The Opioid Crisis in America - Part IV (Drug Abuse Among America's Teens)

Turning the Improbable
Into the Exceptional!
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
Since its founding in 2003, The Advocacy Foundation has become recognized as an effective
provider of support to those who receive our services, having real impact within the communities
we serve. We are currently engaged in community and faith-based collaborative initiatives,
having the overall objective of eradicating all forms of youth violence and correcting injustices
everywhere. In carrying-out these initiatives, we have adopted the evidence-based strategic
framework developed and implemented by the Office of Juvenile Justice & Delinquency
Prevention (OJJDP).
The stated objectives are:
1. Community Mobilization;
2. Social Intervention;
3. Provision of Opportunities;
4. Organizational Change and Development;
5. Suppression [of illegal activities].
Moreover, it is our most fundamental belief that in order to be effective, prevention and
intervention strategies must be Community Specific, Culturally Relevant, Evidence-Based, and
Collaborative. The Violence Prevention and Intervention programming we employ in
implementing this community-enhancing framework include the programs further described
throughout our publications, programs and special projects both domestically and
internationally.
www.TheAdvocacyFoundation.org
ISBN: ......... ../2017
......... Printed in the USA
Advocacy Foundation Publishers
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Dedication
______
Every publication in our many series’ is dedicated to everyone, absolutely everyone, who by
virtue of their calling and by Divine inspiration, direction and guidance, is on the battlefield dayafter-day
striving to follow God’s will and purpose for their lives. And this is with particular affinity
for those Spiritual warriors who are being transformed into excellence through daily academic,
professional, familial, and other challenges.
We pray that you will bear in mind:
Matthew 19:26 (NIV)
Jesus looked at them and said, "With man this is impossible,
but with God all things are possible." (Emphasis added)
To all of us who daily look past our circumstances, and naysayers, to what the Lord says we will
accomplish:
Blessings!!
- The Advocacy Foundation, Inc.
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The Transformative Justice Project
Eradicating Juvenile Delinquency Requires a Multi-Disciplinary Approach
The way we accomplish all this is a follows:
The Juvenile Justice system is incredibly overloaded, and
Solutions-Based programs are woefully underfunded. Our
precious children, therefore, particularly young people of
color, often get the “swift” version of justice whenever they
come into contact with the law.
Decisions to build prison facilities are often based on
elementary school test results, and our country incarcerates
more of its young than any other nation on earth. So we at
The Foundation labor to pull our young people out of the
“school to prison” pipeline, and we then coordinate the efforts
of the legal, psychological, governmental and educational
professionals needed to bring an end to delinquency.
We also educate families, police, local businesses, elected
officials, clergy, and schools and other stakeholders about
transforming whole communities, and we labor to change
their thinking about the causes of delinquency with the goal
of helping them embrace the idea of restoration for the young
people in our care who demonstrate repentance for their
mistakes.
1. We vigorously advocate for charges reductions, wherever possible, in the adjudicatory (court)
process, with the ultimate goal of expungement or pardon, in order to maximize the chances for
our clients to graduate high school and progress into college, military service or the workforce
without the stigma of a criminal record;
2. We then enroll each young person into an Evidence-Based, Data-Driven Restorative Justice
program designed to facilitate their rehabilitation and subsequent reintegration back into the
community;
3. While those projects are operating, we conduct a wide variety of ComeUnity-ReEngineering
seminars and workshops on topics ranging from Juvenile Justice to Parental Rights, to Domestic
issues to Police friendly contacts, to CBO and FBO accountability and compliance;
4. Throughout the process, we encourage and maintain frequent personal contact between all
parties;
5 Throughout the process we conduct a continuum of events and fundraisers designed to facilitate
collaboration among professionals and community stakeholders; and finally
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6. 1 We disseminate Quarterly publications, like our e-Advocate series Newsletter and our e-Advocate
Quarterly electronic Magazine to all regular donors in order to facilitate a lifelong learning process
on the ever-evolving developments in the Justice system.
And in addition to the help we provide for our young clients and their families, we also facilitate
Community Engagement through the Restorative Justice process, thereby balancing the interesrs
of local businesses, schools, clergy, elected officials, police, and all interested stakeholders. Through
these efforts, relationships are rebuilt & strengthened, local businesses and communities are enhanced &
protected from victimization, young careers are developed, and our precious young people are kept out
of the prison pipeline.
