Substance-Use Disorders in Children and Adolescents

Background: The most common substance use disorders in childhood and adolescence have to do with alcohol and cannabis. These disorders begin as early as puberty, are often accompanied by other mental disorders, and, if untreated, very frequently persist into adulthood.

Methods: This review is based on pertinent publications retrieved by a selective search in PubMed on substance use disorders in children and adolescents.

Results: Substance use disorders are among the commonest mental disorders in childhood and adolescence. In Germany, approximately 10% of adolescents have tried cannabis at least once. The prognosis is negatively affected by individual (bio-)psychological traits, mental comorbidities, laws that facilitate consumption, socioeconomic disadvantage, consuming peers, and parental substance use disorders. A timely diagnosis, motivation by the pediatrician, and referral to specialized child and adolescent psychiatric services helps assure that those affected receive appropriate treatment, with the goal of abstinence from the substance as well as improvement in emotional regulation, affectivity, and attention. According to studies from the English-speaking countries and considering all treatment forms, treatment is completed by approximately 60% to 65% of children and adolescents; 20% to 40% of these patients are abstinent six months after the end of treatment. No studies of this type have been carried out to date in Germany.

Conclusion: As the results of treatment are generally poor, there is a major need for research on the treatment and care of children and adolescents with substance use disorders. In particular, the interfaces between outpatient and inpatient care need further improvement.

Disorders involving the use of legal and illegal psychoactive substances (substance use disorders, SUD) begin in adolescence or young adulthood and are among the leading health risks for adolescents and young adults worldwide (1). The World Health Organization (WHO) estimates that more than 9% of the disability-adjusted life years (DALYs) lost to mental and neurological disorders are accounted for by psychoactive substance use in persons under age 24 (2). Harmful use by vulnerable persons often becomes established in early adolescence and can develop thereafter into a chronic use disorder with a high relapse potential and comorbidity.

Learning objectives

This article is intended to familiarize the reader with:

• the explanatory models for the development and maintenance of addiction dynamics that are typical of adolescence, including their multiple biopsychosocial symptom and risk constellations;
• measures derived from these models for the diagnosis and treatment of children and adolescents with SUD, with due consideration of their stage of physiological and psychological development.

The term “harmful use” refers to consumption patterns that can damage health. In dependence, substance use takes precedence over other behaviors, with a strong, sometimes overpowering desire to use a psychotropic substance. Risky use is defined by certain threshold values for each situation in question.

Methods

This review is based on a selective search in the PubMed database for meta-analyses, systematic reviews, and randomized controlled trials (RCT) that contain the search terms “alcohol AND adolescents” (7772 hits), “alcohol use disorder AND adolescents” (1028 hits), “substance AND adolescents” (4188 hits), “substance use disorder AND adolescents” (3538 hits), “cannabis use AND adolescents” (424 hits), or “cannabis use disorder AND adolescents” (274 hits), with special attention to the state of the evidence in Germany as well as to the treatment guidelines and position papers that have been issued by the relevant specialty societies (the German Society for Addiction Research and Addiction Therapy (Deutsche Gesellschaft für Suchtforschung und Suchttherapie, DG-Sucht) and the German Society for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy (Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, DGKJP).

General and clinical epidemiology

All psychoactive substances except tobacco are more commonly used by male than by female adolescents, with a sex ratio of 2:1 for the prevalence of use of some illicit drugs. There is almost no sex difference in tobacco smoking up to age 18 (3). Most adolescents have their first experiences with tobacco and alcohol between the ages of 13 and 15. The first use of cannabis is typically at age 14 or 15; persons under age 18 only rarely try other illicit substances (3, 4).

Tobacco and alcohol

In 2001, 27.5% of adolescents smoked, at least occasionally. This figure has markedly declined since then, to 7.2% (3). Smoking is more common among vocational school pupils and apprentices than among academic-track high school pupils or university students. 20.9% of adolescents in Germany have smoked a water pipe at least once (20.9%). The lifetime prevalence of e-cigarette use among adolescents is 14.5% (electronic water pipes: 11.0%) and is especially high among male adolescents with a low level of education.

The use of alcohol has declined along with that of tobacco, yet alcohol remains by far the most commonly used psychoactive substance among adolescents. More than one-third (35.5%) of adolescents surveyed report having used alcohol in the past 30 days, while 9% report having used it at least once per week over the past twelve months. 14.7% of adolescents reported having engaged in binge drinking on at least one day in past 30 days, and 3.2% on at least four days (3).

