Robert L. DuPont, M.D.
Dr. DuPont is Clinical Professor of Psychiatry at Georgetown University Medical School, Washington, D.C., and President of the Institute for Behavior and Health, Inc., Rockville, Md.
Preventive strategies are an inherent part of psychiatric practice. Essentially, in the course of successful psychotherapy, healing is accompanied by the development of coping abilities that will enable a patient to deal with future stress in a healthier and more effective way.
Drug abuse prevention is no exception. This problem has clearly reached epidemic proportions. Epidemiologic studies indicate that there is a sequence of drug use among youth, from alcohol and/or cigarettes on to the use of marijuana (called gateway drugs), and thence on to cocaine and other serious substances. As puberty occurs, this is the critical time of onset for gateway experimentation: preventive measures must be in place prior to and at that age.
Youth at high risk of drug abuse share certain personality characteristics: interest in present-tense pleasure, lack of concern for the feelings of others, relative imperviousness to the impact of punishment, frequent and easy lying, and alienation from and antagonism toward adults.
Scare tactics may work well for other youngsters. but not so with those possessing this high risk profile. Among the effective methods used thus far is ''peer refusal,'' i.e. training youngsters in the sixth to tenth grades to say no to drugs offered by peers. Mobilization of caring adults is another approach, encouraging them to learn how to set intelligent limits and institute effective controls and methods of punishment. Most important is an attempt to methods of punishment. Most important is an attempt to establish meaningful bonds between youngsters and adults. In the treatment and prevention of adolescent drug abuse, work with family groups is essential
Introduction
Whereas alcohol and drug use is common among American teenagers, it is not universal. Some youths, however, are at high risk for drug and alcohol problems, and a new body of clinical and epidemiologic research supports early identification of those high risk individuals and offers specific interventions. This lesson explores that knowledge and furnishes some suggestions for applying the information to the clinical psychiatric setting.
In order to understand the issue, it is helpful to review the current knowledge about drug use in the United States. Much of that research was recently summarized in the second triennial report to the U.S. Congress from the Secretary of Health and Human Services, entitled [1mDrug Abuse and Drug Abuse[37;0m Research, and some was reported by this author in an earlier lesson in this series.
During the past two decades the United States has experienced an unprecedented increase in the use of illegal drugs. One figure makes that point clear: in 1962, prior to the drug epidemic, only 4% of Americans 18 to 25 years of age had ever used marijuana. By 1979, at the peak of the epidemic, that figure stood at 68%. In 1985, reflecting a recent small but important decline in drug use, the figure was 61%. Nonmedical drug use is usually initiated during the teenage years and rarely after the age of 20. The use of drugs, ranging from alcohol and marijuana to cocaine and PCP, shows peak prevalence between the ages of 18 and 25.
Over the same two-decade span, a corresponding increase occurred in the prevalence of other problem behaviors among youth, including suicide, venereal disease, delinquency and eating disorders. All those problems of teenagers involve the impulsive pursuit of personal pleasure through behaviors that are in conflict with widely held societal values.
The University of Michigan Survey Research Center annually surveys a large representative sample of U.S. high school seniors. Results from the 1986 sample, the most recent year for which data area available, showed 91% of high school seniors had already used alcohol at least once.[1m3[37;0m Equivalent figures for other drugs were cigarettes, 68%; marijuana, 61%; and cocaine, 17%. Within the 30 days prior to the survey, 65% of the high school seniors had used alcohol, 30% had used cigarettes, 23% had used marijuana and 6% had used cocaine. That same survey found that 37% of high school seniors get drunk at least once every two weeks with use defined as five or more drinks in a row at one time. Table I lists prevalence figures for the most commonly used drugs among high school seniors in the United States.
The high school senior survey includes the age at which youth in the United States typically begin drug use. The most frequent time to initiate cigarette smoking is the sixth grade, and the most frequent time for initiating daily cigarette smoking is the ninth grade, where 5% of the class begins daily smoking. Ninth grade is also the most common age for beginning alcohol consumption (25%), for first drunkenness (19%), and for initiating the use of marijuana (12%). Cocaine use is the exception to the pattern of initial drug use in junior high school. Its use is most frequently initiated in the 12th grade (5%). Follow-up studies indicate that drug and alcohol use that is begun in adolescence often persists for many years.
