Drug Abuse by Adolescents: General Considerations

Abstract

After completing this article, readers should be able to: Adolescence is a time of physical, emotional, and psychological maturation as well as a period of searching for independence and experimentation. One area of experimentation associated with adolescence is substance use. (1) Although many adolescents experiment with drugs and alcohol from time to time without enduring problems, those who develop the disorders of substance abuse and dependence make substance use a major public health concern.The Monitoring the Future Study (MTFS) is a nationwide survey measuring smoking, drinking, and illicit drug use among nearly 50,000 8th, 10th, and 12th graders in more than 400 secondary schools in the United States each year. (2)(3) According to the 2006 overview of findings from the MTFS, approximately one fifth (21%) of today's 8th graders, more than one third (36%) of 10th graders, and nearly half (48%) of all 12th graders reported using an illicit drug at least once during their lifetimes. Despite a minimum legal age requirement to purchase alcohol, 6% of 8th graders, 19% of the 10th graders, and 30% of the 12th graders self-reported drunkenness during the month prior to being interviewed. (2)(3)Among the problems experienced by adolescents who use alcohol and drugs are impaired peer relations, depression, anxiety, low self-esteem, acquisition of sexually transmitted infections, teenage pregnancy, date rape, and overall involvement in high-risk sexual behaviors. (4)(5) Motor vehicle crashes, suicide, and homicide also have been linked closely to adolescent substance use. In the United States, approximately 75% of all deaths among 10- to 24-year-olds result from only four causes: motor vehicle crashes, suicide, homicide, and other unintentional injuries, all of which are preventable and can be linked to substance use. (6)Unfortunately, the adolescent's misconception that prescription medications are safe because they are prescribed by a physician has contributed tragically to a recent steady increase in misuse of prescription medications such as narcotics, stimulants (methylphenidate, dextroamphetamine), tranquilizers, and sedatives. (7) The annual prevalence for oxycodone use has reached its highest rate so far in younger users, with an annual prevalence of 2.6% in 8th graders, 3.8% in 10th graders, and 4.4% in high school seniors. Over-the-counter cough and cold medications containing dextromethorphan account for yet another category of recent increase, with teens not fully appreciating the risk because these medicines are so easily accessible. (3)(7) The percent of students reporting use within the past year “with the intent to get high” was estimated to be 4%, 5%, and 7% in 8th, 10th, and 12th graders, respectively. (3)Alcohol is the most commonly abused licit substance by adolescents today, despite being illegal for use in the adolescent age group. (3)(6) Approximately 30% of 12th graders, 19% of 10th graders, and 6% of 8th graders reported being intoxicated or “experiencing drunkenness” during the past 30 days. Marijuana, on the other hand, continues to be the most common illicit drug of abuse, with an annual prevalence of 12% in 8th graders, 25% in 10th graders, and 32% in high school seniors. (1)Substance use occurs on a continuum from the “developmental variation” of experimentation through “substance use problems” to the disorders of abuse and dependence. (8) Figure 1illustrates a developmental model of substance use progression.“Abstinence” is defined as the stage when adolescents have not yet begun to use any psychoactive substances. An initial trial of tobacco, alcohol, or other drugs defines “experimental use,” characterized by occasional use of alcohol or marijuana, usually with peers. At this stage, the teenager may experience good feelings without serious adverse consequences. However, experimentation still can be hazardous. Teenagers have insufficient experience to know safe “doses” of alcohol, and they may consume toxic quantities rapidly without realizing the potential danger. They may put themselves and others at risk by participating in hazardous activities such as operating a motor vehicle. “Nonproblematic use” is characterized by the intermittent, continuing use of alcohol or drugs in the absence of negative consequences. In addition to alcohol, most nonproblematic users tend to use marijuana and, occasionally, prescription drugs. Because of the rapidly addictive nature of some prescription drugs (eg, opioids), however, teens using them may progress rapidly to dependence.“Problematic use” is defined by the occurrence of adverse consequences as a result of use, although the individual may not see any causal link. Substance-related problems include school failure, suspensions, relationship problems with parents or peers, motor vehicle crashes, injuries, emergency department visits, physical or sexual assaults, and legal problems. These behaviors may be accompanied by significant changes in dress, behavior, and peer group. At this stage, some individuals still can reduce or stop their use with limited intervention.