Substance abuse in adolescents.
Article Type: Report
Subject: Teenagers (Health aspects)
Teenagers (Psychological aspects)
Youth (Health aspects)
Youth (Psychological aspects)
Drugs and youth (Risk factors)
Drugs and youth (Reports)
Brain research
Authors: Carbonel, Marino
Ballard, James
Ponton, Richard
Pub Date: 12/22/2008
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2008 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2008 Source Volume: 11 Source Issue: 4
Product: Product Code: E121930 Youth
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 192800785
Full Text: Dr. Marino Carbonell: A recent dramatic finding in neurobiological research may greatly increase the understanding of young adult decision making and the ability to help this age group choose wisely regarding drug abuse. This finding suggests that the young adult brain is still developing physically, and further investigation can answer some of the cognitive issues affecting the appeal of and decision to use drugs. As professionals in the field of substance abuse, what areas should we be focusing on to be further investigated?

Dr. James Ballard: Family of origin--dysfunction breeds pain psychologically. To really treat teen addictions, you must look at the foundational roots. Inner pain from abuse--sexually or relationally, abandonment, divorce of parents, and step-parenting are a few of the areas needing to be focused on.

Dr. Richard Ponton: When the Partnership for a Drug Free America first aired the famous egg-flying, "This is your brain on drugs" spot in 1987, there was some skepticism and a few snide parodies ... however they seemed to get it right. We have learned so much in the last 20 years about brain function as a result of new technology ... we could call neuroscience the frontier within. The new information supports several general principles:

* The adolescent's brain is developing at a rate similar to that of prenatal and infancy periods.

* The impact of alcohol on the adolescent brain is greater than on the adult brain.

* The adolescent's brain is oversensitive to damage from alcohol and undersensitive to warning signs.

We have found in our program that teaching youth about the very real impact of alcohol and drugs on the brain is valuable in that it provides information toward motivations. Providing parents with information is useful in helping them understand their teens' behaviors and their own.


Dr. Marino Carbonell. Authors' Evans, 1998; Johnson, 1995) review of the literature suggest that young adults are ingrained with a relativistic (every moral choice is equally valid and thus, can moral choices really matter at all?) understanding of morality leading to drug dependency in some cases. Does lack of moral choices in teens lead them to abuse drugs?

Dr. James Ballard: Lack of moral choices in teens can lead them to abuse drugs. Teens reflect those around them. If they have been abused early on, they have the proclivity to abuse others and drugs. Drugs for many are taken not just for a chemical high but also for management of emotional, relational, and spiritual pain.

Dr. Richard Ponton: Although it may be so that many adolescents are morally relativistic, one must wonder if that is a function of development or culture. The question of moral development is both complex and rich in potential for the understanding of behavioral choices. Elliot Turiel has argued that research demonstrates that young people can and do make decisions not only on the basis of rules and punishment but also on the basis of perceived fairness and responsibility. That adolescents move in this direction of decision-making is consistent with the work of Kohlberg and James Rest. Why then, we might ask, do they make such bad choices? One part of the complex answer is suggested by brain development research. The pre-frontal cortex, the place where we do our consequential thinking, is under construction. The neural connections are formulated through a magnificent, yet not entirely predictable process of firing and wiring (to use David Walsh's term). The conflict between the emotional "I want to" and the rational "It's not good" sometimes goes to the former and stronger neural habits.

Dr. Marino Carbonell: There are no specific rules for the current generic treatment of drug addiction. More research needs to be conducted to understand the best way to match treatment to patient. What are some examples of therapies from your own experience that best match treatment to patient?

Dr. James Ballard: Teen Challenge.

Dr. Richard Ponton: An outstanding example of treatment matching is found in the work of Porchaska, DiClimente, and Norcross in their metatheoretical approach to stages of change. In working with adolescents, this approach takes on even greater importance. Identifying the client's awareness of the problem, motivation for change, resistance to change, and those resources available to the client for such change enables the counselor to work realistically toward attainable goals with the client.