This is a massive undertaking, and we need all the help and financial support you can give! We plan to
help 75 young persons per quarter-year (aggregating to a total of 250 per year) in each jurisdiction we
serve) at an average cost of under $2,500 per client, per year.*
Thank you in advance for your support!
* FYI:
1. The national average cost to taxpayers for minimum-security youth incarceration, is around
$43,000.00 per child, per year.
2. The average annual cost to taxpayers for maximun-security youth incarceration is well over
$148,000.00 per child, per year.
- (US News and World Report, December 9, 2014);
3. In every jurisdiction in the nation, the Plea Bargain rate is above 99%.
The Judicial system engages in a tri-partite balancing task in every single one of these matters, seeking
to balance Rehabilitative Justice with Community Protection and Judicial Economy, and, although
the practitioners work very hard to achieve positive outcomes, the scales are nowhere near balanced
where people of color are involved.
We must reverse this trend, which is right now working very much against the best interests of our young.
Our young people do not belong behind bars.
- Jack Johnson
1 In addition to supporting our world-class programming and support services, all regular donors receive our Quarterly e-Newsletter
(The e-Advocate), as well as The e-Advocate Quarterly Magazine.
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part IV – Drug Abuse Among America’s Teens
“Turning the Improbable Into the Exceptional”
Atlanta
Philadelphia
______
John C Johnson III
Founder & CEO
(878) 222-0450
Voice | Data | SMS
www.TheAdvocacyFoundation.org
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Biblical Authority
______
1 Corinthians 10:13-14
13
No temptation has overtaken you except what is common to mankind. And God is
faithful; he will not let you be tempted beyond what you can bear. But when you are
tempted, he will also provide a way out so that you can endure it.
James 4:7-10
7
Submit yourselves, then, to God. Resist the devil, and he will flee from you. 8 Come
near to God and he will come near to you. Wash your hands, you sinners, and purify
your hearts, you double-minded. 9 Grieve, mourn and wail. Change your laughter to
mourning and your joy to gloom. 10 Humble yourselves before the Lord, and he will lift
you up.
Psalm 50:15
15
and call on me in the day of trouble;
I will deliver you, and you will honor me.”
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Table of Contents
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part VI – Drug Abuse Among America’s Teens
______
Biblical Authority
I. Introduction: Adolescent Substance Use in the U.S………………… 17
II. The Consequences of Youth Substance Abuse …………………… 23
III.
The Influence of Substance Abuse on Adolescent
Brain Development…………………………………………………….. 29
IV. The Effects of Drugs & Alcohol on the Adolescent Brain ………… 45
V. The Long-Term Effects of Alcohol on Teenagers…………………. 51
VI.
Evidence-Based Approaches to Treating Adolescent
Substance Abuse Disorders………………………………………….. 57
VII. References……………………………………………………………… 67
Attachments
A. Use of Illicit Drugs – Child Trends
B. Principles of Adolescent Substance Use Disorder Treatment
C. Red Flags & Resources (2 nd ed.)
Copyright © 2018 The Advocacy Foundation, Inc. All Rights Reserved.
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I. Introduction
Adolescent Substance Use in the U.S.
Facts for Policymakers
Authors: Shannon Stagman, Susan Wile Schwarz, and Danielle Powers
Publication Date: May 2011
Adolescence is an important period of physical, social, psychological, and cognitive
growth. No longer children and not yet adults, adolescents make significant choices
about their health and develop attitudes and health behaviors that continue into
adulthood. Substance use disorders among adolescents can impede the attainment of
important developmental milestones, including the development of autonomy, the
formation of intimate interpersonal relationships, and general integration into adult
society. Similarly, the use of alcohol and illicit substances by youth often leads to
adverse health outcomes.
Because heightened peer influence and a tendency towards risk taking are normal
developmental changes in adolescence, experimentation with substances during this
period is common. However, using drugs and alcohol at a young age increases the risk
of dependency and addiction, and early onset of drinking increases the likelihood of
alcohol-related injuries, motor vehicle crash involvement, unprotected intercourse, and
interpersonal violence.