“Substance abuse” is a maladaptive pattern of substance use that impairs social or school functioning, causes recurrent physical risk or legal problems, and involves continued use despite harm occurring over a 12-month period, with no diagnosis of dependence. (9) “Substance Dependence” is a disorder characterized by a maladaptive pattern of compulsive use, negative consequences, loss of control over use, preoccupation with use, and tolerance or withdrawal symptoms. (9) Tolerance and withdrawal symptoms can be physiologic, psychological, or both. Dependence is synonymous with “addiction,” which is manifested by continual use of substances when available, solitary use, disrupted family relationships, and loss of outside supports. Referral to an intensive treatment program usually is required at this stage.Numerous studies conducted over the past 3 decades have contributed to an understanding of the etiology of drug use, highlighting both the biopsychosocial risks and protective factors involved. (10) A dynamic interplay between individual, peer, family, and community risk factors is involved. Risk factors are those that precede drug use and increase the probability of later drug use and abuse; protective factors are those that either mitigate the effect of these risk factors or enhance the effect of other protective factors, leading to less drug use. (11)(12)From a developmental perspective, a positive mutual attachment in the parent-child relationship is essential to preventing drug use. Children who are capable of identifying with healthy parental attitudes and behaviors are more likely to internalize these characteristics and express them in their own lives. As a result, such adolescents are less likely to drift toward affiliations with peers who use drugs and are more likely to select a pathway of abstinence for themselves. Conversely, conflicted parent-child relationships (low perceived parental support, poor communication), parental ineffectiveness (insufficient parental monitoring, inconsistent discipline, child abuse/neglect), and parental alcohol or drug use all have been found to be robust correlates and predictors of adolescent substance use. (11)The presence of concomitant childhood psychopathology is another risk factor for the development of substance use disorders during adolescence or later in life. Some of the most frequently identified psychiatric disorders linked to substance use include conduct disorder, attention-deficit/hyperactivity disorder (ADHD), mood disorders, anxiety disorders, and learning disorders. (13) A more rapid progression through the stages of use is common among those who experience early-onset substance use and heightened exposure to peer groups and environments where drugs and alcohol are readily available. (14)Long-term outcomes can vary over time. Although adolescents who meet criteria for a diagnosis of abuse may decrease or discontinue use later in life, those in whom dependence is diagnosed are likely to be the individuals who have higher risk factors and fewer protective factors and are more prone to extending substance use into their adult years. (15)(16) Early onset of use also has been shown to correlate significantly with the risk of developing alcohol dependence later in life. Those who begin drinking alcohol younger than 13 years of age are five times more likely to have a lifetime diagnosis of alcohol dependence compared with those who delay drinking to age 21 years or older. (17)Most of the literature about the influence of biologic factors on addiction has focused on the familial transmission of possible genetic markers for alcoholism. As a result, the “disease model” of alcoholism has become central to expanding understanding of the biologic underpinnings of addiction as an illness. Genetic predisposition plays an instrumental role in determining a person's risk for developing alcohol dependence, more so if the family history is positive in first- and second-degree relatives. In fact, children of alcohol-dependent parents are four to six times more prone to developing alcohol dependence compared with others in the general population who have no positive family histories. (18)Although earlier twin studies had proposed that the heritability of alcoholism was approximately 50% in men, (18) a recent study of Australian twins suggested that approximately 66% of the risk is mediated genetically in both men and women, with the remainder being determined by environmental factors. (19) Currently, the strongest ties linking genes to alcoholism lie in the finding of specific polymorphisms of the alcohol dehydrogenase genes (ADH2 and ADH3), which encode for one of the key enzymes responsible for the breakdown of alcohol. When these alleles are expressed, they encode forms of alcohol dehydrogenase that metabolize alcohol to acetaldehyde quickly, leading to accumulation and toxicity. Symptoms of toxicity often include flushing, nausea and vomiting, sweating, head throbbing, hypotension, or