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).
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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 (individual), 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), prevention (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 recent 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, etiology, 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 through the stresses of the day (cigarettes), and relax in the evening (alcohol). The Marlboro Man and the Virginia Slims woman are widely seen models, and licit drugs are pushed to remedy all of the ills one may face-stress, headaches, depression, physical illness, and so on. Children face a monumental task of sorting out the many images and messages regarding both licit and illicit drugs.
Adolescents are quite adept at spotting 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 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 & Scheli, 1984 ), negative reactions and other adverse consequences to self, others, or property form the backbone for defining abuse, although several distinct but related dimensions are also critical.
Taken together, these dimensions present a comprehensive 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 consequences. 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 settings 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, doseresponse 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 individuals 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 interfering 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.
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 dependence is involved. With this multidimensional perspective for distinguishing 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, irregular, 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 marijuana at a party is not abuse. However, overindulgence of any substance to the point of being very high or stoned is at least acute or temporary abuse, and if it continues this is chronic abuse.
Getting into trouble at school, having 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 Jessor (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 generally 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 cocaine patent medicines of the early 1900s, the brave attempt 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 interesting 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 cigarettes. Although efforts are made, in schools, for example, to provide a balanced picture, youngsters too often 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 attitudes, or school dropout. Any focus on drug use or abuse to the exclusion of such correlates, whether antecedent, contemporaneous, or consequent, distorts the phenomenon by focusing on only one aspect or component of a general pattern or syndrome.