A Typology of Substance-Abusing Adolescents

Early in the history of addiction treatment the field realized that adolescents were not “short adults,” and that they presented with different problems and needs from adults. This awareness resulted in the development of adolescent-specific treatment programs. However, even now we still too frequently speak about adolescents with substance use disorders (SUDs) as if they represent a single category of people, a homogenous group. This month’s column is an attempt to develop a typology of substance-using adolescents. 

The DSM-5 provides a continuum of severity of SUDs—mild, moderate, severe—in contrast to the categories of “abuse” and “dependence” found in the DSM-IV. In applying this to adolescents we run into a problem at the mild end of severity, which is to know where to draw the line between a diagnosable disorder versus adolescents’ experimentation and response to peer pressure. When adolescents initiate substance-using behaviors at earlier ages, the distinction between pathological use and experimentation becomes blurred. Also, for those adolescents diagnosed with SUDs at moderate and severe levels, we have additional obstacles to the usual development and maturation processes associated with adolescence. 

While the attempt here is to look at four different types of adolescents, the characteristics of the patterns are not always mutually exclusive. Although we can describe four different patterns, we recognize that whatever variables we are considering are not discrete groups but rather cluster around the variable’s axis. The variables I wish to describe include: pattern of substance use, the goal desired, the behavior when under the influence, psychological functioning, characteristic social interaction patterns, school performance, and family dynamics.

There are at least four subtypes of adolescents with substance use disorders: 

• Rebellious/aggressive
• Low self-esteem/often depressed
• Shy/anxious
• All American/bright

If alcohol is used, the drinking is very rapid—that is, large quantities in a short period of time (bingeing)—and the goal is intoxication. These adolescents are most likely to begin using earlier and to use illicit drugs. The earlier initiation to substance use often results in earlier development and greater severity of a diagnosable SUD.

They desire a drug-affected state and may drink to block out painful or obsessive thoughts.

   

They may be involved in fighting or destructive behavior and are more likely to commit serious crimes and become involved with the criminal justice system. They may have a co-occurring conduct or antisocial personality disorders although it may be difficult to discriminate between pathology and usual adolescent behavior.

They often report feeling bored and may have feelings of invulnerability and motor restlessness. They may appear hyperactive even when they do not meet diagnostic criteria for ADHD. They may change friends frequently. Females in this group are more likely to use opiates than other types of adolescents and they may be involved in prostitution.

They have frequent aggressive outbursts. They may have a lack of loyalty to others (an exception being gang members) but at the same time demand it from others. The individual may be considered a “loner.”

They generally demonstrate poor academic performance even though they may be intelligent. ADHD and learning disorders are common, and they are likely to act out in school and sometimes be placed in remedial education even when not intellectually impaired. They may be referred to a school program for behaviorally disturbed students and of the four groups of adolescents, are most likely to be suspended or expelled.

They are likely to come from chaotic families with a history of emotional, physical, and/or sexual abuse (Kilpatrick et al., 2000), often a single-parent home. Parents are often drug addicted or sociopathic. Conversely, they may come from a home in which parents are very successful but emotionally distant and some of their behavior may be an attempt to embarrass the family.

Clinicians must not react to the testing of boundaries and roll with resistance to avoid power and control struggles. Motivational interviewing (MI) may even more important in this group than in the others. Staff must provide positive role models, and in a sense “re-parent” these adolescents. Because of the “testing-of-limits” characteristic of this population, staff must set boundaries, provide consistency, and use positive peer pressure to control behavior. When early abuse issues are identified, adolescents must understand that it is not their fault and explore the shame and rage that may have resulted. 

In contrast to the rebellious/aggressive, these adolescents are less likely to binge but find cannabis and simulants attractive and use is more likely to be solitary.

The substance represents a way of medicating themselves and reliving the sadness they feel.

They initially feel better, less sad or depressed, but after the initial drug effect has worn off they become sad again, and may become weepy and despondent. Suicide is a concern here. Females may be sexually active in an attempt to recapture the positive feelings that existed when they first began drinking or using drugs. They often find the substance makes them feel “normal” or the way they always wanted to feel. Later in life these are the AA members who, when telling their story, say “I was an alcoholic from the first drink.”

They may become depressed and despondent over very small failures, perceived slights or rejections, and may be suicidal. They have difficulty accepting compliments. They frequently assume a victim’s role and some sort of actual victimization is not uncommon.

It is not uncommon for them to take on hypermasculine (“the jock”) or hyperfeminine (“sexiest girl”) behaviors. At the other end of the continuum they might be totally immobilized and withdraw from most social interaction, becoming “loners.”

To compensate for feelings of low self-esteem, they are often driven to academic or extracurricular achievement. While they may be very successful in these endeavors, their success does nothing to mitigate their feeling of low self-esteem. Others simply give up and stop trying to achieve.