palpitations, although cardiovascular collapse, convulsions, and death may occur in severe cases. A partial protective effect against the development of alcoholism can be seen in Asian populations in whom these alleles are common. (20)(21) Unfortunately, little information supports or refutes the possibility of biologic transmission for other psychoactive drugs.The primary factors that appear to contribute to a teenager's choice to select one drug over another are its perceived availability, the perceived degree of social approval associated with its use, and how risky the drug is perceived to be. The riskier and less accepted a drug is believed to be, the less likely it will be abused by adolescents; conversely, if a substance is readily available and is considered socially acceptable, an increased trend in use can be expected. (3)(22) For example, Ecstasy use increased by 71% between 1999 and 2001 such that by the end of 2001, more than 1 in 10 teenagers reported using Ecstasy regularly. However, as the dangers associated with Ecstasy became more apparent, its popularity and social acceptance declined to just 4% by the end of 2005. (2) Clinicians must not disregard, however, the concept of “generational forgetting,” whereby knowledge of a drug's adverse consequences fades throughout the years, allowing that drug to experience a comeback in subsequent generations long after falling from popularity. Phencyclidine (PCP), lysergic acid diethylamide (LSD), methamphetamine, and heroin are a few examples of drugs that have resurfaced from the 1960s, with a strong resurgence in heroin use due to its increased purity and use through noninjectable routes (snorting).Substance abuse should be screened for as part of routine adolescent medical care. (23)(24) Pediatricians also should consider substance use when adolescents present with behavioral problems, school failure, or emotional distress. The most effective method of screening is a confidential history, taken without parents present in the room. Teenagers reliably report use of alcohol and drugs if they are assured of confidentiality. (25)(26)(27) Information they provide should be kept confidential unless their safety or someone else's safety is at risk. A common approach for obtaining a structured, developmentally appropriate psychosocial history is by performing a HEADSS assessment, which facilitates communication about an adolescent's Home life, Education/Employment, Activities, Drug use, Sexuality, and risk for Suicide/depression. (28) The interview should begin with general questions about health and progress to psychosocial functioning, including how things are at home and at school, recreational activities, psychological and emotional well-being, tobacco use, alcohol and drug use, and sexual behavior.A screening can begin with three usage questions. “During the past year (or since your last clinic visit), have you consumed any alcohol? Have you smoked marijuana? Have you used any other drug to get high? By ‘other drug,’ I mean street drugs such as Ecstasy or heroin, prescription drugs such as OxyContin or Klonopin that were not prescribed by your doctor or taken the way he or she said, over-the-counter drugs such as dextromethorphan, or inhalants such as glue or nitrous oxide from spray cans.” If the answer to all three questions is “no,” only the CAR question from the CRAFFT screen (Fig. 2) need be asked; if the answer to any of the three questions is “yes,” the entire CRAFFT screen should be administered. The CRAFFT screen consists of six orally administered yes/no questions that are easy to score (each “yes” answer=1). Key words in the test's six items form its mnemonic (CRAFFT).A CRAFFT total score of two or higher has a sensitivity of 80% and a specificity of 86% for identifying substance abuse or dependence. (29) However, the CRAFFT is only a screen, and a positive CRAFFT result should be followed by additional assessment. The assessment interview with the adolescent should include a thorough alcohol and drug use history, including age of first use, current pattern of use (quantity and frequency), impact on physical and emotional health as well as school and family, and negative consequences from use (eg, school problems, accidents, injuries, altercations, legal problems). The assessment also should include a screening for concomitant mental disorders, parent/sibling alcohol and drug use, and other risk behaviors. (24) A parental interview may be included as part of a substance use assessment, although parents typically underestimate their teenage children's severity of use. (30)A complete physical examination should be performed. When performing the eye examination, pupil size should be noted. The nasal mucosa should be examined for inflammation or erosion characteristic of drug insufflation (“snorting”). The liver should be palpated for tenderness or enlargement. The skin examination may reveal needle marks, although this finding is uncommon among adolescents presenting for regular medical care. Abnormal breath sounds, such as wheezing, may result from smoking