10 annotated bibliographies
Substance Use and Abuse Among Children and Teenagers Michael D. Newcomb
Peter M. Bentler
ABSTRACT: During the past several years, there has been a renewed national concern about drug abuse, culminating in the current "war on drugs. "In this review, we emphasize that even though child or teenage drug use is an individual behavior, it is embedded in a sociocultural context that strongly determines its character and manifestations. Our focus is on psychoactive substances both licit (cigarettes and alcohol) and illicit (e.g., cannabis and cocaine). We feel that it is critical to draw a distinction between use and abuse of drugs and to do so from a multidimensional perspective that includes aspects of the stimulus (drug), organism Ondividual), response, and consequences. Our selective review of substance use and abuse among children and adolescents covers epidemiology (patterns and extent of drug use), etiology (what generates substance use), pre- vention (how to limit drug use), treatment (interventions with drug users), and consequences (effects and outcomes of youthful drug use).
In this abbreviated review, we selectively examine the re- cent literature and current status of substance use and abuse among children and adolescents. Our focus is on psychoactive substances both licit and illicit, including cigarettes, alcohol, cannabis, cocaine, and other drugs. We examine the use and abuse of substances by children and teenagers from five perspectives: epidemiology, etiol- ogy, prevention, treatment, and consequences (see Rogers, 1987, for additional overviews and references).
The United States is a drug culture. Drugs are used commonly and acceptably to wake up in the morning (coffee or tea), get t h roug h the stresses of the day (ciga- rettes), and relax in the evening (alcohol). The Marlboro Man and the Virginia Slims woman are widely seen mod- els, and licit drugs are pushed to remedy all of the ills one may face--stress, headaches, depression, physical ill- ness, and so on. Children face a monumental task of sort- ing out the many images and messages regarding both licit and illicit drugs. Adolescents are quite adept at spot- ting hypocrisy and may have difficulty understanding a policy of"saying no to drugs" when suggested by a society that clearly says "yes" to the smorgasbord of drugs that are legal as well as the range of illicit drugs that are widely available and used.
A few words are in order on the distinction between use and abuse of drugs. This differentiation is critical to such diverse topics as societal justification for limiting access to drugs (whether by legal or other means) or for
University of Southern California University of California, Los Angeles
considering psychological intervention. This distinction has been a difficult one to determine. Accepted definitions among professionals or citizens do not exist because abuse is clearly a multidimensional phenomenon. From our study of this literature (e.g., Long & Schcrl, 1984), negative reactions and other adverse consequences to self, others, or property form the backbone for defining abuse, al- though several distinct but related dimensions are also critical. Taken together, these dimensions present a com- prehensive appreciation of the difference between what constitutes benign use of a drug and what is clearly abuse and destructive use of a substance.
The major relevant dimensions include the classic concepts of stimulus, organism, response, and conse- quences. Stimulus involves the nature of the drug and the context of its use (Newcomb, 1988). All drug use occurs in environmental contexts, some of which are problematic, holding constant all other dimensions, while some are not so. Ingestion of drugs in inappropriate set- tings such as the workplace, classroom, driver's seat, or in isolation can be considered abuse, even though some potential consequences may not have occurred yet for an individual (e.g., a crash after drinking and driving or being fired from a job). Different substances have different physiological and psychological effects, dose-response curves, and potentials for negative consequences. For each substance, consuming large quantities or intermediate quantities over prolonged time periods is probably abuse, again because of the potential for harm.
Holding everything else constant, abuse depends on the organism. Not all individuals respond the same way to drugs; nor does the same individual respond the same way at different times in the life course. Regular use of drugs at developmentally critical life periods such as when an individual is very young or has not yet reached puberty can be considered abuse because of the potential for in- terfering with crucial growth and adjustment tasks. Ability to deal maturely with the challenge of drug use depends on personal resources, as well as physiological parameters that determine the response to drug ingestion. Unhealthy attitudes toward use, such as to flaunt independence, are signs of abuse. Inability to evaluate adequately the known potential consequences of use may indicate inadequate organismic resources to deal with use: For example, choosing to use drugs such as crack, phencyclidine (PCP), or strychnine, which are known to have a high probability of dependence, death, toxicity, or other adverse effects, is more than likely abuse.