May come from homes where there is parental physical or emotional abandonment. Some of their parents are extremely permissive while others are very controlling. When there is withholding of love and parental approval, it leaves them believing that nothing can win their parents’ approval, which may result in a continuing drive to be successful. Sexual abuse by parents or parental surrogates is not uncommon (Kilpatrick et al., 2000).

These adolescents do best in treatment that provides heavy structure, such as a short period of inpatient treatment followed by a long period of structured outpatient and continuing care. The treatment goal should be to increase self-esteem and teach them “how to play.” CBT and social skills training can be helpful. Clinicians should try to connect to the adolescents on an emotional level. Often alternative type treatment interventions such as “outward bound” programs, equine therapy, and ropes courses can be very helpful. If depression is present, it must be addressed.

While intake of alcohol by these adolescents may be moderate, it tends to be continuous so that large quantities are consumed. They are therefore less likely to reach high blood alcohol levels. They find cannabis attractive and are likely to use continuously throughout the day, including while at school.

Similar to the low self-esteem/often depressed group, they use use psychoactive substances as medicine. They like the tranquilizing effect of the substances and want to relieve their shyness. 

They may become extroverted and thereby become attractive to others. However, with continued use they may become insensitive to others’ feelings and end up being rejected, which in turn reinforces their anxiety. They may also become sexually active as a result of their use, similar to the low self-esteem/often depressed group. Like those in the the low self-esteem/often depressed group, early substance use makes them into the person they think they should be or want to be.

They tend to be shy, fearful, and anxious, sometimes intensely so. Their emotional states can be chronic and intense and negatively effect their functioning and immobilize them. They may have previously received an anxiety disorder diagnosis and/or may have a social anxiety disorder (Hovens, Cantwell, & Kiriakos, 1994). Suicide is a concern.

They are tentative and ambivalent in social situations. They are sometimes friendly, while at other times they withdraw, confusing their friends. They vacillate between being emotionally present and absent.

They may be more variable in performance than other adolescents, in part depending on their level of anxiety and how it affects their school performance. School performance ranges from excellent to poor. Their anxiety may negatively affect their test-taking ability.

Parental responses to them are inconsistent—warmth followed by pain, followed by affection— and they are surprised by those occasions when love is given but associated with punishment, thereby leaving them unable to predict their parents’ response to them.

These adolescents need to be provided with a structure that allows them to make mistakes and fail, but still have their attempts supported. Staff need to work with adolescent expectations and interpretations of limit-setting, be patient, and help to establish trust. The members of this group might also benefit from alternative treatment strategies like the low self-esteem/often depressed group.

It is likely that they have a pattern of controlled use during the week and bingeing or heavier use at parties or celebrations on weekends. They may get involved in competitive drinking contests, sometimes with disastrous results. They are also attracted to substances with an “image” and more likely to use drugs peers see as “cool.”

Relief from pressure to perform and desire to be carefree.

They may become involved with minor antisocial behavior such as vandalism, usually with other adolescents like themselves. They are competitive, and that includes sexual behavior.

They want to achieve academically and in sports, sometimes becoming the star player in a sport, sometimes more than one concurrently. They usually appear well-adjusted but may become depressed if they do not meet the standards they have set for themselves. They may feel even more invincible and immortal than is usual for adolescents. Intellectualization is commonly employed as a defense against feelings. Members of this group are difficult to identify because of high levels of athletic and/or scholastic performance. A random positive urine drug screen may be the first indication of a problem.

One of the reasons these adolescents are more difficult to identify is that they interact with others appropriately, including adults, and they know how to work within systems. They are very popular, looked up to by other students, may hold elective office in school, and are perceived as most likely to succeed. They are well liked by teachers, coaches, and their parents, all of whom can be expected to deny that a substance use problem exists.

They have high standards for themselves and excel academically. They are likely to go to college and frequently have graduate careers and professional careers as goals.

Many come from very achievement-oriented families or conversely dysfunctional families. The family places more value on achievement, career, and image than on personal happiness. If adolescents come from a dysfunctional family, they are typically the family hero, often treated as a peer by their parents, sometime actually assuming a parental role as a parent to younger siblings and a “partner” to one of the parents.

Because of their high level of achievement and ability to work within systems they are unlikely to have been evaluated by a mental health professional until a crisis. However, if they have been evaluated, common diagnoses are adjustment or anxiety disorder.

These adolescents seem to respond well to group and family therapy. Compared to the other types, they require the least amount of structure, so they do well in IOP. Because of their intellectual abilities and achievement orientation, they can benefit from insight-oriented therapy. They need to be moved toward a “feeling” orientation and to increase the balance of intellect and emotions. If they perceive themselves as being dependent, they may have difficulty with the role of “patient.”

So we are now back to the beginning of this column. While adolescents are clearly different from adults, they are not a homogeneous group and will do best when treatment strategies are matched to one of the aforementioned types.

Hovens, J. G., Cantwell, D. P., & Kiriakos, R. (1994). Psychiatric comorbidity in hospitalized adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry, 33(4), 476–83.

Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., Best, C. L., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68(1), 19–30.