abuse of substances involve an interaction of genetic and environmental factors (i.e., nature and nurture) over the course of development. The genetic contributions are likely to be complex traits involving multiple loci of small effect. Several individual genes that may contribute to the risk for dependence have been identified. The case of alcohol, these include genes encoding alcohol and aldehyde dehydrogenases and gamma amino butyric acid (A) receptor subunits.

Assessment and Screening

Self-report of substance use by adolescents is generally valid and more sensitive than laboratory testing. Collateral reports of alcohol and drug abuse from parents or other adults have low to moderate sensitivity compared to self-report and urinalysis. It may be helpful, in interviewing an adolescent, to begin by asking whether illicit drugs are available at school, whether the patient has close friends who use drugs, and whether the patient has access to drugs. Examples of reliable and valid screening instruments include The Personal Experience Screening Questionnaire, the Substance Abuse Subtle Screening Inventory, the Drug Use Screening Inventory-Revised, and the Problem Oriented Screening Instrument for Teenagers and the easy to use CRAFFT. A score of 2 or higher on the CRAFFT is optimal for identifying any problem use. The CRAFFT questions are as follows: Have you ever ridden in a Car driven by someone (including yourself) who was “high or had been using alcohol or drugs? Do you ever use alcohol or drugs to Relax, feel better about yourself or to fit in? Do you ever use alcohol/drugs while you are by yourself Alone? Do your Family/friends ever tell you that you should cut down your drinking/drug use? Do you ever Forget things you did while using alcohol or drugs? Have you gotten into Trouble while you were using alcohol or drugs?

If the self-report is positive, then it is important to assess the severity of the problem using well established semi-structured interviews such as the Teen Addiction Severity Index, the Adolescent Drug Abuse Diagnosis, or the Personal Experience Inventory. Computerized assessment is possible, for example, the Teen Addiction Severity Index was modified into a self-report administered via a telephone or a website. Modern technology also allows the telephone interactive voice response which provides a daily record of risky situations and drug use.