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Stronger response signs of abuse may involve drug dependence when associated with using increased amounts of the substance to achieve the same effect, needing it to get through the day, being unable to stop using it, craving it when not available, showing withdrawal symptoms, and experiencing negative consequences (as defined in the Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised), American Psychiatric Association, 1987).
Finally, adverse or negative consequences of use on self, others, or property, such as having deleterious health sequelae, impaired relationships, getting arrested, causing an accident, blacking out, or starting fights, indicate that use has progressed to abuse, whether or not physical de- pendence is involved.
With this multidimensional perspective for distin- guishing use from abuse, some general descriptions can be applied to children and teenagers. Any regular use of a psychoactive drug by a child can be considered abuse. This is true regardless of the context, substance, quantity, maturity, reaction, or obvious consequences involved. It is difficult to imagine any type of child drug use that is not abuse, except for, in our society, the occasional,: ir- regular, and low-quantity sampling of alcohol in a positive social context. This type of guided experimentation is probably quite prevalent (e.g., taking a sip of mother's beer). For adolescents, however, the distinction becomes more complicated. Occasional use of beer, wine, or mar- ijuana at a party is not abuse. However, overindulgence of any substance to the point of beingvery high or stoned is at least acute or temporary abuse, and if it continues this is chronic abuse. Getting into trouble at school, hav- ing problems with the police, causing an accident, or starting a fight while high is consequential evidence for abuse. Getting loaded in the classroom or at work is a circumstantial event indicating abuse. Donovan and Jes- sor (1985) have combined some of these dimensions to define a problem-drinking teenager as one who engages in heavy drinking on a regular basis, resulting in negative outcomes.
Our perspective on use and abuse questions the gen- erally accepted emphasis on illicit drugs as an especially important focus for professional and citizen attention. Within the past several years, there has been renewed national interest and commitment toward dealing with drug problems. It is difficult to determine what has caused this most recent concern, but such national attention is not new. There is a cyclical process to society's willingness to face drug problems. For example, there were the co-
Responsibility for writing this article was shared equally by the authors, and the order of authorship was determined by the flip of a coin.
This research was supported by Grant DA0 ! 070 from the National Institute on Drug Abuse.
The production assistance of Julie Speckart is warmly appreciated. Correspondence concerning this article should be addressed to Mi-
chael D. Neweornb, Department of Counseling, WPA 500, University of Southern California, Los Angeles, CA 90089-0031 or Peter M, Bentler, Department of Psychology, University of California, Los Angeles, CA 90024-1563.
~ine patent medicines of the early 1900s, the brave at- tempt at prohibition, reefer madness of the 1930s, the drug cultures of the 1960s, the heroin war of the 1970s, and now the current concern about people getting high on cocaine and killing themselves with crack. It is inter- esting that aside from the lethal toxicity of certain drugs such as crack, relatively little attention has been given to the two drugs with the most proven record of abuse in terms of the population affected and the magnitude of the consequences; these are, of course, alcohol and cig- arettes. Although efforts are made, in schools, for ex- ample, to provide a balanced picture, youngsters too ollen are provided with the mixed message that marijuana and cocaine are bad, destructive, and will rot their brains while seeing media idols holding a drink in one hand and a cigarette in the other. Perhaps this is one explanation of why so many prevention efforts have failed.
Substance use and abuse during adolescence are strongly associated with other problem behaviors such as delinquency, precocious sexual behavior, deviant atti- tudes, or school dropout. Any focus on drug use or abuse to the exclusion of such correlates, whether antecedent, contemporaneous, or consequent, distorts the phenom- enon by focusing on only one aspect or component of a general pattern or syndrome.