The more risk an adolescent is exposed to, the more likely it is he or she will abuse
substances. Some risk factors, such as peer influence, may be more powerful during
adolescence, and likewise some protective factors, such as a strong sense of school
belonging and a meaningful positive adult presence, can have a greater positive impact
during this period. An important goal of substance abuse prevention is to reduce risk
and increase protective factors in the lives of all adolescents, and particularly among
disadvantaged youth.
Prevalence
Facts about Adolescent Substance Use
Figure 1: Illicit Drug Usage for Youth 12-17 in 2009
In 2009, 10 percent of youth aged 12 to 17 were current
illicit drug users. See Figure 1 for a breakdown by drug
type.
In 2009, rates of current alcohol use were 3.5 percent
among persons aged 12 or 13, 13 percent of persons
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aged 14 or 15, and 26 percent for 16 or 17 year olds.
An estimated six percent of 16 or 17 year olds and nearly 17 percent of 18 to 20
year olds reported driving under the influence of alcohol in the past year.
Rates of current cigarette smokers also climbed steadily by age, with one percent
of youth aged 12 and 13, seven percent of 14 and 15 year olds, and 17 percent
of those 16 and 17 years of age reporting current usage.
Racial and Ethnic Disparities
Figure 2: Racial and Ethnic Disparities in Alcohol Use for Youth 12-17 in 2009
Among youths ages 12 to 17 in 2009, Asians had the
lowest rates of current alcohol use (6.5 percent),
compared to 10.6 percent of African-Americans, 11.9
percent of American Indians or Alaska Natives, 15.2
percent of Hispanics/Latinos, 16.1 percent of whites, and
16.7 percent of multi-racial youths.
White adolescents smoked cigarettes at a higher rate than did African-American
adolescents in 2009, with 24 percent of white high school seniors reporting that
they smoke compared to only nine percent of African- American seniors.
Marijuana usage rates were nearly identical among white and African-American
adolescents; about 21 percent of high school seniors from both racial/ethnic
groups reported usage in 2009.
Access/Risk Factors
In 2009, half (49.9 percent) of youths aged 12 to 17 reported that it would be
“fairly easy” or “very easy” for them to obtain marijuana if they wanted some.
Fourteen percent indicated that they had been approached by someone selling
drugs in the past month.
In 2009, 55.9 percent of underage drinkers reported that their last use of alcohol
occurred in someone else’s home.
Thirty percent of underage drinkers paid for the alcohol the last time they drank.
Among those who did not pay, 37.1 percent obtained the alcohol from an
unrelated person of legal drinking age, 19.9 percent received it from other
underage persons, and 20.6 percent were provided alcohol by their parents,
guardians or adult family members.
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Among persons aged 12 or older (2008 to 2009) who used pain relievers nonmedically,
55.3 percent got the drug they most recently used from a friend or
relative for free.
Homelessness is a significant risk factor for substance use. The majority of
homeless youth on the streets use substances such as tobacco (81 percent),
alcohol (80 percent), or marijuana (75 percent).
Protective Factors
The percentages of youth reporting binge alcohol use and use of cigarettes and
marijuana were lower among those youth who perceived great risk in using these
substances.
Youths aged 12 to 17 who had heard drug or alcohol prevention messages in the
last year from a source inside and/or outside of school had a lower prevalence of
illicit drug use than those who had not heard such messages (9.2 and 9.7 versus
12.7 and 11.3 percent).
In 2009, past month use of illicit drugs, cigarettes, and alcohol was lower among
youths aged 12 to 17 who reported that their parents always or sometimes
engaged in monitoring behaviors.
Parent-family connectedness (feelings of warmth, love, and caring) and school
connectedness and engagement (perceived caring from teachers and high
expectations for student performance) have been associated with lower levels of
cigarette, alcohol, and marijuana use.
According to the National Center on Addiction and Substance Abuse at Columbia
University, a child that reaches the age of 21 without smoking, using illicit drugs,
or abusing alcohol is virtually certain never to do so.
System-level Challenges to Decreasing Adolescent Substance Use
Below are some of the factors that make monitoring and decreasing adolescent
substance use especially difficult.
The many varied challenges parents face in effectively engaging with their
children.
o
o
Though the importance of parent connectedness and physical presence in
the home have been noted as key protective factors for adolescents,
many parents struggle to find enough time, largely due to workforce
pressures.