12.1% of 11– to 17-year-olds in Germany engage in risky alcohol use, which is characterized by a score of ≥ 4 for girls or ≥ 5 for boys on the Alcohol Use Disorder Identification Test-C [AUDIT-C]) (5). Its prevalence rises with age and is highest among 17-year-old girls, at 39.9%.

Illegal drugs

Cannabis is the most commonly used illicit substance worldwide (e1). In Germany, about one in ten adolescents (10.4%) has tried cannabis (lifetime prevalence) (3). The use of other illicit drugs is significantly less common (1.7 % among 12– to 17-year-olds). Lifetime prevalences are highest for the use of ecstasy, amphetamine or psychoactive plants. The 12-month prevalence of illicit substance use is 8.3% (cannabis use, 8.1%). 4.0% of adolescents report current use (i.e., use in the past 30 days) (3).

Clinical epidemiology

There are no current studies on the prevalence of SUD in Germany. A study in the United States (6) revealed an 11.4% lifetime prevalence and an 8.3% 12-month prevalence of SUD among 13– to 18-year-olds, where SUD was defined as in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Another recent study from the United States (e2) revealed a 4.5% 12-month prevalence of SUD among 12– to 17-year-olds for 2019.

As for the utilization of addiction support services, the 2015/2016 Care Report (7), core data of the German Addiction Support Statistics (Deutsche Suchthilfestatistik) (e3), and reports by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (e4) have revealed the following trends for Germany:

• Diagnoses of SUD (item F1 in the International Classification of Diseases, ICD-10) among adolescents have become significantly more common since 2002.
• Alcohol-related disorders (ICD-10 item F10) are the most common cause of hospital treatment among children and adolescents. Each year in Germany, approximately 20,300 persons under age 20 receive emergency inpatient treatment for acute alcohol intoxication (ICD-10: F10.0). This diagnosis has more than doubled in frequency since 2000.
• The number of hospitalizations for cannabis-related disorders (ICD-10 item F12; mostly male patients up to age 15) has more than quadrupled since 2002 and now stands at approximately 12,000 cases per year.
• The group of individuals with cannabis-related disorders is steadily becoming larger and younger, because younger persons are being initiated into risky forms of use.
• The treatment of cannabis-related disorders in 15– to 19-year-olds accounts for the largest share of outpatient and inpatient addiction services.

Clinical features, course, and prognosis

Substance use that is typical of adolescence, as opposed to substance-related disorders

For 60–80% of adolescents, the regular use of licit and illicit substances is a temporary behavioral pattern limited to adolescence and early adulthood that increasingly conflicts with changing social demands as the individual ages, and then ceases (e5). Terry Moffitt (8) has coined the descriptive term “adolescence-limited” for this developmental course, which is within the norm from the point of view of developmental psychology; only a minority of persons go on to develop a long-term addictive disorder, presumably because of further risk factors (e6). These so-called “life course persistents” have trouble coping with stress in early childhood, worsening over the course of further development and ultimately presenting as a disorder (e7). The causation of addictive disorders is multifactorial, with genetically based vulnerabilities interacting with environmental risk factors to determine the development of SUD. These vulnerabilities and risk factors include high sensitivity to reward-type environmental stimuli, low inhibitory control, temperament and impulsiveness, early emotional trauma, and an unfavorable family environment. A disorder develops when the “stress load” is high, depending on the degree of vulnerability: the more vulnerable the individual, the less “stress” is needed to trigger the disorder (4, e8).

Children and adolescents with SUD are clinically heterogeneous. Signs that are an initial, nonspecific—but sometimes very clear—warning of harmful use are listed in Box 1.

Box 1

Indicators of harmful substance use by children and adolescents

Consequences of substance use and substance-related disorders

Substance use can markedly damage health, lessen life expectancy, and cause social problems depending on the type, duration, and quantity of the substances used, comorbid mental disorders (if any), and accompanying problematic psychosocial constellations. Approximately one-third of traffic fatalities among 15– to 20-year-olds are related to substance use (9). Substance use significantly increases the risk of being either a perpetrator or a victim of an act of violence. Girls who engage in binge drinking have a threefold increased risk of becoming a victim of an unwanted sexual act (10). Substance use by persons who also have a depressive disorder or a critical life event is associated with attempted and completed suicide. Excessive use often leads to dropping out of school or vocational training. The psychosocial problems of persons who engage in harmful use tend to worsen because of a tendency to engage socially mainly with other persons of the same kind (11). Such persons may also become increasingly likely to commit crimes while intoxicated or crimes with the purpose of acquiring drugs (12). SUD in children cause major problems for their families and social assistance systems. Persons who use psychoactive substances are also more likely to act impulsively (13). The health risks associated with substance use vary depending on the developmental state. Along with the harmful effects of prenatal exposure to psychotropic substances (e9), studies have revealed persistent (neuro-)pathological effects caused by (e.g.) alcohol use in adolescence. The chronic consumption of alcohol, or its use in large quantities per episode of consumption (binge drinking), harms cortical and subcortical brain regions much more severely and lastingly in adolescents than in adults (evidence level 1b) (14).