Epidemiology Despite occasional dramatic case reports of involvement with drugs by grade school children, the prevalence and incidence of a significant amount of drug use in the first decade of life have not been reliably documented. Sys- tematic research on adolescent abuse is almost as rare, no doubt because of the relatively low prevalence of the phenomenon.
Because of availability, experimental use of tobacco products has the widest prevalence during preadolescence. A substantial portion of children at least experiment with puffing cigarettes by age nine, and in a new and disturbing trend, a small but significant portion (13% of third-grade boys in one Oklahoma survey) use smokeless tobacco. A child's first drink lags somewhat; occurring typically around age 12 for boys and a bit later for girls. Although age data are difficult to obtain, inhalants may have been used by this age, remarkable primarily as a first con- sciousness-altering substance used by children.
Only regarding early adolescence are reliable U.S. national prevalence figures available through surveys sponsored by the National Institute on Drug Abuse (NIDA). The triannual National Household Survey of Drug Abuse permits estimates to be made for 12- to 17- year-olds, and the annual Monitoring the Future survey of high school seniors provides estimates for the approx- imately 80-85% of students who are in school (such es- timates are attenuated because of the higher rates of use among dropouts). Both surveys provide data on lifetime, annual, and monthly prevalence of a wide variety of drugs, and the high school senior survey also provides data on daily use that may provide suggestions on drug abuse.
Prevalence figures from the 1985 National House-
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hold Survey (NIDA, 1987) show that smoking (45%) and drinking (56%) are the most prevalent activities in the early adolescent age group. However, nearly 30% had tried at least one illicit drug or controlled substance without medical orders during their lives. The primary drug in this category was marijuana (used by 24% of the teen- agers). In contrast, use of any one drug other than alcohol, cigarettes, or marijuana was low. For example, inhalants (9%), analgesics (6%), and stimulants (6%), were more prevalent than cocaine (5%), the current national drug of concern. Any use of heroin by this age group was too low to be presented (<. 1%).
Steady declines in most drug use have been noted from the Monitoring the Future study (Johnston, O'Mal- ley,& Bachman, 1987) since 1980. (Nonetheless, the United States continues to have the highest rates among the industrialized nations.) The one prominent exception was the troublesome increases in lifetime prevalence of cocaine use (up to 40% as reported in some young adult samples; Newcomb & Bentler, 1988) and abuse (daily use, inability to stop using). In the most recent survey, 57% of high school seniors had tried an illicit drug, and more than a third had tried an illicit drug other than marijuana. Use of marijuana, stimulants, and sedatives declined not only among high school youngsters but in related samples of college students and young adults. Equally optimistically, a decline in the growing attrac- tiveness of cocaine was observed in 1987, with only 15% of seniors ever trying this drug and only about 5.6% trying the especially dangerous crack cocaine. These trends were accompanied by increasing perceptions of risk associated with using cocaine (up from 36% to 48% in one year), as well as a significant increase in disapproval of use of every illicit drug; 97% disapproved of regular cocaine use. The results were interpreted as a decline in demand for illicit drugs, though the remaining general pattern of prevalence was quite consistent with survey results from previous years. Patterns of lifetime prevalence of illicit drug use were fairly similar in seniors studying overseas in De- partment of Defense Dependents Schools.
Nevertheless, use of licit drugs remains very high, with 92% of seniors having had some experience with alcohol, and 66% using it in the past month. Regarding abuse, 5% were daily drinkers and 37.5% reported at least one occasion of heavy drinking (five or more drinks in a row). About one fifth of seniors were daily cigarette smokers. These youngsters are clearly at serious health risk. The overseas seniors showed somewhat higher rates of daily drinking and smoking.
Prescriptions to adolescents for minor tranquilizers, barbiturates, and amphetamines declined over the past decade, reducing youngsters' ability to turn to medication for problem solution. This is a hopeful sign regarding cultural attitudes, although prescriptions for opiate-type drugs have not declined.
There are, of course, some significant sex differences in prevalence, as well as geographical differences. More girls than boys smoke and take amphetamines, and urban usage rates are typically higher than rural rates.