Dr. Marino Carbonell: Breaking the addiction cycle depends on the drug of choice. Some addicts try to stop "cold turkey," meaning the addict stops all at once with no treatment. Another option is tapering off, meaning that the addict gradually stops taking drugs and may need some help to quit. Another technique is taking a substance to help with the addiction urge such as Antabuse (for alcohol) or nicotine gum. A 12-step program or other support group can help addicts deal with abstinence, and, finally, intervention treatments (whether inpatient, outpatient, community based, or private therapy). Can the experts on the panel expand on the effectiveness of these treatment models? Is the 12-step program still an effective model to prescribe?

Dr. James Ballard: No. I do not believe the 12-step model works! Reasons. 1) 45% of those who attend AA meetings never return after their first meeting. 2) 95% never return after the first year. 3) Their own statistics reveal only a 5% retention rate. 4) Although there are a number of spin-off groups, I do not see the effectiveness now that they evidently had years ago.

Dr. Richard Ponton. The research is clear and unequivocal in stating that addiction is a biopsychosocial disease, and many would add spiritual to that holism as well. Thus, the various attempts to break the cycle emphasize one or the other aspects of the disease. I believe, that as we have found in all psychotherapy (see Nathan & Gorman, 1998), pharmacological approaches are useful in concert with behavioral and cognitive-affective change.

Given the serious sequelae of adolescent opioid addiction, many treatment experts believe that buprenorphine should be the treatment of choice for adolescent patients with short addiction histories or those with histories of multiple relapses. Because adolescents often present with short histories of drug use, detoxification with buprenorphine, followed by drug-free or naltrexone treatment, should be attempted first before proceeding to opioid maintenance. According to the Substance Abuse and Mental Health Services Administration, Naltrexone may be a valuable therapeutic adjunct after detoxification. Naltrexone has no abuse potential and may help to prevent relapse by blocking the effects of opioids if the patient relapses to opioid use. Naltrexone has been a valuable therapeutic adjunct in some opioid-abusing populations, particularly youth and other opioid users early in the course of addiction.

In considering the use of 12-step programs for adolescents, several factors must be considered. The cookie-cutter approach that 12-step programs help everyone flies in the face of the data. While research on fellowship programs provides some challenges, because of the anonymous and natural nature of the programs (the key to their success), some research suggests that about 80% of those who visit a fellowship do not return. That, by the way, is not all that different from the research on single visits to therapists' office. A prescriptive approach to the use of AA as an adjunct to treatment suggests to professionals that we look to the personality, social situation, and etiology of the addiction in order to determine if AA or another fellowship program would promote the treatment and recovery process. I do not hold the position of "Give it a shot, it couldn't hurt." Indeed, if I place obstacles in the way of recovery or set up barriers to the process, it can hurt. In some cases, asking an adolescent to commit to something for 90 days sets him up for failure. Having kids try on AA or NA, processing the experience with them, and allowing them to explore the program as a potential resource has proven successful in the work we have been doing with kids.

Dr. Marino Carbonell: A study commissioned by the University of Texas Medical Branch found that the psychological damage from physical abuse may play a role in substance abuse. The results of this particular study strongly support a positive correlation between drug abuse and physical and sexual abuse. Does the panel support this assessment? What are some of the indicators that would lead a child from one of abuse to an abuser of drugs?

Dr. James Ballard: I support this assessment. As I mentioned in an earlier question (2), indicators would include verbal, physical, or sexual abuse in childhood, divorce of parents, single parenting, abandonment, abuse of alcohol or drugs, availability of drugs in the home environment, and peer pressure. These are a few of the indicators of why youth turn to drugs to face life.

Dr. Marino Carbonell: One of the ways to treat young adult drug abuse is to modify the cultural climate, focusing children to value and achieve independence, adventure, intimacy, consciousness, activity, and commitment to community among many other things. What can schools and families do to promote a healthy, drug-flee lifestyle? Are the programs in place such as D.A.R.E. and Informed Families making an impact?