Approximately 9% of cannabis users develop dependence over a lifetime (e10); the rate is higher (17%) among those who began using cannabis in adolescence, and higher still (25–50%) among those who used cannabinoids daily in adolescence (15). Experimental studies suggest that the epigenetic effects of cannabinoids can impair myelination of the pubertal brain (16). Intense cannabis use in adolescence impairs memory, learning, recall, attention, problem solving, reasoning ability, and intelligence (evidence levels 1b-4) (17). These findings accord with the documented age-related structural and functional changes in the cerebral gray and white matter of cannabis users (evidence level 1b) (18, e11). In vulnerable individuals, there is a dose-dependent association with depressive disorders (odds ratio [OR]: 1.2–1.6; evidence level 4) (e12), suicidality (OR: 0.64–4.55; evidence level 4) (e12), bipolar disorder (OR: 2.97; evidence level 1a) (e13), anxiety disorders (OR: 3.2; evidence level 2) (e14), and the concomitant harmful use of alcohol and other illicit drugs (19, e15, e16). Cannabis use can trigger psychosis in vulnerable individuals and significantly worsen the course of schizophrenic psychosis (20). The high tetrahydrocannabinol (THC) content in cannabis products plays a major pathogenetic role (21). Adolescents who use cannabis intensively are more likely to drop out of school (OR: 1.2–7.9; evidence level 2) (e17) and have worse educational outcomes than nonusers (evidence level 1a) (22, e18).

Predicting the course of substance-related disorders

Early-onset, markedly increasing use that is reinforced by peers is the characteristic situation in which a substance-use disorder is likely to take an unfavorable course. The following are also unfavorable prognostic factors (23, 24, e6, e19):

• legal conditions that facilitate substance availability and use
• reward-associated personality traits (impulsivity, curiosity), early behavioral problems and comorbid mental disorders due to underdeveloped self-regulation skills
• childhood neglect and maltreatment
• socioeconomic disadvantage, low educational attainment, problems at school, and deprived social environment
• association with consuming peers
• parental SUD and mental disorders, problematic parent-child relationships

In contrast, the following features (when marked) improve the prognosis of SUD in adolescents:

• fear of negative effects of substance use
• Self-confidence and psychosocial skills
• absence of comorbid mental disorders
• abstinent peers
• socioemotional support from parents.

Young substance users may present to a physician because of conflicts with parents, teachers, or vocational trainers resulting from substance use. Other reasons include psychological problems (depressive symptoms), performance problems, negative experiences during intoxication (panic attacks, mood swings, horror trips, impulse breakthroughs, overdose), and substance-induced psychiatric syndromes (severe anxiety, affective and psychotic disorders). Treatment may also be sought because of orders imposed by family and criminal courts or because of the bodily harm and long-term damage resulting from harmful use.

Comorbid mental disorders

Clinical and epidemiologic studies show a significant overlap between SUD and other adolescent psychiatric disorders (25); these disorders play an important role in treatment planning (26). Among persons with SUD, psychiatric comorbidity is far more common in child and adolescent patients (76%) than in older ones (>18 years: 23.4%) (27).

The most common psychiatric comorbidities are conduct disorders (28–62%, depending on the study) with and without hyperkinetic disorders, followed by depressive, anxiety, and impulse control disorders (16–61%). Further comorbidities include social phobic disorders, eating disorders, borderline personality disorders, substance-induced psychoses (due to cannabis, ecstasy, amphetamines, cocaine, D-lysergic acid diethylamide [LSD]), and schizophrenic psychoses (25, e20). Typical comorbidities among boys are conduct disorders and combined conduct and emotional disorders, attention deficit disorder with and without hyperactivity (AD[H]S), and personality disorders (antisocial and narcissistic personality disorders). Among girls, the most common comorbidities are depressive disorders post-traumatic disorders, disturbances of emotional development, and borderline personality disorders (e21).