Because use is a necessary antecedent to abuse o f substances, national and regional surveys of drug use provide an important source of information about the seriousness of substance use in the general population. This is especially true because it is often hard to evaluate whether dramatic ease reports reflect actual wider trends and because there are many correlates of substance use that imply serious personal and social problems. However, the absence of systematic and regular information about high-risk individuals in these surveys, such as youngsters who are not in school, no doubt provides an overly op- timistic view of the substance use phenomenon.
Et io logy
At a basic level, some types of alcohol abuse appear to have a genetic component, although the magnitude and mechanism of such a factor are not dear. No evidence yet exists that can separate genetic and family environ- mental contributions to drug abuse. In general, so far only environmental and intrapsychic factors have been implicated in drug use and abuse among children and teenagers, although it seems likely that genetic factors may contribute more to drug abuse than use (which ap- pears to be initiated in social settings).
Past behavior is often the best predictor of future behavior, and in drug use this consistency extends to variants of the behavior in which similar but less serious types of drug use are good predictors of subsequent use of more serious drugs. A typical progression may be starting with coffee and tea, beer or wine, or cigarettes, moving to hard liquor and marijuana, and subsequently moving to other illicit drugs such as amphetamines, co- caine, or heroin (Kandel, Kessler, & Margnlies, 1978). Involvement at one stage does not necessarily lead to in- volvement at the next stage; rather, involvement at the next stage is unlikely without prior involvement in the previous stage. The mechanism that drives such staging, such as availability, anxiety reduction, changing norms in peer groups, or physiological processes associated with learning to appreciate the effects of a drug, are not known. There are some hints that these may not be the same at all stages, with psychopathology being implicated pri- marily at later stages (Kandel et al., 1978).
The search for correlates of substance use has been the main basis for inferring etiological variables. In spite of the obvious idea that the causes of drug abuse may be different from the causes of use (Long & Scherl, 1984), little systematic research exists that verifies such a hy- pothesis at the youngest ages, although several studies have confirmed this notion among teenagers. For instance, most use of drugs occurs as a result of social influences, whereas abuse of drugs is more strongly tied to internal, psychological processes (e.g., self-medication against emotional distress).
At younger ages, the major correlates of use are also the correlates of heavy use and, by implication, of abuse. Because of the inevitable correlation of other problem behaviors with drug use (Donovan & Jessor, 1985), the predictors of drug involvement are similar to predictors
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of general problem behavior. Because drug use is a nat- urally occurring phenomenon, a substantial effort is needed to separate out spurious associations from true causal effects. The main mechanism for achieving this has been the use of longitudinal designs with statistical controls substituted for the more desirable experimental control, using methods such as structural equation mod- eling (e.g., Bentler, 1986; Stein, Newcomb, & Bentler, 1987).
A wide range of influences on initial involvement in substance use has been identified. Nevertheless, peer in- fluences (modeling use, provision of substances, and en- couraging use) are the most consistent and strongest of all factors. In addition to prior experience with drugs and peer influences, other factors associated with initial in- volvement with drugs include social structural variables, such as socioeconomic status (heavier use among more disadvantaged groups); family role and socialization vari- ables (greater use in disturbed families, with adult drug use models, and with lack of religious commitment); ed- ucational variables (poor school performance associated with greater drug use); psychological variables, such as self-esteem (low self-esteem leading to greater drug use); attitudinal variables, such as tolerance for deviance (non- traditionalism associated with greater drug use); behav- ioral variables, such as deviant behaviors or lack of law abidance (implying greater substance use); emotional variables, such as need for excitement; and psychopatho- logical variables, such as stressful life events, depression, and anxiety (implying greater drug use).
Because the range of variables leading to initial in- volvement in drug use is so large, recent views of this phenomenon have emphasized the risk factor notion often used in epidemiology (Newcomb, Maddahian, & Bentler, 1986). Risk factors include environmental, behavioral, psychological, and social attributes. Possessing a greater aggregate number of risk factors not only is a reliable correlate of drug use but increases drug use over time, implying a true etiological role for these variables (New- :comb et al., 1986).
