31.16 Adolescent Substance Abuse
1273
behavioral and remediation interventions combined with phar-
macotherapy are likely to be the most effective approach to
early-onset schizophrenia.
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▲▲
31.16 Adolescent
Substance Abuse
Substance use is a public health concern among American
youth. The most common substances used by adolescents in the
United States are tobacco, alcohol, and marijuana. Adolescent
substance use and abuse, however, includes a wider range of
substances, including cocaine, heroin, inhalants, phencyclidine
(PCP), lysergic acid diethylamide (LSD), dextromorphan, ana-
bolic steroids and various club drugs, 3,4-methylenedioxymeth-
amphetamine (MDMA or Ecstasy), flunitrazepam (Rohypnol),
gamma-hydroxybutyrate (GHB), and ketamine (Ketalar). It is
estimated that approximately 20 percent of 8
th
graders in the
United States have tried illicit drugs and about 30 percent of
10
th
through 12
th
graders have used an illicit substance. Alco-
hol remains the most common substance used and abused by
adolescents. Binge drinking occurs in about 6 percent of adoles-
cents, and teens with alcohol use disorders are at greater risk of
problems with other substances as well.
The American Psychiatric Association’s
Diagnostic and Sta-
tistical Manual of Mental Disorders,
Fifth Edition
(DSM-5),
in contrast to the previous
Diagnostic and Statistical Manual
of Mental Disorders,
Fourth Edition, Text Revision
(DSM-IV-
TR), does not separate the diagnoses of substance
abuse
from
substance
dependence.
Instead, the DSM-5 provides criteria for
substance use disorder, accompanied by criteria for intoxica-
tion, withdrawal, and substance-induced disorders. The previ-
ous DSM-IV-TR criterion of recurrent substance-related legal
problems has been deleted in the DSM-5, and a new criterion,
craving, or a strong desire or urge to use a substance, has been
added. In the DSM-5, a threshold of two or more criteria must
be present. Cannabis withdrawal and caffeine withdrawal are
new disorders in the DSM-5. The combined substance use
criteria including both abuse and withdrawal phenomena may
strengthen the validity of the disorder in adolescents, and the
elimination of the criterion for “legal problems” is also an
appropriate change for adolescents, since this is less common
for younger adolescents and for adolescent females who use
substances. Two recent commentaries raise concerns regarding
the application of DSM-5 criteria to adolescents with respect
to the symptom of
tolerance,
particularly to alcohol, that may
occur across the board, and may be developmentally normal for
adolescents who use alcohol but for whom there is no clinical
impairment, and for
withdrawal
symptoms, which may have
clinical significance but is only moderately associated with level
of severity of substance use.
Many risk and protective factors influence the age of onset
and severity of substance use among adolescents. Psychosocial
risk factors mediating the development of substance use disor-
ders include parent modeling of substance use, family conflict,
lack of parental supervision, peer relationships, and individual