On the one hand, studies have shown a marked aggravating influence of SUD on the course of psychiatric disorders in childhood and adolescence. On the other hand, it can be shown that mental disorders often precede substance use (25) and thus increase the risk for SUD, e.g., because of self-medication, or negatively affect its course, e.g., through the discontinuation of SUD treatment programs.

Diagnostic evaluation

For mental disorders, including SUD, the International Classification of Diseases (ICD-10) of the World Health Organization (WHO) is essential. Its 11th edition, issued last year, differs substantially from the prior edition: categories have been expanded, diagnostic criteria modified, and new diagnoses introduced (28) (eTable 1).

eTable 1

Diagnostic criteria for subtance dependence according to ICD-11 and ICD-10

Adolescents generally report their own substance use reliably if they trust the person asking the questions. These self-reports are supplemented by information from parents and others. There are suitable procedures for the taking of a structured drug history (eTable 2). A urine toxicology screen is part of the standard diagnostic evaluation.

eTable 2

Substance use history form

No German-language structured interview instruments exist for the diagnosis of SUD. The American RAFFT (“relax, alone, friends, family, trouble”), which is normed for 12- to 18-year-olds, is helpful for screening; it can indicate risky consumption patterns and is recommended for use by pediatricians and family doctors (Box 2). Further diagnostically relevant indicators of substance-related disorders in childhood and adolescence are given in Box 3.

Box 2

RAFFT for drug use

Box 3

Diagnostically relevant indicators of a substance-use disorder in childhood or adolescence

Treatment

The following information on the treatment of adolescents with SUD are based on the treatment guidelines of the Association of Scientific Medical Societies in Germany (AWMF) (e22-e24) and on specialty society recommendations on treatment and quality standards for acute and post-acute treatment and medical rehabilitation (29, 30, 31, 32). All of the recommendations presented for specialized therapies are based on expert consensus, with the exception of psychotherapeutic approaches, for which there is evidence of moderate to very good quality (Boxes 4 and 5).

Disorder- and age-specific treatment

The proper treatment of a child or adolescent with a substance use disorder depends on the particular disorder present and on the age of the patient. The specific effects of psychoactive substance use must be considered as well as the special developmental and psychopathological aspects of childhood and adolescence. Treatment concepts that are appropriate for addicted adults may not be appropriate for children and adolescents. The following special considerations apply:

• It is much more common for the treatment of adolescent patients to be requested by family members than by the patients themselves. Pediatricians and family doctors are often the relatives’ first point of contact.
• Motivational interviewing approaches are very helpful for promoting insight and readiness to change (e25).
• When the treatment begins, the families of children and adolescents with SUD are often already suffering from persistent conflict situations, relationship problems, instability, and deficient care. Nevertheless, the children still need a great deal of parental attention while they are being treated.
• Children and adolescents with SUD differ from adult patients in their need for pedagogical support and the need to make progress in their education and/or vocational training.
• Adolescents become socialized mainly by their coeval peers, whose behavior markedly affects these patients’ utilization of treatment.

In Germany, children and adolescents are now mainly treated for SUD in specialized outpatient clinics and departments of child and adolescent psychiatry and psychotherapy:

• outpatient counseling and treatment services,
• day clinic treatment (very rarely),
• inpatient treatment.

Indicators for the choice of outpatient treatment and partial or total in-hospital treatment are summarized in eBox 1.

eBox 1

Indicators for the choice of outpatient versus inpatient treatment

The treatment has several phases (29):

• qualified withdrawal treatment (in child and adolescent psychiatry clinics specializing in the treatment of addiction: www.dgkjp.de)
• continuing treatment of comorbid mental disorders (in clinics for child and adolescent psychiatry)
• continuing medical rehabilitation (withdrawal and long-term therapy in medical institutions)
• professional support of education and vocational training
• support in the structuring of everyday life, if necessary also as inpatient aftercare in youth welfare homes.

It is estimated (29, 31, 32) (eBox 2) that children and adolescents with SUD are a widely underserved population. Many regions lack adequate services with respect to

eBox 2

Care structure for children and adolescents with substanceuse disorders in Germany

• youth-specific addiction counseling and care facilities,
• beds for qualified withdrawal treatment for adolescents,
• medical rehabilitation facilities.