Recent work on etiological variables has tended to be very consistent with prior results obtained during the previous decade. At this point, effort on understanding the correlates and etiology of drug use would not seem to be an important research priority, except to distinguish the causes of very heavy use or abuse and to distinguish differential etiologies for different substances or different problem behaviors, should these exist.
Prevention The best way to deal with any problem is to prevent it from happening. The most effective manner to handle drug use among children and teenagers is to educate youngsters and prevent the use and abuse of drugs before they occur. This is a conceptually and intuitively appealing approach to primary prevention of drug use that has been appreciated and tried for many years. Unfortunately, the outcomes of such efforts have been decidedly mixed and unimpressive (Bangert-Drowns, in press).
Prevention efforts have focused on the agent (drugs themselves), environment (social milieu relative to drug use), and host or demand (user of the drugs). Although supply reduction continues to be a federal goal, because drug availability is clearly related to use, efforts to control or limit the agent whether through law, technology, or social controls have been insufficient to prevent use (Schinke & Gilchrist, 1985). Most prevention efforts are directed at a combination of environment and host fac- tors. Such approaches accept the fact that drugs are avail- able and can never be totally removed (prohibition being a good example) and that personal desire (host) and social facilitation (environment) are the most realistically ame- nable elements in the equation. In economic language, these aspects are concerned with demand reduction.
Prevention programs have typically targeted what have been called "gateway" drugs. These include ciga- rettes, alcohol, and marijuana, which, according to stage theory, are generally used before harder drugs such as LSD, heroin, or cocaine. This approach assumes that preventing or at least delaying use of these drugs will pre- clude the use of drugs higher in the sequence.
Scare tactics such as the old movie "Reefer Madness" and informational approaches have not been effective. In fact, some early approaches actually increased drug use rather than reducing or preventing it. Such discouraging and opposite results convinced the National Commission on Marihuana Abuse to recommend a ban on prevention programs in 1973. However, in the 1980s slightly more encouraging results have been noted.
There have been many studies and review articles on drug prevention and education programs, and Tobler (1986) has presented an interesting and informative meta- analysis of this literature. Such an analysis is dependent on the quality of the studies included, which vary con- siderably in this area of study. Tobler identified five types or modalities of prevention programs that either directly confronted drug problems in the curriculum or indirectly addressed drug use and were aimed at reducing the cor- relates of drug use. There are two indirect approaches: (a) affective enhancement, aimed at intrapersonal and so- cial growth, and (b) alternatives programs, focused on community and leisure activities, remedial skills such as job training, physical activities (e.g., camping), or one- on-one tutoring tailored to meet the needs and deficits of at-risk youngsters. At-risk youngsters are those who are already involved in drug use, delinquency, or other prob- lem behavior or who have a high likelihood of engaging in such behaviors. There are generally three types of direct approaches to drug use prevention: (a) the knowledge or information approach, which represents the earliest at- tempts at drug education; (b) peer programs focused on refusal skills and social life skills, encompassing the sim- plistic tactics of "Just say no" as well as more compre- hensive and realistic approaches that focus on peer in- teraction, social skills and competency, and enhancement of self-esteem; and (c) a combination of knowledge and affective approaches.
Five outcome measures were targeted to define sue-
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cess of drug prevention and education: (a) increased knowledge about drugs and their effects; (b) changes in attitudes related to drugs or other deviant behavior; (c) enhanced personal and interpersonal skills; (d) decreased negative behavior as objectively gathered from collateral contacts (e.g., parents, police, or teachers) or records (e.g., grades or attendance); and (e) decreased or noninitiated drug use. Drug use assessments are typically collected by self-reports, with physiological measures sometimes taken as well (e.g., via saliva).
