DETECTING TEEN SUBSTANCE ABUSE

New Government Guidelines Provide Screening Tools for Parents and
Professionals

The recent news stories seemed to be in direct contrast. In Fairfax County,
a worried mother told of being so concerned that her teenage son was using
illegal drugs that she placed a wiretap on his phone to confirm it. While
in Pennsylvania, the parents of five high school girls killed in a recent
car accident were stunned to learn that their children had been inhaling
dangerous chemical solvents, which played a role in the deaths.

Both anecdotes point to the need for new ways for parents, doctors,
teachers and mental health professionals to detect adolescent substance
abuse early, before parental wiretaps are necessary and fatal accidents
occur. That is the goal of guidelines released last week by the federal
Substance Abuse and Mental Health Services Administration (SAMHSA).

"The new guidelines bring some rigor to the field," said Alain Joffe, head
of adolescent medicine at the Johns Hopkins Medical Institutions in
Baltimore and a member of the American Academy of Pediatrics' Committee on
Substance Abuse.

The guidelines are also designed to give physicians, teachers, coaches and
others who regularly deal with teens screening tools to determine who may
have a substance abuse problem. Among the indications for undergoing
substance abuse screening are psychological difficulties, substantial
behavior changes, hospital emergency room visits for trauma injuries as
well as for gastrointestinal disturbances, sudden changes in grade-point
averages, unexplained school absences and a general tendency toward being
accident prone.

The new recommendations also offer guidance to professionals on who and how
to treat and have implications for the payment of treatment, Joffe added.
"I will use some of these screening instruments in my practice and based on
the results of how the kid scores will decide if this is someone I can
handle or is it someone I should send on to someone with more expertise,"
he said. "We've had virtually nothing to go on until now."

While there are indications that drug use among adolescents may be leveling
off, "we are concerned that our young people continue to use drugs and and
drink at an unacceptable rate," SAMHSA Administrator Nelba Chavez said in
releasing the guidelines last week.

An estimated 77,000 teens under the age of 18 were in substance abuse
treatment in 1996--nearly double the 44,000 adolescents undergoing such
treatment in 1991, according to SAMHSA.

The majority of teens enter substance abuse treatment only after they have
gotten into trouble with the juvenile justice authorities. "If adults
become aware of the warning signs [of substance abuse], they will be in a
better position to provide a timely evaluation to vulnerable teens before
they act out with criminal behavior," said H. Westley Clark, director of
the Center for Substance Abuse Treatment, which issued the guidelines for
SAMHSA. "We could also prevent the risk-taking that affects their health
and well-being for the rest of their lives."

Studies show that teens who drink alcohol and use drugs are more likely to
engage in other risky behaviors that increase the odds of early pregnancy,
contracting sexually transmitted diseases such as the human
immunodeficiency virus (HIV) that causes AIDS and exposure to violence or
involvement in motor vehicle accidents.

The guidelines also advocate a shift from the confrontational, heavy-handed
methods of tackling suspected drug and alcohol use in teens to a more
subtle, "motivational" approach.

"Strong-arm tactics have a high potential to backfire," said Ken C.
Winters, director of the Center for Adolescent Substance Abuse at the
University of Minnesota and chairman of the consensus panel that wrote the
guidelines. "They can likely start to create a larger gap between parents
and kids [rather] than building bridges."

In the new guidelines, adults are encouraged not to yell or use accusatory
tones, threats and inflammatory labels such as alcoholic or drug addict
when they confront a teen about substance abuse. A more effective approach,
the guidelines suggest, is simply to talk honestly and openly about
parental concerns.

"Kids don't mind being asked about possible drug or alcoholic use," Clark
said. "They just don't want to be accused or browbeaten. . . . And if we
fail to ask them questions to screen for substance abuse, then we fail the
kids."

One of the most difficult moments for parents is when children, once they
are confronted, compare their own drug or alcohol use to that of their
parents, challenging their parents by pointing to the adults' use of
alcohol or cigarettes. "Parents often feel paralyzed" when this happens,
Clark said.

All too often, he explained, that frustration leads to a breakdown in
communication between the child and parents and may result in ultimatums to
the child that rarely work and simply escalate the situation. "That's when
parents revert to saying 'You do this or else!' " Clark said.

To overcome a child's denial that often occurs with substance abuse, the
guidelines suggest helping teens focus on the way that alcohol and drug use
may be interfering with their life. Problems in school, missing work or
getting kicked off a team can help an adolescent see that alcohol or drugs
are already taking a toll.

When adolescents argue that their drug and alcohol use "is not a problem,"
parents can repeat those words to help guide them to an expert for further
evaluation. "Parents might respond that if you don't really have a problem,
then you have nothing to fear about going for an assessment with a
professional," Winters said.

Once substance use is confirmed in teens, the next step is treatment with a
mental health professional.

The guidelines underscore that teens require special treatment and often
don't do well in programs that are designed for adults. For example,
traditional 12-step addiction recovery programs usually are revised for
teens to focus on the first five steps, which are more developmentally
appropriate for adolescents, according to the guidelines. Residential
treatment programs need to be less confrontational for teens than for
adults and some teens may need treatment longer than the standard 28 days.

Family therapy for teen substance abuse should deal not only with the
teen's relationships within the family and with peers, but should also take
into account how parents monitor their children in age-appropriate ways,
according to the guidelines.

Other key issues to be explored during the counseling are the quality of
family life and the potential of sexual or physical abuse of the
adolescents within the home.

The guidelines counsel treatment providers that adolescents are entitled to
privacy and suggest that professionals honor confidential conversations to
keep open the lines of communication.

"Parents, teachers, employers, peers may not be contacted for information
about the adolescent's substance abuse without the written consent of the
patient," according to the guidelines.

More than two dozen experts spent nearly two years reviewing the latest
research on substance abuse screening and treatment before writing the new
guidelines. They are available on the World Wide Web at
www.samhsa.gov/csat/csat.htm (go to TIPs, No. 31) or by calling the
National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686;
TDD (for hearing impaired) at 1-800-487-4889.