During the period of maximum growth of adolescent hospitalization for substance abuse, Stanton wrote an article addressed to pediatricians in order to remind them of the wisdom of the ages: family and cultural background are critical for learning how to drink and other values which determine children's resistance to substance abuse; substance abuse in adolescence is generally a stand-in for a set of other individual, family, and cultural dysfunction; most adolescent substance abuse is experimental and disappears with maturity; even clearly dysfunctional substance use rarely justifies hospitalization, while the message that a child is permanently afflicted with the disease of alcoholism/addiction should be avoided at all costs.
Pediatrician 14: 62-69, 1987
What Can We Expect from Treatment of Adolescent Drug and Alcohol Abuse?
Morristown, New Jersey
Substance abuse * Adolescent drug use * Alcoholism * Substance abuse treatment * Substance abuse prevention
Our fears about youthful substance abuse and our faith in popular treatments are misdirected. Most illicit substance use by the young is not pathologic or compulsive. Excessive substance use among the young most often involves alcohol. Youthful substance abusers tend to abuse many substancestherefore an understanding of substance abuse requires an awareness of individual motivation and of the person's social circumstances. Therapy lacking this understanding has proven fruitless. Our best hope for the youngwhether or not they have significant histories of substance abuselies in engaging the natural processes of maturation, real-world rewards, and the creation of a world worth living in.
How Do People Learn to Control Their Consumption?
Learning how to moderate consumption is an essential element in growing up. Appetitive behavior is a fundamental feature of human existence (most notably in the cases of eating and drinking); yet, appetitive disorders (from obesity and bulimia to alcoholism and drug abuse) are the most prominently noted dysfunctions today among adolescents, leading to a dramatic growth in hospitalizations for those in this age group. Why have these ailments become so widespread in our time? How will we best combat them as a society, as professionals, as parents? Since the 1970s, the tendency has been to create disease categories to subsume appetitive disorders and to place these problems in a medical context that assumes these are diagnosable and treatable maladies. Yet, before we can address the question of treatment, we need to put excessive and moderate consumption in a larger framework.
Alcohol is the most universally consumed psychoactive substance. Throughout world history, most cultures have not regarded the drinking of alcohol as a problem or potential problem. In contemporary America, many ethnic groups and physicians (among others) believe beverage alcohol contributes to health and a civilized life [1, 2]. At the same time, we are overcome with anxiety today about the effects of alcohol and instruct children mainly about alcohol's addictive and dangerous properties. This is, of course, because we note so many negative consequences from drinking and wish to alert children to these dangers and prevent them from hurting themselves through alcohol use. Yet the methods used by the groups within our larger culture that have shown the greatest success at avoiding drinking problems, including Chinese, Italian, Greek, and Jewish Americans, point to quite a different approach. These and other groups and individuals who successfully inculcate moderate drinking practices view drinking as a benign accompaniment to good times and something all children must learn, often from quite an early age.
The Cantonese in New York City's Chinatown, for example, 'drink and become intoxicated, yet for the most part drinking to intoxication is not habitual, dependence on alcohol is uncommon and alcoholism is a rarity' [3, p. 179]. The avoidance of alcoholism in this community did not, however, require the prohibition of childhood drinking:
The children drank, and they soon learned a set of attitudes that attended the practice. While drinking was socially sanctioned, becoming drunk was not. The individual who lost control of himself under the influence of liquor was ridiculed and, if he persisted in his defection, ostracized. His lack of continued moderation was regarded not only as a personal shortcoming, but as a deficiency of the family as a whole [pp. 186-187].
Today we tend to regard this type of 'moralistic' approach to drinking and alcoholism as outdated and cruel, placing undue pressure on the individual with a problem. Yet, the Chinese have had rather good success with such an approach: an examination of police blotters at the local precinct between the years 1933 and 1949 revealed 15,515 arrests had been recorded in Chinatown; in not one of these arrests was drunkenness mentioned in the charge. Perhaps, some would claim, this represents massive cultural denial of alcohol problems. Yet DSM-III presents drunken arrest as a principal criterion for alcoholism. Even if these people were merely repressing alcoholic outbursts, their success at minimizing drunken misbehavior is a marvel.