Lifetime Use Current Use The Gateway Drugs Alcohol 91 66 Cigarettes 68 30 Marijuana 51 23 Cocaine 17 6 Hallucinogens (including 12 4
Stimulants 23 6 Sedatives 10 2 Tranquilizers 11 2
Source: National Institute On Drug Abuse, National Trends in
Drug Use and Related Factors Among American High School
Students and Young Adults. 1975-1986; U.S. Department of
Health and Human Services, Washington, D.C., 1987
A related body of research has indicated a sequence of drug use by youth. The sequence begins with alcohol and/or cigarettes and moves on to marijuana. Those three substances-alcohol, cigarettes, and marijuana-are called the gateway drugs because they are often the gateway into the drug dependence syndrome.[1m4[37;0m They are perceived by actual and potential drug users as relatively harmless and easily controllable by the user. The younger a person is when he or she uses a controllable by the user. The younger a person when he or she uses a particular gateway drug, the more likely will be the progression to the next substance in the sequence. Thus, youth who begin alcohol use in the seventh grade are more likely to use marijuana than are youth who first use alcohol in the 11th grade. Younger first use of any drug is positively associated with an increased risk of problem-producing use of that drug.
A committee of drug-abuse-prevention experts recently discussed the goal of zero tolerance for youth, and reached consensus that there should be no use whatsoever by youth of drugs or cigarettes. That committee's members were not in unanimous agreement on the goal for the use of alcohol. Some advocated a goal for teenagers of complete abstinence from alcohol, whereas others favored the goal of no excessive use, no problem-producing use, or no use in early adolescence. The gap between achieving any of those goals and the reality of drug and alcohol use reported in the high school senior survey establishes the magnitude of the drug-abuse-prevention challenge.
Two points are particularly relevant to the problem of preventing drug abuse among high-risk youth. Onc, since first drug use occurs in early adolescence, any effort designed to stop use of drugs must target youth prior to the sixth or seventh grade and two, although large percentages of youth begin drug use during their teenage years, not all do so. Thus, the teenage population comprises both relatively "high-risk" and relatively "low-risk" youth with respect to substance abuse problems.
This lesson focuses on what is known about the youth who are at high risk and on what can be done to reduce that risk. In particular, it deals with the role of the psychiatrist in the process of identification and intervention with high-risk youth.
The Cardiovascular Disease Model
An appropriate model for substance-abuse prevention is the recent commitment to prevention of cardiovascular disease. In an attempt to reduce the risk for cardiovascular disease, researchers are working rapidly to quantify risk factors and develop specific risk-reducing interventions. Those efforts have focused primarily on health-related behaviors such as smoking, diet and exercise-life- style factors for the prevention of disease. The life-style patterns contributing to cardiovascular risk, as with drug abuse risk, are formed at a very young age. Although the rates of cardiovascular disease within the population are high, it is no longer considered reasonable to simply accept them as inevitable.
Use of the model of cardiovascular risk for drug abuse risk is significant for several reasons. First, it helps establish the legitimacy of the goal of prevention of drug abuse. Second, it conceptualizes the process of risk identification as a health concern, not only a moral or legal matter. The comparison of cardiovascular risk reduction and substance-abuse risk reduction also makes clear that, although primary responsibility rests with the individual and the family, the clinician can play a vital role by helping both the person with the problem behavior and his or her family identify and reduce the risk. In the area of cardiovascular disease as well as in drug abuse, a strong genetic component related to risk is present and is an important added reason to reduce controllable risk factors.
In drug-abuse prevention, as in cardiovascular disease prevention, there is an interaction between individual behaviors on the one hand and social control over behavior on the other. For example, the growing social pressure against cigarette smoking influences many personal decisions by individuals. Making smoking illegal in public places, such as restaurants and airplanes, is understood to be a public health issue, not a moral one.
