Diagnosing Substance Abuse
Many of the signs that make up the criteria for the DSM-5 diagnosis of a substance use disorder are normative behaviors for teenagers. For this reason, sometimes the beginning of a substance use disorder in adolescents is missed because the behaviors are overlooked as being a part of “normal” teenage development. Based on this fact, a study from Addiction recommends that care be taken in applying the following criteria when diagnosing teenagers:
- Tolerance: Teenagers may more quickly and more easily develop tolerance for substances for a variety of reasons, especially when moving from experimentation to more regular use. Care should be taken in applying this criterion.
- Risky behavior: Adults are more likely to engage in hazardous activities while using drugs or alcohol than teenagers are, partly because teens are less likely to have access to these activities. Also, abuse of some drugs, like tobacco, does not necessarily occur in hazardous situations. As a result, this criterion may not apply, even though a substance use disorder is present.
- Withdrawal: Withdrawal symptoms usually begin to appear after years of drug abuse, making them less likely to occur in teenagers, even with frequent heavy use. Therefore, lack of withdrawal symptoms does not necessarily mean that a substance use disorder is not present.
- Cravings: The existence of cravings and how they are defined in teenagers may be vague. Some teens who use heavily report cravings, but the definition of cravings for younger people may affect whether or not they are reported accurately. This criterion also benefits from deeper scrutiny before diagnosis.
Because of this, scrutiny should also be applied to defining a substance use disorder using two or more of the DSM-5 criteria. Because some of the criteria are normal behavior for teens, there may be diagnosis of a disorder where only mild use is present, requiring a clearer definition of how each criterion applies to decide whether prevention measures are more appropriate than dedicated treatment.
Treatment Types and Placement
The ASAM criteria for adolescents are revised to reflect different levels of severity, while still based on the same basic scale. This is because, for the most part, teens with substance use issues are considered to be at a lower level of abuse than adults from the start. In addition, teenagers in stable living environments are less likely to need residential care because family members can contribute to monitoring use and providing high levels of care due to the teenager not living alone. A number of similar factors are taken into account when determining the appropriate level of care for teenagers who are struggling with drug or alcohol abuse.
For example, according to the ASAM Continuum decision engine, while the ASAM level 3.5 services for adults are considered to be high-intensity residential treatment, adolescents at this level are considered to need only medium-intensity residential treatment.
As part of treatment, family participation is considered to be extremely important in helping teens reduce their drug or alcohol use, as explained in the book Reducing Underage Drinking: A Collective Responsibility.
Aftercare and Relapse Prevention
According to Reducing Underage Drinking: A Collective Responsibility, studies show that about one-third of adolescents who relapse do so within the first month after treatment, and two-thirds do so within the first six months. In addition, teenage relapse risk is based on peer pressure and the feeling that continuing to abuse substances contributes to social standing. This is in marked contrast to adults, who tend to relapse due to stress or other negative emotional effects.
For this reason, aftercare is considered to be vital for preventing relapse in teens, even more than in adults. Continuing care for a substance use disorder must be provided for all levels of care in teens to help counter the social pressure and challenges that lead to a higher risk of relapse in young people.