The assumption has been that ethnic moderate drinking styles like those of the Chinese and Jews would dissipate as these people became assimilated into American society. Two investigators hypothesized alcoholism rates among Jews in an upstate New York city would be higher than previously recorded due to the assimilation of many nonreligious Jews. Instead, they did not find any Jewish problem drinkers; accepting at face value all case reports by zealous local proponents of an 'epidemic' of alcoholism in the Jewish community, the investigators calculated a rate of alcoholism of perhaps 1 %, but more likely 0.1 %, or from one tenth to one hundredth of that reported in the United States at large .
At one time, the NIMH policy was to encourage moderate drinking styles in American youth . This idea has been abandoned. Despite the validity and success of the socialization of moderate-drinking practices, this approach has proved too complex to implement as a national policy. For one thing, there are few communities as well-integrated and cohesive as the Chinese in America. What remains clear in the example of drinking, however, is that indigenous cultural attitudes about substance use, group agreement on clearly defined norms, a strong community to back these norms up, and positive values (such as the shared value placed on education and achievement among the Jews and Chinese) are important ingredients in a culture-wide attack on problem substance use.
Drug Use and Abuse among American Youth
In the case of illicit drugs, our goal has not been moderation but to eliminate all use of illicit drugs such as marijuana and cocaine. However, this goal has not been achieved and, since the 1960s, the trend has been very much in the opposite direction. Today, most high school seniors nationwide have used an illicit drug; nearly 40% have used cocaine by the time they are 27 . At the same time, few college or high school students act like the prototypical 'dope fiend,' even in their use of substances assumed to be highly addictive. In their annual national survey of student drug use, investigators at the University of Michigan reported that 17% of 1985 college students had used cocaine in the previous year (this figure has remained the same since 1980); yet only 0.1 % of 1985 college students had used the drug daily in the previous month .
What these data tell us is that an overwhelming majority of young people who have used cocaine do not become compulsive users. Most seem to avoid addiction within a context of school and work accomplishment that acts to dampen their urge for greater drug involvement. For example, a study of experimental administration of amphetamines to subjects in a college community found that most young subjects reported enjoying the sensations of the drug, while they actually took less of the drug over several experimental administrations . Apparently, the drug interfered with outside activities the users preferred over the sensations the drug offered, however appealing these were in isolation from the rest of their lives.
Certainly, many American young people abuse a range of substances. The substance most report using to become regularly intoxicated is alcohol. On the other hand, at a point when cocaine use had grown enormously, less than 5% of those reporting for drug treatment presented cocaine as their principal drug of abuse . While many in treatment had used cocaine, cocaine was simply one among a host of substances they used, often in a harmful manner. The Michigan student data found the best predictors of extent of cocaine involvement were first, use of marijuana and, third in importance, cigarette smoking. Those in treatment primarily for cocaine abuse also regularly drank and smoked as well .
Young people's involvement with drugs is very strongly associated with peer-group membership . This poses one further questionwhy do some children come to associate with groups that use drugs and drink heavily? The answer seems to be both that young people who share certain traits join together in the first place, and that the group then reinforces attitudes and behaviors its members already shared . The young people may not accept drug use as a value before becoming a part of the group but rather share a cluster of values and outlooks that make substance abuse more likely (see list below). At a social level, lower socioeconomic status and minority group membership predispose young people to substance abusean example is the case of native American young people. Disturbed families are also an important factor in young people's substance abuse .
What these consistent findings from a variety of types of research indicate is that substance abuse, alcoholism, and addiction are not diseases that strike people irrespective of their social settings and psychological dispositions. Certainly, examples exist of well-heeled alcoholics and drug addicts who are successful professionally. But to emphasize these individual examples at the expense of broad epidemiological findings severely misleads and handicaps the effort to make sense of our society's substance abuse problems.