Identification of Youth at High Risk
The search for markers of high risk for drug abuse has been carried on for many years and the resulting body of information shows differences in relative risk for the use of particular substances. For example, those youth at high risk of cigarette smoking are not identical to those at risk for cocaine use. However, the most striking finding of contemporary substance-abuse research is that commonalities for the risk of the various drugs far outnumber differences. That holds true for both legal drugs, such as alcohol and tobacco, and illegal drugs, such as marijuana and cocaine. (The distinction between legal and illegal is tenuous with youth, for whom alcohol and tobacco use is illegal.) Markers of high risk of drug abuse also predict the relative risk of a wide range of problem behaviors of youth, including poor school performance, sexual promiscuity, and eating disorders. Delinquency, in particular, has been linked to the risk of chemical dependence in youth.
As the drug-abuse epidemic increased over the last two decades, general skepticism about finding clear-cut markers of high risk prevailed. Drug use itself, at least in its early stages, was perceived to be not only increasingly common but even an inevitable part of the adolescent rite of passage. However, as the drug-abuse epidemic has begun to wane, drug use is again being regarded as a serious health problem, and prevention of drug use is regarded as a public health goal.
Many health professionals indicate a surprising contrast in attitude toward cigarette smoking by the young and alcohol use by the same age group. They are in virtually unanimous agreement, for reasons of health that regular cigarette smoking by young people is unacceptable. It is only slightly less universally recognized that any experimenting with cigarettes by youth is undesirable. Contrast those views on cigarette smoking with the ambivalent attitudes among cigarette smoking with the ambivalent attitudes among health professionals about youthful alcohol use. Teenage drinking is tolerated by many physicians working with adolescents. The attitude of many physicians about marijuana and cocaine use among young people falls somewhere between the strongly negative attitude toward cigarette smoking and the accepting attitude toward alcohol use. From a public health standpoint, we should treat alcohol and other drugs as we now treat cigarettes. In this author's view, it means establishing and reinforcing the standard of zero tolerance of cigarette, alcohol, and marijuana use by teenagers. The law establishing 21 as the legal drinking age reinforces that goal.
One recent study that explored the question of relative risk for substance abuse among youth surveyed 10th graders on a wide variety of behaviors, including physical activity, nutrition, stress, and substance use.[1m9[37;0m The variables were grouped into six categories: demographic, psychological, social environmental, behavioral, physical, and substance use. With respect to substance use (cigarette, alcohol, marijuana cocaine and other drugs), the authors established six levels of use: (1) those youth abstaining from all substances, (2) those who have experimented with one or more substances at least once in their lives, (3) those who use one or more substances at least once a month but less than once a week, (4) those who use one or more substances at least once a week, (5) those who use one or more substances almost every day, and (6) those who use one or more substances every day.
Using multiple regression analysis, the study showed the strongest single indicator for increased substance use by boys and girls was their friends' marijuana use. Tenth graders who reported their friends did not use marijuana were less likely to use cigarettes, alcohol, marijuana, or other drugs. Youth who said their friends did use marijuana were at a significantly elevated risk of substance use themselves.
Among boys, that risk factor was followed, in order of significance for substance use, by perceived safety of cigarette smoking, poor school performance, parents' education, and the use of diet pills, laxatives, and diuretics to control weight. Together, those factors accounted for 44% of the variance between the youth who used substances and those who did not.
For girls, friends' marijuana use was also the most powerful predictor of their own substance use. Following in order of importance were poor school performance; self-induced vomiting for weight control; perceived safety of cigarette smoking; use of diet pills, laxatives, or diuretics for weight control; parents' education; perceived adult attitudes about cigarettes; and nonuse of seat belts. Those factors accounted for 53% of the variance for girls in the study. The study' s authors concluded, "These findings suggest that for many purposes substance use may be considered a single behavior regardless of the specific substance(s) used and that substance use may exist as part of a syndrome of adolescent problem behaviors."
Other studies show youth who are at high risk of drug abuse share a constellation of personality characteristics, including impulsiveness, pessimism, lack of ambition, and poor work habits. It has also been shown that high-risk youth lie easily, are extroverted, and are often in conflict with adults. Those characteristics bear similarities to the psychopathic personality described by James M. A. Weiss in three earlier lessons in this series.