tobacco, marijuana, cocaine, or heroin. Urine and serum toxicologic examinations are of limited usefulness for screening and generally are less sensitive than a good history. Except in emergencies, laboratory testing should not be performed without the knowledge and consent of the competent adolescent. (31)Pediatricians should avoid performing drug screens at the request of parents because the clinical information yielded by screens is very limited and performing such testing risks damaging the doctor-patient relationship when adolescents are pressured into providing specimens. Laboratory tests for drugs may be an important adjunct to outpatient substance abuse treatment when the results are available only to the patient and treatment team. Results always must be interpreted cautiously, and pediatricians should be familiar with the sensitivity and specificity (threshold values) for specific drugs and the different methods of testing. Urine specimens must be collected by using direct observation or according to the Mandatory Guidelines for Federal Drug Testing Programs (information available online at http://www.drugfreeworkplace.com).Urine specific gravity and the creatinine concentration always must be obtained because urine concentration affects the validity of the drug test directly. All positive screen results must be confirmed by gas chromatography and mass spectrometry. In general, serum half-lives of drugs of abuse are brief, and urine testing only reflects drug use within the last 48 hours. A notable exception is marijuana, whose active ingredient, D9-tetrahydrocannabinol (THC), and its carboxylic acid metabolite may be detected in the urine for several weeks after discontinuation of daily use. (32) Therefore, when drug testing for THC is being performed as part of a treatment program, serial urine specimens must be obtained for quantitative THC and creatinine (as a measure of urine concentration/dilution) measurements. Abstinence is supported by a finding of serial decreases in the THC:creatinine ratio.In the acute setting, adolescent patients may present with symptoms of acute or pathologic intoxication. Table 1 provides a comprehensive overview of the signs and symptoms of intoxication and withdrawal as well as treatments for common drugs of abuse. (The table can be accessed at pedsinreview.aappublications.org/cgi/data/30/3/83/DC1/2.)Following the assessment, the clinician must determine the severity of the problem and the need for treatment. Individuals who are experimental users or nonproblematic users do not necessarily need to be referred to mental health specialists. They may respond favorably to brief office interventions. On the other hand, teenagers who seem likely to have a diagnosis of dependence should be referred to specialized treatment as soon as possible. Clinicians also should refer those who have signs or symptoms of a concomitant mental disorder, such as major depression, bipolar disorder, bulimia, or ADHD. In all cases, the most important aspect of the assessment is the safety of the patient. If the patient is in any jeopardy, immediate admission to a hospital should be arranged.Psychiatric comorbidity in adolescents who misuse psychoactive substances often is the rule rather than the exception, with comorbidities including unipolar or bipolar depression, anxiety, conduct disorder, oppositional-defiant disorder, and ADHD (Table 2). (33)(34)(35)(36) Evidence suggests that adolescents who have substance use disorders also are more prone to report a history of trauma, as evidenced by physical or sexual abuse, than are adolescents who have no substance use disorder. (46) In addition, psychiatric disorders in adolescents often predate the substance use disorder, and once the substance use disorder develops, the psychiatric disorder may be exacerbated. (33)Use of substances of abuse can induce, mimic, or exacerbate an underlying mental illness. For example, cocaine and alcohol use both can cause and be a consequence of depression and can result in (or exacerbate) anxiety or psychosis. Substance use is linked directly to a higher frequency of inpatient hospitalization among those who have concurrent mental illness. (47)(48) Adolescents who have concomitant disorders are more likely to be less compliant with medications, more likely to drop out of treatment, and at higher risk of relapse. (48) Although comorbidity complicates the treatment of both disorders and is associated with a poorer prognosis overall, simultaneous treatment of the psychiatric disorder often helps to alleviate the substance use disorder and vice versa. (48)(49)Diagnostically and therapeutically, it is important to clarify whether an adolescent is struggling with a concomitant mental illness (eg, major depressive disorder or psychotic disorder) or if he or she is presenting with a substance-induced psychiatric disorder (eg, cocaine-induced psychotic disorder or alcohol-induced anxiety disorder). Inquiring in detail about the presence or absence of psychiatric symptoms during “windows” of abstinence from drugs or alcohol can help