In general, the knowledge, affective, and knowledge/ affective approaches had little effect on any of these out- comes (and sometimes increased drug use). These rep- resent host-only approaches (organismically focused, in psychological terminology) to the exclusion of the envi- ronment (stimulus factors), which helps explain their failure. Peer programs had the strongest effect on several outcomes for the average teenager. In other words, the enhancement of social skills and assertiveness reduced drug use or prevented the initiation of drug use for the typical teenager, including actual behavior. For instance, the peer modality can help the teenager at a party, who is wavering about whether to try the marijuana joint being passed around, to decline the offer. More explicitly, peer approaches reduce the use of drugs but have less impact on abuse of drugs. Abuse of drugs occurs for different reasons than does intermittent or occasional use of drugs. Those at risk for abusing drugs were most influenced by the alternatives programs. For those most vulnerable to abusing drugs, prevention aimed at promoting alternative activities, building confidence and social competence, and providing broadening experiences was most effective. These more successful programs combined interventions for the host and environment, which helps explain their relatively greater success compared with the host-only or agent approaches.
These results support the etiological findings that benign or nonproblem use of drugs occurs in social or peer settings (addressed in the peer program models) but that the abuse or problem use of drugs is generated by internal distress, limited life opportunities, and unhap- piness (not ameliorated by the peer programs, but ad- dressed somewhat by the alternative programs). The real question for the future must be where the finite amount of energy and money should be directed: Toward the gen- eral use of drugs or toward the destructive abuse of drugs?
A more recent meta-analysis of drug prevention programs was far more pessimistic than Tobler's results. Bangert-Drowns (1988) found that no approach to drug prevention or education had any appreciable effects and that we must reexamine our methods to reduce demand among teenagers. Such negative and discouraging con° dusions are not uncommon in this field of research, which highlights the need for greater investment and creativity in combatting the drug problems of our youth. Such ap- proaches must be built on solid empirical evidence and not simply well-intended beliefs about what "should" work.
At preadolescence, prevention of use may be appro-
priate because of the closer association between use and abuse during this developmental period. This same goal is probably not as appropriate in adolescence under cur- rent cultural conditions.
Adolescence is a period of experimentation, explo- ration, and curiosity. In this society, drug use has become one aspect of this natural process to the extent that a teenager is deviant (from a normative perspective) if he or she has not tried alcohol, cigarettes, or marijuana by the completion of high school. Although it is important to delay the onset of regular drug use as long as possible, to allow time for the development of adaptive and effective personal and interpersonal skills, it may be less important to prevent the use of drugs than the abuse, misuse, and problem use of drugs (which place a tremendous burden on the individual and society). It is in this area that pre- vention programs have been less successful and are in need of continued development. The typical teenager who experiments with beer or shares a joint at a party is un- likely to be the one who will have severe problems with drugs later in life. Labeling this person as a "druggy," sick, screwed up, or in need of treatment is liable to be more destructive than the use of the drug itself (Peele, 1986),
Prevention and intervention should focus on the misuse, abuse, problem use, and heavy use of drugs to meet internal needs, cope with distress, and avoid re- sponsibility and important life decisions and difficulties. The youngsters facing these tasks are in need of help, education, and intervention. It is misleading to bask in the success of some peer programs that have reduced the number of youngsters who experiment with drugs (but would probably never have become regular users, let alone abusers) and ignore the tougher problems of those young- stets who are at high risk for drug abuse as well as other serious difficulties.
Treatment When prevention fails, then intervention and treatment are necessary. Both inpatient and outpatient hospitals and clinics have sprung up around the country in recent years to treat the drug-abusing adolescent. For the teenager acutely affected by drug addiction, crisis intervention and detoxification may be necessary and indeed life saving. For those who are truly abusing drugs or are chronically affected, effective counseling and therapy may be essential to straighten out their lives. For those who are in fact physically dependent, such as those with heavy smoking or heroin habits, treatment beyond detoxification and counseling that recognizes the physiological basis of the habit may be needed.