Dr. James Ballard: With our cultural climate in a state of confusion, it is imperative that families, schools, and congregations begin to come to the forefront of modification of society. Instead of being reactive, they must become proactive. D.A.R.E. and Informed Families are making an impact, but there needs to be more such organizations, on the community, state, and national level. Looking at youth as a whole is imperative. Assisting them by seeking personal involvement in community-based programs must take center stage in coping with the plague of pain.

Dr. Richard Ponton: I would argue that there is a need to change the thinking and conversation from programs to people. The data from the Search Institute in Minnesota is rich and informative. It suggests that there are 40 developmental assets, some that are within young people and some that are provided to them from the people around them. The evidence is overwhelming to suggest that the more of those assets young people have ... the less likely they are to use alcohol or drugs or to engage in a variety of other high-risk behaviors. Beyond that, the more likely they are to thrive and demonstrate other markers of success. In prevention and treatment we are focusing on strategies that increase those assets in the young people and enhance the awareness of the role of the school and the community in providing opportunities for asset development. D.A.R.E. or any other program is not the answer. If the D.A.R.E. officer becomes a source of strength to the youth, if the D.A.R.E. program is in a school that is a safe place to be in and where the child is supported, empowered, and challenged, and if the teens leave D.A.R.E. and go home to a place where there is both love and limits, then we begin to provide a culture of resilience and thriving.

Dr. Marino Carbonell: The consequences of failing to intervene early and failing to provide age-appropriate substance abuse and mental health treatment are substantial and long term. However, there is growing evidence that successful early intervention and treatment carries a significant benefit for the individual and society. What types of early intervention can be offered? What is the cost/ benefit of early treatment?

Dr. James Ballard: There should be a removal of temptation from their home--locking up of pills, etc. Parents need to become aware of behavior change--personality factors, grade change, attention to sleep-wake cycle or mood patterns, the possibilities of a level of secretiveness or sneaking around.

The establishing of family rituals. There are three major types of rituals according to Drs. Merry Evenson and Glen Jennings at the Texas Women's University Department of Family Services: 1) Family celebrations, 2) Family traditions, and 3) Patterned family interactions.

Such rituals stabilize the family in two aspects of time: 1) In the here and now, rituals are an anchor for the family. 2) Rituals also have the power to link past, present, and future.

Rituals have five basic functions for both the family and individual: 1) Reduction of anxieties. 2) Promotion of actions. 3) Resolution of contradictions. 4) Promotion of relabeling. 5) Action as a protective device.

Dr. Richard Ponton: Although the issue of cost effectiveness is a complex one (please see the National Institute on Drug Abuse Web site for a discussion of this), a very basic metric is the cost of higher vs. lower levels of treatment. The cost of inpatient residential treatment is on average more than six times that of outpatient service (NIDA, 2003). This metric does not measure the cost of missed opportunity, potential long-term health consequences, and potential criminality associated with drug and alcohol use as it continues.

So why is it that so often we miss the opportunity for intervention? Perhaps it is because we don't quite understand what intervention is and who needs it. It has been said that a good intervention presents reality in a receivable way. In order for that to happen, someone has to say, "Here is the effect of this behavior on outcome." It requires that alcohol and drug issues become the foreground of the discussion, not the background. To mix my metaphor, the good intervention tunes the attention to alcohol and drugs like tuning in a radio station ... to the crisp and clear broadcast ... "what is not working is your use." Intervention requires schools, police, the courts, and the community to get on the same page ... because the less they are, the more there is static in the message. The parents, too, have static. They don't want to know that there is a problem ... indeed they can't know that there is a problem until they know that there is hope for a solution. The tuning process overpowers the static of denial and hopelessness with the signal of information and hope. In our community, every child who is found to be involved in underage drinking is sent by the police, the school, or the judiciary to a program we call EXPLORE. This two-session program provides information to the teens and assesses their patterns of drinking using a reliable and valid inventory. In the second session, the program provides that information to the parents along with parenting skills and resources for treatment. Of the youth who have been involved with this program, 50% have indicated a need for further treatment and 75% of them have volunteered for it.