Clinical experience confirms not only are those characteristics predictors of substance abuse but also substance abuse promotes and, in a vicious cycle, deepens them. For many high-risk youth, those personality characteristics are apparent even before puberty. Although no reliable estimates exist for the incidence of high-risk behavior in the United States, my own clinical experience has led me to believe that about 10% of teenagers have such characteristics to a severe degree and an additional 20% have them to a moderate degree. One of the more important findings of the research on high-risk youth is that the bonding of youths to adults is significant to the risk of drug abuse in adolescence. Youth who relate Youth who relate to adults in active, positive ways are less likely to use and abuse drugs than are youth who view adults as their enemies and who spend as little time as possible with adults.
It has often been observed that youth with learning disabilities have an elevated risk of drug abuse, and recent research has clarified that complex issue. Learning-disabled youth with good work habits and strong relationships with adults are not at elevated risk of drug abuse, regardless of the severity of their learning disability. On the other hand, learning-disabled youth possessing the high-risk personality characteristics that have been identified are at increased risk of drug and alcohol problems. In other words, the risk of drug abuse is linked to the child's character not to his or her learning disability.
Characteristics of High-Risk Youth
As I work with adolescents in my own practice, I look for the five characteristics for high risk of substance abuse listed below. (1) interest in present-tense pleasure: high-risk youth value the here-and-now over the rewards of delayed gratification. (2) Lack of empathy: youth who do not care about the feelings of other people are at a higher risk of drug abuse. (3) Lack of sensitivity to punishment: youth who are responsive to punishment are less likely to be involved with drugs whereas those relatively impervious to punishment are at higher risk. (4) Easy lying: youth who lie easily, and often, are far more likely to have drug and alcohol problems than are youth who are honest. (5) Distance from and rebellion against adults and others in authority: youth who spend much of their time away from parents and other adults and who have antiauthority values are at increased risk of drug and alcohol problems.
Having identified those character traits of high-risk youth, three points require emphasis. First, rarely are those characteristics either totally present in or totally absent from the personality of any particular teenager. Second, those characteristics tend to diminish after about 16 to 18 years of age (absent perpetuation by frequent drug use). Third, the risk of drug use for an individual is positively related to the extent to which those characteristics are present. Not only does it resemble the profile of the psychopathic character, the list of character traits associated with high risk of drug abuse is also typical of confirmed chemically dependent people of any age. In itself, adolescence, as a phase of the human life cycle, is a risk factor for drug and alcohol problems.
Intervention to Reduce the Risk of Substance Abuse
It is useful to know who is at high risk, but also what can be done to reduce that risk? It is paradoxical but not accidental that many of the techniques best suited for preventing teenagers from drug and alcohol abuse are relatively less effective with the high-risk population. For example, it is often said that scare tactics do not work with youth when dealing with drug abuse prevention. That commonly repeated finding is misleading, however. Many youth are, in fact, frightened about the consequences of the use of drugs and alcohol and they respond to scare tactics by not using drugs. Those relatively easily frightened youth are, however, the least in need of such preventive education, since they are the most likely to be concerned about the approval of adults and their own futures. Thus they are relatively less likely to use drugs, even without being confronted by scare tactics. It is the youth who are skeptical-if not hostile-to adults, those who lack empathy and who are not easily influenced by punishment, and those who focus on present-tense rewards who are at high risk of chemical dependence. Scare tactics about drug and alcohol problems are less effective for that latter group because they are not scared.
Drugs and alcohol are especially seductive for rebellious, anti-adult youth who lie easily and who are relatively impervious to the future consequences of their actions. Drug and alcohol use has a payoff in a relatively certain, present-tense "high." whereas problems caused by drug use tend to arise in the future. Drug-caused problems are also unpredictable with respect to any particular user, so youth who are unconcerned about the future and who assume they will do fine no matter what the odds are relatively impervious to the messages of drug-abuse prevention. That is especially true of prevention messages that emphasize risks of drug use, particularly when the risks are for the individual youth, delayed and/or uncertain.