Unfortunately, there is growing concern that for var- ious reasons, not the least of which is the profit motive, treatment programs are purposefully blurring the dis- tinction between use and abuse (any use equals abuse) and preying on the national drug hysteria to scare parents into putting their teenager in treatment with as little provocation as having a beer or smoking a joint. For the teenager whose drug use is only a function of experimen-
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tation and socializing, the treatment may very well be worse than the disease (Peele, 1986). If using marijuana is the criterion for needing treatment, then well over half of this nation's youth should be in therapy for drug use. Aside from the adverse effects on the family relationships and long-term consequences of mislabeling the teenager, placing normal youngsters in drug treatment will place them square in the middle of a group of drug-abusing youths. As a result, if they did not enter treatment as abusers, they well may exit it as abusers because of the alienation and forced disengagement from their family and the socializing effects of truly drug-abusing teenagers.
Although there are many programs and facilities for treating adolescent drug abuse, resulting in a burgeoning industry, this topic is the least researched of any discussed in this article. We found only a handful of articles dealing with any aspect of drug treatment for teenagers. This is an area sorely in need of attention and accountability.
There is no question that a small minority of teen- agers have significant problems with drugs and are in great need of treatment. It is equally important that such treatment be comprehensive and effective. Despite the fact that a great deal is known about treating adult drug abusers, this knowledge is only generally related to treating adolescents, who are confronted with qualitatively differ- ent developmental tasks and life crises. Very little is known about how to determine the most effective approaches to treating teenage drug abusers, the appropriate modalities, and the success of these treatments. In general, those pro- grams that involve the family in treatment and are tailored to appreciate and incorporate the unique aspects of the adolescent life period are more successful. Even so, relapse rates are variable and often alarmingly high (typically in the range of 35% to 70%). Little evidence is available to argue whether inpatient or outpatient treatment is most useful, although lengthy and expensive residential treat- ment for adult alcohol abuse is apparently no more suc- cessful than shorter, less costly outpatient programs (Miller & Hester, 1986). It is not clear, however, whether such conclusions can be drawn about treatment of ado- lescent alcohol and drug abusers, and there are some in- dications that longer treatments may be more beneficial (Friedman, Glickman, & Morrissey, 1986).
Despite the general paucity of research on drug treatment for teenagers, several initial attempts have been made, and the following summarizes the loci of such ef- forts. Pretreatment individual characteristics of the teen- ager have been used to predict a range of treatment out- comes, and a variety of posttreatment situational char- acteristics have been explored to explain relapse. Individual characteristics have included age, race, edu- cation level, sex, prior admission, health insurance, em- ployment status, arrest history, primary drug of abuse, academic status, and family cohesion. Treatment outcome has long been considered multidimensional (in the adult treatment literature), encompassing abstinence from drug use in addition to other components of psychosocial functioning. Some of these other criteria relevant to teen- agers have included school functioning (e.g., performance
and attitude), social functioning, social integration and support, retention in treatment, time spent in treatment, and change in type or frequency of drug use. Various types of social, environmental, or situational factors have been studied to account for relapse following treatment (e.g., socialization with pretreatment friends).
In an ambitious effort to determine the teenage client characteristics of successful treatment, Friedman et al. (1986) analyzed data collected on more than 5,000 ad- olescents treated for drug problems in outpatient clinics. They found that reduction in posttreatment drug use was significantly related to undergoing longer treatment, being White, having fewer prior admissions, and having a pri- mary drug problem other than marijuana. Other research they cited found that successful treatment outcome was associated with being enrolled in school, abusing nonopi- ares, being White, being older at age of first abuse, not being a multiple drug abuser, spending more time in treatment, and having fewer pretreatment arrests.
These client characteristics reflect only one com- ponent of successful treatment. Other factors that must be studied carefully include treatment variables (rationale, techniques, modaiities, and process) and nontreatment influences (e.g., client maturation and family support). Much work must be done to verify the effectiveness and accountability of adolescent drug treatment and to justify the proliferation of drug treatment programs for adoles- cents.
