The use, abuse and treatment of substance abuse in children and adolescents has been a major focus of attention for parents, school personnel, law enforcement officers and mental health professions. The prevalence of Substance Use Disorder in this age group is rising, the age of first usage is dropping, and the progression of the disease and the mortality rate is increasing. Substance abuse can interfere with natural growth and normal interaction and development: relationships with peers, academic performance, attitudes toward law and authority and acute, chronic organic effects. Drug abuse by 12 to 17 year olds has climbed from a low of 5.3 percent in l992 to a fluctuation from 9 and 11 percent since l995. Furthermore, the age of first usage of drugs or alcohol has dropped. More than 50% of 6^th graders have tried alcohol or other illicit substances.

Warning signs of adolescent drug use include a drop in school performance, irritability, apathy, mood change (including depression), poor self-care, weight loss, over-sensitivity to questions about drinking or drugs, and sudden changes in friends. Screening devices should include routine medical examinations and the use of urine analysis to confirm a diagnosis when necessary.

Peer group, school environment, age, geography, race, values, family attitudes, risk-seeking temperament and biological predisposition all contribute to adolescent substance abuse. Whereas non-users are more likely to describe close relationships with parents, users more frequently indicate they do not want to be like their parents and do not need their approval or affection. Frequently there is a positive family history of chemical dependency. Children of divorce have a greater risk of substance abuse.

In the treatment of substance use disorders, the role of the family is more important to adolescents than to adults. Inpatient or residential treatment is recommended for adolescents whose drug problem has interfered with functioning in school, work and home environments, and those who could not maintain abstinence through outpatient treatment. Depression and suicide inclinations, hyperactivity, chemical dependence and drug overdoses all indicate need for inpatient treatment.

Intoxication with drugs and alcohol in adolescents or children may lead to a lack of inhibition, violence and medical complications. Most adolescents entering inpatient drug and alcohol treatment programs have additional mental health problems, such as attention-deficit disorder, anxiety disorder and eating disorders. Treating attention-deficit disorder in adolescents significantly reduces risk of developing substance abuse patterns in later life.

Suicide ideation and behavior is common in adolescents with substance use disorders and if there is family history of suicide or depression, the risk is increased. Increased alcohol and drug abuse in adolescents is often associated with risk-taking behavior linked to the spread of HIV infection.

The treatment of adolescents requires both structure and flexibility. Most programs rely heavily on a therapeutic environment with individualized treatment planning. Programs that are most successful are structured, encourage openness, peer support, spontaneous expression of feelings, allow patients to engage in independent decision making and use cognitive and behavioral approaches. Relapse prevention for adolescents is often more difficult than for adults, and the goal of total abstinence becomes more difficult to achieve. A patient should not be rejected.#

Silver Hill Hospital is a nationally recognized psychiatric and substance abuse treatment center providing a full range of services for adults and adolescents, from inpatient to partial hospital, halfway houses and outpatient programs. For further information, call (203) 966-3561, Extension 2509.

Dr. Richard Frances is President and Medical Director of Silver Hill Hospital. Dr. Avram Mack is a Child Psychiatry Fellow at Columbia Presbyterian Hospital.