distinguish between the two types of disorders. Regardless, if in doubt, it always is best to treat what appears to be the primary psychiatric disorder. (50)Adolescent substance use differs from that of adult abuse in that progression from casual use to dependence occurs more quickly, teenagers are more likely to use multiple substances, and adolescents often are at higher risk of presenting with psychiatric comorbidities. Because no single approach is suitable for all individuals, treatment always should be tailored to each adolescent's particular needs. A thorough assessment that evaluates his or her problems multidimensionally (biopsychosocially) is critical to matching youngsters to programs that are adolescent-specific and formulating treatments that are age-appropriate. (2) Physicians should inquire about the patient's readiness for change, relapse potential, recovery environment, withdrawal risk, medical complications, and psychiatric or behavioral comorbidities prior to determining the most optimal, least restrictive treatment setting. The American Academy of Child and Adolescent Psychiatry has developed a list of principles for adolescent treatment (Table 3). (50)Drug addiction is a complex illness that can affect every aspect of an adolescent's functioning in the family, at school, and in the community. Because of addiction's pervasive consequences, treatment typically involves several components, including rehabilitation, counseling, behavioral therapy, psychopharmacology, case management, family therapy, and other types of services. Options range and vary from outpatient office-based management to residential inpatient treatment or hospital care, with or without detoxification. (50)(51).For patients deemed to be medically and behaviorally stable, outpatient treatment is the mainstay of substance abuse treatment and consists of individual therapy, group therapy, family therapy, or a combination of these. Day treatment programs such as intensive outpatient programs or partial hospitalization also may be implemented when an adolescent is making the transition from a more intensive level of care or needs greater supervision than can be provided by outpatient visits. Treatment can be delivered by a variety of practitioners, including certified drug abuse counselors, physicians, psychologists, nurses, and social workers. Although specific treatments often are associated with particular settings, a variety of therapeutic interventions or services can be included in any setting. (50)(51)CBT is a structured, goal-oriented therapeutic approach designed to teach patients specific skills for maintaining abstinence by identifying and modifying thoughts and feelings that precede drug use. Through repeated recognition of high-risk situations, patients gradually are able to engage in healthy decision-making that results in substituting risky behaviors with behaviors other than drug use or avoiding high-risk situations altogether. Although the particular therapeutic techniques vary, they commonly include keeping a diary of significant events and associated feelings, thoughts, and behaviors; questioning and testing assumptions or habits of thoughts that might be unhelpful and unrealistic; gradually facing activities that might have been avoided; and trying out new ways of behaving and reacting. Relaxation and distraction techniques often are included. CBT sometimes is used with groups of people as well as individuals, and the techniques commonly are adapted for self-help manuals. CBT may be used alone or in combination with motivational enhancement therapy. (52)(53)MET is a patient-centered counseling approach for initiating behavior change that aims to help adolescents resolve ambivalence about engaging in treatment and stopping drug use. MET employs strategies that evoke rapid and internally motivated change by eliciting self-motivational statements. Motivational interviewing principles are employed to strengthen motivation and structure a plan for change. The core constructs around which MET is organized are the “stages of change” (2) (Table 4), which represent categories along a continuum of motivational readiness to change a problem behavior. MET moves away from the belief that one is either “ready or not ready to change” and invites patients to accept a process in which motivation for change is more dynamic and fluctuates. Therapists work closely with patients on establishing decisional balances (the pros and cons of change), strengthening self-efficacy (confidence in the ability to change across problem situations), identifying situational temptations to engage in the problem behavior, and modifying behaviors that are specific to the problem area. Coping strategies for managing high-risk situations are reviewed; in subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. (55)Group therapy offers adolescents a safe environment where concerns about peer pressure, relationships, prevention of relapses, and other treatment issues can be addressed. The dynamics of group therapy set the stage for interpersonal and