Qualified withdrawal treatment, post-acute treatment, and medical rehabilitation

The fundamental goal of the treatment of children and adolescents with SUD is abstinence from addictive substances. Important intermediate goals can include lessening substance use, preventing relapses, and improving functional levels (30, 33). The treatment of children and adolescents with SUD is highly structured and is intended to promote patient insight through a multimodal, interdisciplinary approach. The therapeutic spectrum ranges from psychotherapy and environmental measures to as somatic and pharmacological treatments (summarized in Box 4, with further information on the efficacy of individual treatments in Box 5). in qualified withdrawal treatment and post-acute treatment, psychotherapeutic approaches such as individual and group therapy of various types, family therapy, relapse prevention and social skills training are combined with ward-integrated specialized therapies (movement, body, occupational and music therapy, acupuncture, relaxation methods). Patients often need concomitant psychoactive medication to stabilize their affect and impulse control. Further components of child and adolescent psychiatric care for these patients include individualized pedagogical support, socialization in the group, and educational or pre-vocational measures.

Box 4

Elements of the treatment of addiction in children and adolescents

Box 5

The efficacy of treatment approaches for children and adolescents with substance-use disorders (SUD)

Qualified withdrawal treatment takes from four to twelve weeks, depending on the individual situation, indication, substance abuse, follow-up measures, and course of treatment. The need for, and course of, further treatment of comorbid mental disorders and consolidation of abstinence varies from patient to patient; usually, another three months of post-acute inpatient treatment are required, or more if necessary (e24, 31). Medical rehabilitation as a further treatment for addicted adolescents is only rarely offered in Germany (32). Further ambulatory treatment after a period of inpatient treatment is provided by child and adolescent psychiatrists and psychotherapists, in tandem with various measures provided by the youth welfare, family assistance, and occupational integration services (e25).

Treatment outcomes and prognosis

The outcome of treatment of children and adolescents with substance-related disorders is essentially determined by three parameters:

• staying in treatment until its regular, planned end (retention rate);
• achievement of the treatment goals (abstinence, improvement of mental comorbidities);
• relapse rate.

Regular treatment completion is considered the best predictor of long-term success.

Studies in the English-speaking countries have documented retention rates of 60% to 65% for children and adolescents undergoing any type of treatment (e26). In outpatient treatment, nearly 60% of children and adolescents are abstinent upon treatment completion. 20–40% of patients who complete the treatment do not have a diagnosis of SUD six months later (34, e27, e28). No corresponding study findings exist for Germany.

The risk of relapse is highest in the first six months after treatment completion (35). In adolescents, the risk of relapse is typically much higher when peers (especially former friends from the drug scene) exert social pressure; when substances are readily available or are used by parents, siblings, or peers; when there are persistent comorbid mental disorders; or when the patient does not attend an aftercare program (35, 36).

Overview

In Germany, a high standard of treatment for children and adolescents with SUD is maintained by the provision of qualified inpatient withdrawal and post-acute treatment in accordance with the relevant guidelines. Problems situated at the interfaces between outpatient and inpatient care still need to be addressed through improved fitting between care structures.

There is a major need for further research and development on the prevention (e29) and treatment of SUD in this age group, and on the provision of care, with the ultimate goal of improving intervention outcomes, which are still unsatisfactory in general (eBox 3). The new German Centers for Child and Adolescent Health (Deutsche Zentren für Kinder- und Jugendgesundheit, DZKJ) will play a central role in this effort (37).

eBox 3

Research desiderata on treatment approaches for children and adolescents with substance-use disorders (SUD)

Conflict of interest statement

Prof. Thomasius is Chairman of the Joint Commission on Addiction of the child and adolescent psychiatric professional societies and associations in Germany (DGKJP, BAG KJPP, BKJPP). He is Past President of the German Society for Addiction Research and Addiction Therapy (DG-Sucht). He is also one of the main authors of the AWMF S3 guidelines on alcohol-related disorders, tobacco-related disorders and medication-related disorders, as well as a leading member of the Task Force on Transition Psychiatry.

The remaining authors state that they have no conflict of interest.

Manuscript received on 27 May 2021, revised version accepted on 25 January 2022.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Prof. Dr. med. Rainer Thomasius

Deutsches Zentrum für Suchtfragen des Kindes- und Jugendalters (DZSKJ), Universitätsklinikum Hamburg-Eppendorf

Martinistr. 52, D-20246 Hamburg, Germany

Cite this as:
Thomasius R, Paschke K, Arnaud N: Substance-use disorders in children and adolescents. Dtsch Arztebl Int 2022; 119: 440–50. DOI: 10.3238/arztebl.m2022.0122

►Supplementary material

eReferences, eTable, Case Illustration, eBoxes:
www.aerzteblatt-international.de/m2022.0122

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