In addition to economic and social deprivation, a number of clear psychological patterns have emerged in predicting substance abuse in the young. These include: (1) Alienation. Adolescents who abuse a range of substances are more isolated from social networks of all kinds. At the same time (and perhaps as a result of their isolation), they associate with groups of heavy drug users that reject mainstream institutions and other involvements connected with career success and accomplishment [9, 10]. (2) Rejection of achievement values. Research since the 1970s has consistently found young substance abusers are less motivated and successful at school . In the analysis of high-school students' involvement with cocaine discussed previously, the second leading predictor of cocaine abuse was truancy. Clayton  indicated truancy most likely preceded cocaine use, and thus that alienation from school was a precondition for drug abuse. (3) Antisocial aggressiveness and acting out. Numerous studies have shown strong detection rates for substance abuse through MMPI subscales whose items indicate 'an assertive, aggressive, pleasure-seeking character' also often present in criminality and delinquency [12, p. 617]. These scale items and similar measures are not consequences of alcohol and drug abuse. Several studies have found that those who became alcoholics had higher sociopathy and defiance of authority scores in adolescence or early adulthood .
Natural History of Substance Abuse in the Young
It would be extremely misleading and dangerous to infer from the above findings that high-school students and others who do not become positively engaged in school or who show other traits such as alienation and antisocial acting out are preordained to become alcoholics or addicts. Indeed, they are far from preordained to become heavily involved with drugs or alcohol as adolescents. These constellations are associated with difficulty in adolescent adjustment and may make the passage to adulthood more difficult (which may be indicated by substance abuse).
However, we must note that even for those who do abuse substances, the majoritythe large majoritywill cease abusing drugs and alcohol in early adulthood. Thus the rate of alcohol-related problems is highest for young men between the ages of 18 and 24 , including both those in the military  and those in school . The same age patterns hold for illicit drug use. For example, O'Donnell et al.  discovered that of young men in their twenties who had ever used heroin, only 31% had used the drug in the previous year. Jessor , one of the leading investigators of adolescent substance-use problems, described what some have called the process of maturing out (this description is based on both male and female subjects):
Development, at least in the mid-and later twenties, appears to be in the direction of greater personality, perceived environment, and behavioral conventionality. That direction may well follow from the assumption of new life roles in work and family and the occupancy of new social contexts other than that of school, both factors constituting conventionalizing influences [17, p. 131].
To put this analysis in a more positive context, as children mature they find they have the ability to achieve more meaningful rewards than those offered by drugs and overdrinking, rewards so superior that they dominate the adult outlook from approximately the mid-twenties on.
We need always to remember that no therapy of any kind has ever matched the simple process of growing up in terms of the sheer numbers of cures for substance abuse it has produced. We are naturally concerned about children hurting themselves as adolescents or young adults when they abuse substances, but as a long-term prognosticator, no indicator is better for the cessation of problematic substance use than the assumption of adult roles, responsibilities, and self-images. At the same time, encouraging children to assume real-world responsibilities greatly enhances their chances of avoiding substance abuse when young, and of achieving overall adult integration. Vaillant and Vaillant  found in a long-term study of psychological health in men that 'capacity to work in childhood... surpassed social class, multiproblem-family membership, and all other childhood variables in predicting adult mental health and capacity for interpersonal relationships' [18, p. 1433].
Treating Substance Abuse Effectively
The idea that most substance abusersincluding those whose cases appear quite severe in adolescencewill outgrow these problems very strongly contradicts the image of alcoholism (or drug dependence) as an irreversible, progressive disease. Many physicians are aware of patients who undergo and then relinquish periods of problematic drinking, and of young people who outgrow drug and alcohol abuse. Nonetheless, the idea of an inevitable progression to death and destruction due to substance abuse is a standard feature in the presentations treatment personnel make to parents. The highly visible and competitive market for the sale of substance abuse treatment places a premium on persuading parents often quite forcefullythat medical and residential treatment is essential.
Aggressive marketing of this kind led between 1980 and 1984 to a more than quadrupling in hospitalizations of adolescents, mainly for chemical dependence . However, there has been a notable failure to establish the success of medical therapy for alcoholism, even by those who strongly support such treatment. For example, George Vaillant, a leading psychiatrist in the field of alcoholism, has written that it is imperative to engage problem drinkers in medical treatment. At the same time, he noted that his own inpatient hospital programwhich included compulsory AA attendancedid not lead to greater remission than studies had found for untreated alcoholics . This major work, then, was unable to establish an improved prognosis due to the medical therapy typically used for alcoholism in the United States.