intrapersonal growth and differ from the dynamics played out in one-to-one interactions with an individual therapist. Teens also may find safety in numbers and become more involved with the encouragement and example of their peers. Gathering with other adolescents who share similar struggles not only provides some reassurance to the teen that he or she is “not the only one with a problem,” but also coincides with the developmentally normal preference of adolescents to be together. In addition, in the context of limited resources, group therapy is cost-effective, as long as potential group members are screened carefully to guarantee appropriateness for each of its members. (50)Another form of peer-based support may be found in 12-step fellowships, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Alateen, which often form part of a substance abuse treatment program. (51) Many adolescents begin to attend AA while they are hospitalized and often are encouraged to continue their attendance on discharge. Although not every patient affiliates with AA, it is important to make efforts to understand which patients are more likely to attend and benefit from attendance. The body of research into the characteristics and factors that predict success from self-help group attendance is limited, but evidence to suggest that AA/NA programs lead to higher levels of commitment to abstinence is growing. (56) Hohman and LeCroy (57) found 12-step affiliation to be associated with having prior alcohol or drug treatment, having friends who did not use drugs, having less parental involvement in treatment, and possessing more feelings of hopelessness (depression). Ideally, adolescents should attend young people's meetings and, as is generally recommended for people early in recovery, obtain a sponsor who is aware of his or her individual developmental level when progressing through the 12 steps. (15)Multiple forms of family therapy have been studied in randomized clinical trials, including functional family therapy, (58) brief strategic family therapy, (59) family systems therapy, (60) multidimensional family therapy (MDFT), (61)(62)(63) and multisystemic therapy (MST). (64) Two of the modalities implemented most commonly are MDFT and MST. MDFT was developed to treat adolescents who have substance abuse and behavioral problems. This manual-based therapy is characterized by individual and family sessions occurring up to four times per week, coupled with interim phone contact and intensive advocacy with the adolescent's school and the court system, when pertinent. (61)(62)(63) MST is an intensive 4-month program developed to address the needs of adolescents at high risk of incarceration or foster care. Therapists work closely with parents to identify the goals for treatment, ascertain the causes of the substance disorder, and implement solutions. MST includes comprehensive psychiatric and substance abuse services, with sessions held in the family's home. (64)A successful juvenile drug court uses the case management system, which includes positive reinforcement for compliance as well as clearly outlined consequences that are swiftly enforced for violation of court-ordered program guidelines. Limited studies indicate that juvenile drug court involvement reduces recidivism and substance use, arrests, and criminal behavior while simultaneously improving school and vocational outcomes. (65)Contingency management (CM) treatments are based on a simple behavioral principle that if a good behavior is rewarded, it is more likely to be repeated in the future. (66) The premise behind CM is to use these and other reinforcement procedures systematically to modify behaviors of substance-abusing adolescents in a positive and supportive manner. Patients are called at random to provide urine specimens at least once a week, and rewards are provided for each specimen that tests negative for drugs. These rewards often consist of vouchers that can be exchanged for gift certificates, clothing, music, sports equipment, theater tickets, or other items of interest to adolescents. (52) Although several studies have demonstrated that CM is efficacious in retaining patients in treatment, reducing substance use, increasing group attendance, and improving adherence to medications, additional research with adolescent populations is needed. (52)(67)Developing medication treatments for substance use disorders continues as an area of research. Unfortunately, opioids and alcohol are the only substances for which corresponding pharmacotherapies exist for treatment in adults. To date, the United States Food and Drug Administration (FDA) has not yet granted approval for treatment in adolescents. (68). Following the introduction of methadone as agonist replacement therapy in the mid-1960s, the treatment of opioid dependence in adults has relied primarily on the establishment of methadone maintenance programs, strictly monitored by federal guidelines. (69)(70) However, in the past decade, newer medications (levomethadyl acetate [LAAM] and buprenorphine) have been found to be similarly