A final ironic note is that although most of the treat- ment programs focus on the reduction or elimination of drug use, little consideration is given to abuse of cigarettes, which is apparently rampant in many treatment facilities by both patients and counselors. This is a nontrivial problem, given that the consequences of teenage cigarette abuse are often more negative and adverse than use of other "real" drugs, as discussed below. Thus, even though a great deal of prevention effort is devoted to cigarette use, treatment of cigarette abuse is largely ignored, and it is rarely even conceptualized as a problem. Yet, this is the drug on which adolescents are first liable to be truly dependent, because of the addiction potential of nicotine.
Consequences Not all drug use is bad and will fry one's brain (as the commercials imply). Such claims, as reflected in the na- tional hysteria and depicted in media advertisements for treatment programs, repeat the failed scare tactics of the past. All drug abuse is destructive and can have devas- tating consequences for individuals, their families, and society. The difference or distinction lies in the use versus abuse of drugs.
There is little research on the consequences of teen- age drug use. The short-term consequences of abuse are obvious: car accidents, fights, and missing school, to name a few. Long-term consequences require lengthy longitu- dinal studies that follow a group of teenagers from ado- lescence to adulthood, and results of these studies are only now beginning to reveal meaningful results.
Infrequent, intermittent, or occasional use of drugs
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by a basically healthy teenager probably has few short- term and no long-term negative or adverse consequences. Long-term consequences of abuse, heavy use, or misuse of drugs as a teenager can potentially affect many areas of life as an adult.
There has been a tendency to focus on the short- term or acute negative consequences of drug abuse, while ignoring the longer term consequences. Although the short-term consequences of abuse are many and can be quite tragic (e.g., a fatal accident if driving while drunk), so too may be the long-term consequences. One reason that cigarette abuse among teenagers is often not consid- ered a focus of t reatment is that there are rarely if ever short-term problems with such behavior, despite the fact that some evidence indicates that cigarettes may be the most deadly drug from a long-term perspective. We found that in the quantities typically used by normal adolescents, cigarettes had more negative health effects and increased health service utilization than use of alcohol, cannabis, or hard drugs over a four-year period (Newcomb & Ben- tier, 1987).
In a series of interrelated analyses, we examined the impact of teenage drug use on seven areas of life when these teenagers were young adults (Newcomb & Bentler, 1988). These areas included family formation and sta- bility, criminality and deviance, sexual involvement, ed- ucational pursuits, livelihood pursuits, mental health, and social integration. High levels of teenage drug use reflected a tendency toward precocious development, characterized by early involvement in marriage, family, and the work force and forsaking of educational pursuits. Polydrug use as a teenager interfered with the developmental tasks of adolescence, which led to poor or unsuccessful role ac- quisition as young adults (e.g., failed marriages and job instability). Interestingly, there were some differential ef- fects for specific types of drugs. Heavy use of hard drugs increased loneliness, decreased social support, increased psychoticism, and increased suicide ideation. On the other hand, use of alcohol (to the exclusion o f other drugs) increased social integration (i.e., reduced loneliness and increased social support) and enhanced positive self-feel- ings (increased positive affect and reduced self-deroga- tion).
Most children and teenagers will become drug users in their lives, whether limited to alcohol, caffeine, and cigarettes or extended to marijuana, cocaine, hard drugs, and prescription medications. The age at which initiation and, in particular, regular use occur is quite crucial. Childhood and adolescence are critical periods for the development of both personal and interpersonal compe- tence, coping skills, and responsible decision making. Drug use is a manner of coping that can interfere with or preclude the necessary development of these other critical skills if it is engaged in regularly at a young age. For instance, i f a young teenager learns to use alcohol as a way to reduce distress, he or she may never learn other coping skills to ameliorate distress. Thus, teenage drug use may truncate, interfere with, or circumvent essential maturational processes and development that typically
occur during adolescence. As one result, teenage drug users enter adult roles of marriage and work prematurely and without adequate socioemotional growth and often experience greater failure in these adult roles. Following the area of treatment, consequences of teenage drug use are the second least understood and researched area of child and teenage substance use. They deserve greater attention.
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248 February 1989 • American Psychologist