Substance Use Disorder in Children and Adolescents

The purpose of this article is twofold. The first is to help parents understand the nature of substance use disorders. The second is to identify signs that indicate that their child may be suffering from such a disorder. This is not an academic treatise on the subject but rather a practical approach.



The Fear

Let me illustrate with an example. Shimon was 15 when his parents received a call from his Rosh Yeshiva (school head). Shimon had always been an excellent student and an enthusiastic learner. Some older students at the yeshiva had introduced him to using marijuana. This helped him relax and feel as though he was enjoying himself.


At first, it did not affect his learning. As time went by and he progressed to daily use, his memory and concentration deteriorated. His performance in class was markedly degraded. A school counselor confronted him, and he admitted that he had not only been smoking marijuana every day but had begun to experiment with ecstasy as well. He promised to stop using drugs and scheduled regular visits with the counselor. Although he told this trusted advisor that he was no longer using, he quickly relapsed and returned to previous levels of use. The Rosh Yeshiva told the parents that Shimon would not be able to continue at the school unless he first sought treatment for his substance use problem.


This story highlights a very typical progression from experimentation to regular use, and from regular use to impaired functioning. It is not surprising that parents would have no knowledge in advance of this problem. Keep this narrative in mind as we discuss the nature of substance use disorders and the effects thereof.


Image result for teenage addiction


Grasping The Current State

Between 3-6% of adolescents nationally suffer from a substance use disorder. Those of us working in mental health are all too sadly aware of the most recent scourge of opioids and their attendant fatalities. We know too well the horrors created by excessive alcohol, cocaine, and other substance use. These disorders are truly terrible for adults to confront; the growing child or teen is far less equipped to face these frightening challenges.


The current diagnostic terminology found in the Diagnostic and Statistical Manual 5th edition of the American Psychiatric Association is the standard in the field. It describes “Substance Use Disorders” for the various substances (e.g. “Opioid Use Disorder”). It has done away with terms like addiction, dependence, and abuse.


The key concepts in understanding these disorders include loss of control of use, continued use despite mounting consequences, impairment, and tolerance and withdrawal.



Loss of Control

The first of these, loss of control of use, is when a point is reached in the relationship of the person with a particular substance at which they can no longer make a choice to use or not. While efforts are almost always made to reduce use as consequences accrue, the person must eventually admit that they are powerless to stop using and require an intervention. The person struggling with such a disorder often finds this very confusing and extremely humiliating. These psychological effects often fuel denial and rationalization. Continued use despite mounting consequences is a clear result of the loss of control of use.



The Consequences

Consequences of loss of control occur in multiple domains. For the child and adolescent population, these will often be seen in particular areas such as a decline in academic function. Other consequences can include impaired memory, concentration, and motivation.


One particularly sad consequence can be disturbed family relationships. Trust and honesty are damaged, as secrecy and lying are invariable partners in substance use disorders. The struggle to redefine one’s relationships with parents, normal in adolescence, becomes far more pronounced and pathological. Parental values are often openly rejected in favor of those of a deviant peer group. Parents can become desperate to try to bring order to the chaos created by the child’s drug use. Efforts to impose control can then lead to a spiral of rebellion and reaction. Parents, terrified by the dangers posed to their child’s wellbeing and even survival, may find that the greatest danger to their child is the child himself.


As teens abandon previously cherished values, goals, and relationships, we often see instability in relationships with peers and new affiliations. The adolescent surrounds himself with like-minded friends who support his ideas about drug use. The alliance against parents and the larger society reinforces and crystallizes the self-destructive rebellion. The adolescent finds himself in something of an echo chamber, wherein his own misperceptions and errors are parroted back to him.


It goes without saying that the above examples do not exhaust the potential consequences of substance use disorders. Legal consequences become more prominent as adolescents approach adulthood. Involvement in criminal activity to finance substance use is common. In certain cases, young people will steal from their own families to pay for drugs. The ultimate consequences lie in the realms of injury, incarceration, overdose, and even death.



Tolerance and Withdrawal

Tolerance and withdrawal refer to physical phenomena frequently seen in substance use disorders. These are seen most prominently with alcohol, benzodiazepines, other sedative-hypnotic agents, cocaine, and opioids. Tolerance refers to the brain’s adaptation to regular exposure to a drug. Withdrawal refers to physical and emotional symptoms that emerge from sudden cessation of using a drug to which one has become tolerant. These syndromes range from the mild to the intensely uncomfortable to the life-threatening, depending on the level and duration of use and the properties of the drug itself.



The Signs

What should parents look for if they begin to suspect their son or daughter may be suffering from a substance use disorder? The answer to this question flows from what we have said above about the effects of substance use disorders. The following signs may point to such a condition: academic decline, withdrawal from the previous peer group, withdrawal from previously valued activities (such as sports or volunteer work), development of a new, possibly delinquent peer group, and significant changes in family relationships. The teen may become secretive, defiant, and argumentative. If these constitute significant changes from what they were previously like, it behooves those caring for them to explore the possibility of substance use. More severe signs should prompt a higher index of suspicion: staying out beyond approved curfew, money or belongings missing from the parents, defiance towards authority figures outside the home, aggression, obvious signs of intoxication, heightened impulsivity, and mood instability.



Children vs Adults

The contrasts between the effects of substance use disorder in adults and in children and adolescents are functions of developmental differences. Adults do not typically have parents overseeing their activities, and thus tend to have less overt conflict about their substance use until it reaches higher levels. Although we are close to our spouses, parents are particularly attuned to changes in their children and are more ready to sound the alarm when they become concerned. The adolescent does not have the same presumption of autonomy as the adult, and so treatment can be started with somewhat less resistance than with adults.


The adolescent is at a critical developmental juncture both biologically and socially. Problems at this time may have long-lasting effects on education, career, and marriage. The adolescent brain is still developing and changing rapidly, and substance use may have more profound negative results. On the other hand, adults may have more insight and capacity for self-monitoring and thus may be more willing to pursue evaluation and treatment.



Closing Thought

With this knowledge in hand, parents can be alert for the behavioral changes in their children which may signal the presence of a substance use disorder. The most reliable indicator that something is wrong is ultimately the intuition of the parent. Parents know their children better than anyone else. Once the inner alarm is raised, parents can use the information presented in this article to explore the possibility that the problems they are seeing are due to substance use disorder.




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