Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

25. Adolescent Substance Abuse 561of users in sixth grade or earlier. These “gateway drugs” were alcohol, tobacco,and inhalants (O’Malley, Johnston, & Bachman, 1995).Gender and Ethnic GroupIn general, male students use more substances of all kinds than female students;however, the differences are consistently getting smaller (Wallace et al., 2003).O’Malley and colleagues (1995) suggested that “closing the gap” by adolescentfemales may have to do with slightly earlier female maturation and with theirtendency to associate with older male students. Excluding Native Americanyouth, Hispanic students score highest among all other ethnic subpopulationsat 8th grade for all illicit drug classes. At 12th grade, they are the highest forcocaine, heroin, and steroids. Hispanic males and females manifest the highestlevels of marijuana use and binge drinking similar to white youth (in excess of40% for 10th graders). Asian American students manifest the lowest rates ofuse.NOSOLOGYSubstance use and abuse occurs on a continuum, and the cutoff point for makinga diagnosis of abuse/dependence is somewhat arbitrary, particularly in adolescents(Rohde, Lewinsohn, & Seeley, 1996). Clinical psychiatry has traditionallyfollowed the dichotomous paradigm of the DSM nosology regardless ofits limitation providing information in terms of pathogenesis and treatmentresponse (Bukstein & Kaminer, 1994). In addition, the serious negative impactof drugs on adolescents or adults who experience subdiagnostic levels of problematicsubstance use has been recognized but has not been addressed by theDSM system (Lewinsohn et al., 1996).The same DSM-IV-TR diagnostic criteria are utilized for both adolescentsand adults in the diagnosis of substance abuse and dependence. Empirical datagenerally support the utility of DSM-IV-TR criteria for alcohol dependenceamong adolescents (Martin et al., 1995). Lewinsohn and colleagues (1996)reported on the strong similarity between adolescents and adults in the frequencyof 8 of the 11 symptoms in DSM-IV-TR criteria for abuse and dependence.Among adolescents with a diagnosis, the most frequently reported symptomswere reduced activities, tolerance, consuming more than intended, anddesire to cut down (Lewinsohn et al., 1996; Stewart & Brown, 1995).Abuse and dependence are distinctly separate (Hasin, Grant, & Endicott,1990). A majority of adults diagnosed as abusers never progress to dependence.Abuse is not necessarily a prodrome, and it may be developmentally limited inmany adolescents. “Diagnostic orphans” are those youth who have subthresholdsymptomatology of alcohol dependence (i.e., one or two symptoms only) but no