Two psychologists examined controlled studies (those involving comparison or control groups) of alcoholism treatment . They discovered that the therapies the research had demonstrated to be effective were almost never practiced in American treatment centers, while unproved therapies were widely employed. For example, they found that inpatient (compared with outpatient) treatment and length of treatment had no impact on outcome. In nearly all cases, the survey revealed, therapies that have proven successful have been those that mediate patients' dealings with their environmentse.g., social skills training, stress management, marital and family therapy. This emphasis on success in dealing with job, family, and environment as the major source of beneficial outcomes for alcoholism very strongly resembles the conclusions Vaillant  and others have drawn from treating alcoholics.
Vaillant made the following points about his and others' research: 'Patients cited changed life circumstances rather than clinical intervention as most important to their abstinence' [p. 192]; 'Orford and Edwards  reported that improved working and housing conditions made a difference in 40 percent of good outcomes, intrapsychic change in 32 percent, improved marriage in 32 percent, and a single 3-hour session of advice and education about drinking... in 35 percent' [pp. 188-189]; 'the most important single prognostic variable associated with remission among alcoholics who attend alcohol clinics is having something to lose if they continue to abuse alcohol' [p. 191]. Due to all of the above, Vaillant [p. 287] quoted approvingly Orford and Edwards' recommendation that 'alcoholism treatment research should increasingly embrace the closer study of natural forces' which can then be utilized in therapy.
The Drawbacks to Hospitalizing Adolescent Substance Abusers
Vaillant also declared: 'it may be easier for improper treatment to retard recovery than for proper treatment to hasten it' [p. 293]. In this light, despite the failure to demonstrate the value of hospital treatment of alcoholism , inpatient care has become the typical therapy for nearly all alcoholics and problem drinkers in the United States. Moreover, the model of inpatient treatment has been generalized to all forms of substance abuse, and particularly to young substance abusers who almost never exhibit clinical symptoms of alcoholism or drug addiction. These children are called 'chemically dependent' and are placed in standard 28-day programs built on the disease model of alcoholism. Such programs place great importance in educating patients about the disease nature of alcoholism (or chemical dependence) and insist that patients acknowledge they have a disease.
Some researchers and clinicians have pointed out that patients pick up very little information in this setting . Rather, the treatment setting encourages a group influence process in which individuals are converted to a new identity, hopefully in this case a drug-or alcohol-free one. This conversion experience cum therapeutic process, however, carries added burdens for the young person beyond those found with chronic alcoholics. That is, patients are told they have a disease and that they will relapse if they ever drink or use a drug again. However, these young people have already frequently been lectured on abstemiousness along with all other young Americanswith little effect.
The danger is that the adolescent has been set up for relapse, since there is almost no chance he or she will remain forever abstinent. And, indeed, the pattern of adolescent treatment is one of alternating treatment and relapse. In particular, the young personespecially the troubled young personis overwhelmed by group influences, either in treatment among peers who are also recovering from chemical dependence or else after leaving treatment, in the form of familiar drug-using groups. This process is illustrated by the woman who told me she was completely satisfied with her son's residential school and therapeutic community, except that, when he came home, he went 'straight over to the local drug dealer's house' and resumed taking drugs.
Disease-oriented treatment programs circumscribe adolescents' worlds so they deal only with others recovering from similar problems, a natural consequence of the lifetime identity as an addict the therapy attempts to inculcate in patients. Yet the data indicate the enormous plasticity of substance abuse over the life span, even with severe symptoms of alcoholism and addiction. For example, Fillmore  discovered that college students who regularly drank to blackout rarely did so 20 years later . In a 27-year follow-up of this group, indeed, college students who acted out while drinking were less likely than other drinkers to have drinking problems in middle age . The high changeability of drinking problems with age has been corroborated more recently with drinkers from the age of 16 to the age of 31 .