Dr. Marino Carbonell: Deciding to send a young adult to a residential treatment facility is a family decision. Decisions are best made when problems are identified, because by the time parents consider residential treatment, they have probably tried other methods. However, teen centers have been focusing on the age rather than the addiction. What factor should teen treatment centers focus on? Should both factors matter?

Dr. James Ballard: The focus should be on addiction above all else. Centers treating addictions are now focusing more on problems rather than age. I offer the following as examples:

1. Teen Challenge. Their Web site (www. describes the Teen Challenge program and the services they offer. Their programs, outreaches, and presentations are geared toward both teens and adults. It is one of the oldest, largest, and most successful programs of its kind in the world and has a distinctive Christian philosophy that many congregations and faith-based organizations can relate to. I have referred several youth to them over the years and have been grateful for the ministry of Teen Challenge and the recovery of these youth. I would highly recommend them as a resource.

2. Saint Jude Retreat House established in 1992. It is a Social-Educational Alternative to conventional drug rehab and alcohol rehab centers along with alcohol and drug treatment programs. They have the highest independently verified success rate in America. They are truly confidential, cost effective, and the most experienced non-12-step program in America. Alcoholism and drug addiction are learned behaviors and not a disease.

3. Teen Interventions--Help for the struggling teens. 1-800-840-6537.

4. Second Nature Wilderness Program. The industry's most sophisticated wilderness therapy treatment program. They provide insight, direction, and hope to troubled teens and their families. Therapists and other staff members assist the teens to discover reasons behind their actions. Teens become students of themselves. They then can make healthy choices regarding the future. Second Nature understands that many parents are not sure where to go for help for their teen. They have an entire staff of qualified individuals who can provide solutions to questions regarding the needs of troubled teens or parents' needs. They can be contacted at 1-866-205-2500 or through their Web site at

Dr. Richard Ponton: Residential treatment provides a unique option on the continuum of care for adolescent substance abuse disorder. The American Society of Addiction Medicine has identified several criteria for admission to residential treatment including emotional and behavioral issues of moderate or high severity, resistance of moderate or high severity, significant continued use or relapse and lack of success in lower levels of treatment, and an unsupportive or inconsistent recovery environment. Successful use of inpatient treatment includes such hallmarks as a positive approach to treating the whole individual, incorporation of the family in the recovery process, the development of community resources for the young person, and the establishment of a discharge plan that includes aftercare.

Although I am not sure what you mean by the focus of treatment centers on the age rather than the addiction, I maintain that no addiction exists in a vacuum. The age, developmental stage, family, and social network all affect the addiction and, with the exception of chronological age, all are affected by the addiction.

Dr. Marino Carbonell: The low opinion of treatment values held by young adults has been shown to be a major cause of resistance to their treatment, and this resistance is being constantly reinforced when young adults are placed in same-age settings. Additionally, when assessing young adult treatment facilities, one of the first issues an individual confronts in caring for the young adult patient is the issue of confidentiality. What are some suggestions that can address and respond to this issue of confidentiality (or lack of) in teen treatment therapy?

Dr. James Ballard: There are materials available in books to assist parents and counselors regarding confidentiality. Boundaries, Boundaries With Teens, Boundaries in Marriage--all written by Cloud and Townsend--provide valuable assistance. There are treatment facilities now available that emphasize trust and confidentially. Note statements in number 8.

Dr. Richard Ponton: It seems to me that if we said that there was generally a low opinion of treatment among heart patients, kidney patients, or clients with depression, regardless of age, that would serve as a call to action to do something different. I believe the same is true for adolescent substance abuse treatment. It has not been the experience of our program that young people hold a negative view. In fact, in our Intensive Outpatient Program, one of our greatest sources of clients is referral from other teens who have been through the program. There is simple reason for this. Treat clients with dignity, respect, and kindness. When clients enter our program, we incorporate parents from the outset ... as positive resources in their teens' lives. In so doing, we make the case that participation in the program requires the weekly participation of the parents and a consent for release of information to the parents. The consent is specific and limited so that both the youth and the parents know what to expect.