Intervention Strategies
A recent report reviewed three broad categories of interventions directed towards adolescents at high risk for drug and alcohol use in an effort to reduce the use of drugs:[1m6[37;0m programs, general efforts, and individual efforts. Typical of the first approach are smoking-prevention programs conducted in schools, many of which have been shown to be moderately effective. To reduce the onset of cigarette use through carefully controlled intervention in the 6th to 10th grades, the programs teach youth "peer refusal" techniques and support youth in "saying no" to cigarettes. Those anti-smoking programs have recently been extended to combat drug and alcohol use with good but somewhat less impressive results.
The second type of intervention effort is more general than the highly focused prevention programs described above. Typical are school initiatives such as eliminating designated smoking areas and tightening rules regarding drug and alcohol use at school and in the home. Additional approaches are parent-support and 'tough love ' efforts.
The third type of intervention, individual efforts, demands the mobilization of caring adults, especially parents and teachers. In relating to high-risk youth, the caring adults should be clear on their common goal-the young person should grow up to be a healthy, independent adult-and they must take responsibility, even as they bond with the particular high-risk youth. Caring adults should identify drug and alcohol use and intervene so that such use, if it occurs, is detected and an appropriate response is made to discourage any future use. The role for the psychiatrist, who frequently is brought into the picture only after serious problems of school failure and rebellion against parental authority arise, is often vital.
One of the characteristics of high-risk youth is relative imperviousness to punishment, while another is a failure to recognize the future consequences of current behaviors. Those traits make discipline and punishment difficult for both adults and youth. While some might advise abandonment of either punishment or limit-setting, I have found the opposite approach to be more successful. Punishment for drug and alcohol use and other rule-breaking needs to be swift and sure, but it seldom needs to be severe or prolonged. The goal of punishment, to help the child regain control of his or her behavior, is best done by moderate, consistent, and evenhanded punishment. The rules and limits must be established and carried out in an environment that includes discussion of the reasons for punitive action; an explicitly stated commitment by the adults to help the teenager mature into independent adulthood, and a willingness on the part of the parents to submit on the part of the parents to submit their rules to outside review if the child feels they are unreasonable.
Psychiatrists sometimes become part of the family milieu when the youth at high risk is not the problem of central focus, such as occurs when other family members, including siblings or parents, are being seen in the clinical setting. An example is a parent who is in treatment for a drug or-more commonly-an alcohol problem. In that situation, the psychiatrist must act effectively to support the identification of and intervention with youth in the family who are at high risk of chemical dependence, particularly because of the high risk for drug abuse among teenagers whose parents or siblings have a chemical dependency.
When dealing with a family at high risk, or a particular teenager at high risk, I find it useful to bring the family together, explain the elements of risk for drug and alcohol problems to them, and offer to work with them to reduce that risk. I have described elsewhere the basic structure of family life: the family is a team working together to help the child grow up to be a healthy productive, and independent adult. The greatest threat to achieving that goal is drug and alcohol use, which, in the long run, threatens the child's independence, even though to some teenagers it may appear to promote it in the short run.
Teenagers can be helped to recognize their parents are allies (unless, as happens, there is evidence to the contrary) and their potential for lying is a major threat to that vital bond. A phrase I use is "We are only as sick as our secrets." In fact the most powerful antidote I can offer to high-risk youth is ruthless honesty. Teenagers need to understand they can easily determine right from wrong by asking themselves if they can tell those who love them the truth, the whole truth, and nothing but the truth about an action. If they cannot tell the whole truth, they should not do whatever it is they are considering. Lying to parents and adults has become such a common behavior in the teenage culture that it is often assumed, even by mental health professionals, to be part of the teenager's normal efforts to be independent. Lying is both dishonest and immoral. It does not work for the teenager but rather reduces his or her ability to adapt successfully and the parents and other caring adults' ability to help.
Parents are not always right when it comes to judging their teenager's behavior, but they are more often right about the teen's best interest than the teenager himself or herself, especially if the teenager is one of the high-risk youth this lesson describes. Nevertheless, parents do make mistakes. When the parents and child are in conflict over any particular rule or behavior, I suggest they submit the disagreement to someone they all agree has the child's best interest at heart, such as a grandparent, counselor, or the psychiatrist.
All children-but especially- high-risk youth-should understand the nature of the adult-child relationship. Being a child carries limits imposed by adults on choices and behaviors and acceptance by the child of adult authority. The teenage years should be considered an advantaged not a disadvantaged stage of the human life cycle. Because high-risk youth prize immediate pleasure, even at the expense of their own long-term self-interest, it is often confusing for them.