effective. (71) Concern regarding cardiotoxicity with levomethadyl acetate has led to cessation of its use, (72) thus opening the door for buprenorphine to gain popularity as an office-based alternative for opioid maintenance. Buprenorphine is a partial opioid agonist and, therefore, may have some advantages over methadone, including fewer withdrawal symptoms and a lower risk of overdose. (73) In addition, its availability as a buprenorphine-naloxone preparation lessens the risk for diversion or abuse and marks a milestone as a medication with the potential to increase the safety, availability, and acceptance of opioid abuse treatment in the United States. (74)(75)(76) (Additional information can be obtained at http://www.samhsa.gov.) Finally, although disulfiram, naltrexone (oral and intramuscular), and acamprosate have received FDA approval for the treatment of alcohol dependence in adults, (77) they are not approved for use in adolescents.Although most adolescents typically do not experience physical withdrawal symptoms from the most commonly used substances (eg, cannabis), those who are dependent on alcohol, other sedative-hypnotics (eg, benzodiazepines), or opioids often experience withdrawal symptoms that require monitored medical management in an inpatient facility. (50) Detoxification in a hospital should be considered for all patients who meet criteria for alcohol, opioid, or sedative-hypnotic dependence and who display symptoms of physical withdrawal from these substances (Table 1).Psychiatric hospitalization may be warranted for adolescents struggling with concomitant mental illness that either has preceded substance use, occurred simultaneously, or been exacerbated by persistent use of drugs and alcohol. In a structured 24-hour psychiatric treatment facility, adolescents are offered services ranging from assessment and consultation to psychopharmacology, family therapy, and recommendations and referrals for aftercare. Once medically stable, an adolescent may be a candidate for step-down to acute residential treatment (ART) as an alternative to prolonging inpatient hospitalization. Based on a multimodal approach and therapeutic milieu model, ARTs work closely with parents and teens to build and strengthen interpersonal relationships, learn more about themselves through groups and classroom experience, and reinforce emerging healthy alternative behaviors for managing feelings and impulsive behaviors rather than engaging in substance use. When deemed necessary, additional evaluation to address specific concerns such as childhood trauma, eating disorders, learning disabilities, and school conflict can be coordinated. The goal is to collaborate with each adolescent and his or her family to promote the smoothest possible transition from the therapeutic milieu back to the community. (50)(51)As occurs with ARTs, long-term residential programs provide a variety of daily therapeutic sessions, including individual, group, and family therapy, as well as psychological education and psychopharmacology over an average of 6 to 12 months. These programs can accommodate adolescents who have both psychiatric and substance use disorders and have been unable to stop using substances or may have other self-injurious behaviors such as “cutting” or a history of suicide attempts. Some residential programs are “locked” for the most at-risk youths. (50)(51)Therapeutic communities provide treatment for adolescents who have severe chemical dependency and behavioral difficulties, have failed less intensive treatments, and are unable to live at home. This treatment modality generally is longer in duration (18 to 24 months) and potentially may serve as a step-down for adolescents who have completed more intensive treatment elsewhere. (50)(51)Therapeutic schools are designed to meet the academic and therapeutic needs of adolescents who have a variety of mental health and behavioral problems. Although these schools are not designed exclusively for substance abuse treatment, many have substance abuse services as part of their curricula. Therapeutic schools may be residential (include a boarding component) or function solely as a day school, with adolescents living at home. (50)Wilderness therapy programs typically serve adolescents who have a variety of behavior problems and have resisted changing their behaviors despite multiple treatments. Wilderness therapy promotes group living in an unfamiliar environment, with application of outdoor-living skills and physical challenges as vehicles for boosting personal and social responsibility and encouraging emotional growth. Although not specifically designed to treat drug problems, drug use is common among teens in these programs, and most such programs have some specific drug treatment component. Wilderness therapy programs generally last 3 to 8 weeks. Despite their growing popularity, however, they have not been studied adequately. Parents should inquire carefully about such programs, including whether the program is licensed by the state, before deciding which to use for their teenager. (50)