Behavioral Consult

Substance Use in Teens

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

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