These results suggest that undergoing drinking or drug-use problems can often serve as an educational experience that minimizes the likelihood such problems will occur later in life. Similarly, although research from investigations of children of alcoholics indicates they can suffer from a range of problems and are more likely than ordinary people to become alcoholics themselves, the data do not indicate such children are obligated to become alcoholics . It is still the case, more often than not, that children of heavy drinking parents will become moderate drinkers . Research that has found less drinking and drunkenness among college-age children of alcoholics furthermore suggests that youthful problem drinking and adult alcoholism may be the result of entirely distinct processes . In this case, it may be impossibleand dangerousto predict from one phenomenon to the other.
To summarize the dangers for young substance abusers of typical therapy based on the disease model: (1) a preoccupation with patients' genetic make-ups may actually retard children's potential to grow into mature identities in which they do not need to believe they are permanently alcoholic or chemically dependent; (2) a preoccupation with lifelong abstinence in this young population may be not only unnecessary but unrealistic, and may actually encourage regular relapse episodes; and (3) a preoccupation with substances and patients' reactions to them can interfere with the development of crucial abilities patients need to improve their relationships to their environment and their coping skillsskills at school and work; at dealing with friends, family, and stressful situations; at making decisions, solving problems, and becoming engaged in constructive activity.
Advice and Cautions for the Health Professional
The absence of the demonstrated superiority of conventional treatment to natural remission processes along with other drawbacks to such programs, especially for children, suggests caution in referring children to hospital-based or other residential treatment. Yet such referrals have increased dramatically. These referrals are often coercive, the result, for example, of 'interventions' in which the child is bombarded with accusations about his 'chemical dependence' from a selected group of friends, teachers, counselors, and family members. The psychological implications of a technique based on isolating the individual adolescent and attacking his or her self-image are far-reaching.
Although many helping professionals (physicians included) are nervous about this type of intervention conducted in the name of therapy and about the hospitalization of increasing numbers of young people, many also are unable to withstand the pressure to hospitalize drug users or teenage drinkers. Often, this pressure is passed along from parents who believe they are obligated to enroll children in inpatient treatment or residential programs. After all, what if the child is about to hurt himself or is embarked on a career of self-destruction that will culminate ultimately in addiction or death?
The data presented here on the self-ameliorating course of much substance abuse and the intermittent nature of adolescent use of powerful drugs are important counteractives to these fears. At the same time, of course, in some cases physicians or other counselors may feel custodial care is necessary for the protection of the child. Rather than using drug or alcohol use as indicators of the need for hospitalization, however, the health professional should consider other standard indicators of the wisdom of inpatient care. Are there concrete indications (such as accident-proneness) that the child is likely to harm himself or others, or has the child lost the ability to function at a tolerable level?
Sometimes, it may be wise to remove the child from the home environment simply to break up an unpleasant or destructive family situation. Children who are abusing drugs are often least successful at functioning independently of their families, making a therapeutic community appealing as the most readily available haven. Nonetheless, health professionals and counselors must maintain an awareness of the costs of such treatment and of what it cannot accomplish. Children abusing substances ordinarily display negative prognosticators in such areas as family life, socioeconomic status, concurrent antisocial and destructive behaviors, and lack of engagement in school or other career paths. None of these issues can be resolved by hospital care itself. A family physician or counselor must keep in mind what the child will dohow the child will function and how he or she will spend time and with whomfollowing treatment.
Thus, clear decisions should be reached with the family and child about aftercare plans, so that treatment does not become a regular drying-out break between just-as-regular bouts of substance abuse. School attendance and performance, recreational activities and peer groups, family problems, and issues of the child's basic functioning and direction in life must always remain at center stage. Familial matters such as family financial resources or parents' values about self-reliance are crucial and valid inputs in decisions about seeking treatment and the kind of treatment sought. Discomfort with or lack of faith in treatment, we have seen, are not irrational fears on parents' parts. Only the most severely self-destructive cases warrant violating basic parental values or placing the family in economic jeopardy.