Dr. Marino Carbonell: The research revealed that teens with a higher degree of personal devotion, personal conservatism, and institutional conservatism were less likely to engage in alcohol consumption and other drug use. This revelation is particularly significant because the onset of alcoholism and drug addiction usually occurs in adolescence. Discussion from the expert panel: Is a well-developed spiritual life a deterrent to addiction?

Dr. James Ballard: A well-developed spiritual life is definitely a deterrent to addiction. We have been created in the image of God--spirit, soul, and body. Our inner beings, spirit and soul, are eternal. We are housed in a temporal body. As one thinks so is he. Our thoughts, actions, and feelings impact our physiology. One who has committed his life to Christ is a child of God. As the new identity is understood, a person has God's presence living within. No longer does one have to be a victim of the past or endure pain of the present. Where there is a well-developed spiritual life in childhood with parents committed to the holistic approach to parenting, it can enable youth to see themselves as persons of worth and meaning. This will provide a powerful deterrent to addiction. For additional information, you may reach me at

Dr. Richard Ponton: Thank you for this important and thoughtful question. There is a significant body of literature discussing spirituality and religiosity. Although there is some correlation of religiosity to conservatism, they are not synonymous. We can suspect that young people in more conservative families and in more conservative communities are less likely to use substances, have more support in their no-use decisions, are less anonymous and disconnected in their community, and if they use, are more likely to start later. Each of these is protective and none of them are spiritual or religious in their essence. In regard to spirituality, researchers have looked at the protectiveness of a relational spirituality (that is, a belief in a relationship of meaning with God and/or the Universe). In an interesting study from 2007, Knight et al. found several constructs included in spirituality such as forgiveness, belief, daily positive spiritual experiences, and positive spiritual coping strategies to be associated with lower alcohol use among teens. Conversely, they found several religiosity variables such as commitment, organizational religiousness, and private religious practices to have a nonsignificant relationship to use or abstinence from alcohol. Although this topic defies simplicity as much as it defies certainty, I suspect one thing that protects teens from substance abuse is their understanding of meaningfulness in their life and their role in the community and family. At is best, that is the role of both spirituality and religion.

Dr. Marino Carbonell, EdD, LMHC, CAP, ICADC, is the founder and director of the South Miami Hospital adolescent addiction treatment program and is now in private practice. His focus is helping adolescents and families deal with substance and alcohol abuse, parent/teen conflict resolution, stress, and anxiety. He also works with the adult population in dealing with all types of addiction disorders and treatment, family systems, and relationship dynamics. He is a Life Fellow of the American Psychotherapy Association.

Dr. James Ballard, DMin, CRT, is an Academy Certified Master Chaplain-III with the American Psychotherapy Association. He received a Master of Divinity Degree and a Doctor of Ministries Degree from Southeastern Baptist Theological Seminary. A charter member of the American Association of Christian Counselors, he is also a member of the Association of Couples for Marriage Enrichment.

Dr. Richard Ponton is the Director of Human Services for the Township of Ocean in New Jersey. He is a Fellow of the American Psychotherapy Association and currently serves on the Editorial Advisory Board.
U.S. teen drug use

A study found that in 2006, on an average day,
hundreds of thousands of U.S. teens were smoking,
drinking and using illegal drugs.

Used on an average day

Cigarettes       1,245,240
Alcohol            630,539
Marijuana          586,454
Inhalants           49,263
Hallucinogens       26,645
Cocaine             13,125
Heroin               3,753

First time use

Teens who used the
following drug for the
first time on an
average day

Alcohol              7,970
Illicit drugs        4,348
Cigarettes           4,082
Marijuana            3,577
Pain relievers       2,517
Inhalants            1,603

* Non-medical use

NOTE: Adolescents
aged 12 to 17 years

[c] 2007 MCT

Source: Substance Abuse and Mental Health Services

Graphic: Melina Yingling

Note: Table made from bar graph.
Gale Copyright: Copyright 2008 Gale, Cengage Learning. All rights reserved.