Families dealing with high-risk youth need to know whether or not their high-risk teenager is using either drugs or alcohol. I support parents' knowing the truth about their children, including taking urine tests for alcohol and/or drug use whenever a question arises about such use. Some parents, and many teenagers, see such direct parental action as an undermining of trust. My experience is exactly the opposite. Parents of high-risk children who trust them about drug and alcohol use without exercising the option of testing them for such use are likely to be unaware of serious problems that can fester and lead to truly devastating results. The psychiatrist can often help the family, including the youth, think about that issue and provide access for the family to drug testing.
The effort to help high-risk youth avoid drug and alcohol problems is most likely to be successful if it is begun before the child enters puberty and the risk of drug and alcohol abuse becomes extreme. Parents of a high-risk child are often aware of significant differences between the high-risk child and other children, even siblings. Those differences usually manifest themselves at an early age, most often in response to punishment and in a propensity to lie. It is helpful to explain high-risk characteristics to both the parents and children in order to reduce their guilt and confusion. Once they understand they need not feel guilty about them, they can begin to understand the need to work together as a team to overcome the problem created by high-risk characteristics in the same way they would approach any other handicap. On the other hand, if practical understanding is absent, and if the guilt of the parents is supported and even encouraged by the psychiatrist, appropriate prevention and treatment is frustrated.
It is common to see one high-risk youth in a family with other children who lack that characteristic. On the other hand, all of the children in a particular family can have high-risk characteristics. Families coping with high-risk youth need to understand they will generally be misunderstood by other families who have not coped with that specific problem. It is common for other families to emphasize open and honest communications and trust as the central features of their child-rearing practices and to disparage the mistrust and rigid rules they perceive as characteristic of families coping with high-risk youth.
Families with youth who lack high-risk characteristics are not wrong in their approach to parenting. Their approach works for teenagers who are honest and concerned about the future consequences of their actions, especially when they are positively involved with adults they see as helping them achieve their long-term goals. The lack of understanding shown by uninvolved people is rarely malicious, but it can add to the confusion and guilt experienced by families coping with high-risk youth. The psychiatrist and parent peer support groups, such as Al Anon, can help clarify that issue for the parents and encourage them to take the steps necessary to help their child maximize his or her chances for a good life. For high-risk youth such tough love is often a matter of life and death.
Often the key to real, lasting recovery is participation by the child and the parents in one of the many self-help groups related to Alcoholics Anonymous, such as Tough Love, Families Anonymous, Al Anon, and Parent Peer Groups. Talking with others who know firsthand the problems of the high-risk syndrome helps both youth and parents to develop and sustain a sense of purpose and hope. In my experience, Al Anon and Parent Peer Groups are particularly helpful to the parents of high-risk youth.
The characteristics defined as high risk are not unique to the United States and they are not new in the last two decades. What is new is the powerful social support from the teenager's peer group and others for such impulsive, pleasure- driven behavior and the widespread, easy availability of drugs and alcohol. Those two elements have put new fuel on old biological fires. Summary
High-risk youth possess a combination of related character traits that are similar to psychopathic characteristics which are an exaggeration of normal adolescent behavior. The five key features of the high-risk syndrome are impulsive pursuit of instant gratification, lack of concern for the feelings of others, insensitivity to punishment, easy lying, and rebellion against adults in authority. Those characteristics, which are seldom totally present or totally absent in any one teenager tend to intensify around 16 to 18 years of age and then diminish with time, unless they are perpetuated by drug and alcohol abuse. The high-risk syndrome is found in all social classes, most often in boys, and while clearly maladaptive, it does not preclude successful adjustment as an adult.
The psychiatrist can support and educate both parents and children about the risks of drug abuse and the goals of drug-abuse prevention: to help the child get through the most vulnerable period, 12 to 20 years of age, free of the use of drugs, including tobacco, alcohol, and marijuana- the gateway drugs. That goal is difficult to achieve, particularly for high-risk youth who need specific, sustained help in surviving and benefiting from the teenage years.
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