Finally, pediatricians and other primary care physicians and professionals should not downplay the particular brand of expertise they bring to any individual client's case. This is especially true since the tempting analogy to hospitalization for nonbehavioral illnesses ('You would send a child for intensive care for a progressive case of pneumonia, wouldn't you?') is not justified by the present state of treatment efficacy. Knowledge of and involvement with the child's family, awareness of the child's history and overall functioningincluding both strengths and weaknessesand other kinds of information the general practitioner is most likely to be familiar with are often the keys for successfully treating the young patient.
(1) The most effective, enduring, and widespread means for preventing drug and alcohol abuse (including alcoholism) are culturally imparted attitudes and patterns of consumption. Low-alcoholism cultural groups are marked by a relaxed attitude toward appropriate drinking by the young as well as adults. Regular intoxication and particularly alcohol-inspired misbehavior, on the other hand, are condemned by strong, clear family and group norms. (2) The abuse of alcohol and the use of illicit drugs are norms for many groups of young people in the United States. Abuse as defined by periodic (but frequent) excessive use is far and away most common with alcohol among all psychoactive substances; even most cocaine users are casual and intermittent users. The few who use drugs on a daily or nearly daily basis are likely to abuse many substances (including cigarettes, alcohol, and all types of illicit drugs). (3) The characteristics of such multisubstance abusers are, at a social level, association with groups of other young people who also abuse substances, and disadvantaged and minority backgrounds. Such young people are often characterized by low achievement motivation and the absence of other prosocial values and involvements; social, academic, and family alienation; and patterns of antisocial aggressiveness and misconduct. Peer group commonalities in drug abuse are a result of such prior attitudes as well as of peer pressure. (4) These predispositions to alcohol and drug abuse notwithstanding, substance abuse in adolescence or early adulthood is not a good predictor of drug addiction or alcoholism, primarily because most young people outgrow excessive substance use. This is a normal outcome of maturation. It also suggests that therapy should encourage the assumption of values toward work, accomplishment, family, and social institutions that facilitate the maturation process. (5) The benefits of medical treatments for alcoholism and addiction have not been clearly demonstrated. Where therapy shows clear benefits, it is associated with other positive life changes in work, family, and social environments. On the other hand, the danger of adolescent treatment is that it typically identifies substance abuse as a permanent, inbred disease state. The kind of coercive interventions that have become increasingly popular in the 1980s may convince young people they are alcoholics or chemically dependent (addicted) in such a way as to make this a self-fulfilling prophecy.
The focus on treatment may fail to confront essential issues facing our society. It ignores the high-risk groups of young people (such as children of unwed, teenaged mothers) whose social conditions guarantee high rates of problem behaviors including substance abuse. These groups must be addressed so as to engage them in positive activities and accomplishments, integrate them into the broader society, and assist them to develop life-sustaining and esteem-gathering skills. At the broader level, America is the country in the Western world with the worst substance abuse problems among the young, despite this country's investment in by far the largest substance abuse treatment industry in the world. It seems the substance abusers who are helped are readily replaced by endless new supplies of young substance abusers and older alcoholics and addicts.
Massive sums spent on the interdiction of drug supply lines and on military and police campaigns against drug dealers likewise have not reduced the number of substance abusers . Nor has a network of drug lecturers, programs, and media campaigns designed to get young people to avoid drugs produced notable success . The chief of the prevention research branch of the NIDA has declared: 'those programs that use scare tactics, moralizing and information alone may actually have put children at increased risk' . Yet these are the most popular and oft-utilized approaches to drug education.
That young people do not have enough of an investment in life to reject opportunities for addiction and unconsciousness is a strong commentary on our society. The reversal of these problems may require interventions we are as yet incapable of conceiving. Recently, I asked secondary school students in a Western city to list their worst fears and greatest aspirations. The leading fears were of dying and of nuclear war (this city was near a nuclear missile site), followed by fears about drugs (which many already were using and others would soon use). We need to be able to convince children that life is worth living and that they are capable, not only of avoiding drugs, but of achieving a worthwhile existence. To do this, we have to create a world that is worth living in; we also must persuasively present values of achievement and positive accomplishment; of friendship and community; of health and self-preservation; of fun and adventure; of responsibility for self and contribution to others; of consciousness and intellectual awareness; and of a commitment to life that goes beyond personal protectiveness and fear .
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