Many parents believe that their adolescent children follow their directives,
and often underreport their own children’s drug and alcohol use.
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Scarcity of school-based and other prevention programs that provide drug and
alcohol education and interpersonal and behavior skills training.
o Of every federal dollar spent on substance abuse and addiction, only 1.9
cents went to fund prevention and treatment programs aimed at reducing
the incidence and consequences of substance abuse and addiction.
o
Universal school-based prevention programs often do not contain content
tailored for at-risk youth and families.
Lack of access to and funding for confidential substance use prevention and
treatment.
o
o
Limited government funding for substance use treatment is one of the
main challenges in delivery of care.
Even where treatment programs exist, not all states allow minors to
consent to their own care for substance use disorders.
School-based Substance Abuse Prevention Programs
In Evidence-based Health Promotion Programs for School and Communities,* the
authors identify evidence-based, peer-reviewed programs designed to prevent health
problems often experienced by adolescents. For school-based prevention of tobacco
and substance abuse, the authors recommend the following programs:
Protecting You/Protecting Me: Focuses on reducing alcohol use and increasing
protective factors for children age 6 and up. www.madd.org/underage-drinking/pypm
Life Skills Training: Seeks to prevent substance use and violence by improving drug
refusal skills and increasing knowledge.www.lifeskillstraining.com/index.php
CASASTART: Aims to reduce alcohol and drug use, decrease association with
delinquent peers, improve school performance, and reduce violent
offenses. www.lifeskillstraining.com/index.php
Class Action/Project Northland: Focuses on delaying the onset of alcohol use,
decreasing likelihood of alcohol use and reducing alcohol-related problems for
adolescents.
Project ALERT: Aims to give middle school-age students insight and skills for resisting
substance use. www.projectalert.com
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*Inman, D. D.; van Bakergem, K. M.; LaRosa, A. C.; Garr, D. R. 2011. Evidence-based
Health Promotion Programs for School and Communities. American Journal of
Preventive Medicine 40(2): 207-219."
Recommendations
Initiate public awareness campaigns to inform both youth and adults,
particularly parents, of the risks of substance use. Many adolescents gain
access to substances through parents and other adults, and prevention
messages from sources outside of school may help to highlight risks.
Provide funding to inform and support parents at the community
level. Family-focused prevention programs have decreased the use of alcohol
and drugs in older children and improved effectiveness of parenting skills that
favorably affected their children’s risk factors.
Support the replication of effective culturally and linguistically competent
school- and community- based prevention programs. At-risk students are
more likely to internalize prevention content if it is focused on their individual
needs, and community-based organizations are able to tailor their intervention
and prevention programs specifically to the needs of their target communities.
Provide more school-based extracurricular activity
opportunities. Adolescents aged 12 to 17 who participated in extracurricular
activities in 2009 were less likely to have used alcohol, cigarettes, and illicit drugs
in the past month.
Ensure confidential access to mental health services and substance use
treatment for adolescents. Removing barriers to care will help adolescents get
treatment earlier and avoid substance-use disorders.
Fund accessible, comprehensive, and intensive substance abuse
prevention and treatment programs targeted at homeless youth. Efforts
such as increasing the number and visibility of mobile vans and outreach staff,
locating storefronts with “streetwise” staff in areas where youth congregate, and
strengthening links among existing service systems may lead to more homeless
youth receiving needed services.
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II. The Consequences of
Youth Substance Abuse
Young people who persistently abuse substances often experience an array of
problems, including academic difficulties, health-related problems (including mental
health), poor peer relationships, and involvement with the juvenile justice system.
Additionally, there are consequences for family members, the community, and the entire
society.
Academics
Declining grades, absenteeism from school and other activities, and increased potential
for dropping out of school are problems associated with adolescent substance abuse.
Hawkins, Catalano, and Miller (1992) cite
research indicating that a low level of
commitment to education and higher
truancy rates appear to be related to
substance use among adolescents.
Cognitive and behavioral problems
experienced by alcohol- and drug-using
youth may interfere with their academic
performance and also present obstacles
to learning for their classmates (Bureau
of Justice Statistics, 1992).
Physical Health
Injuries due to accidents (such as car
accidents), physical disabilities and
diseases, and the effects of possible
overdoses are among the health-related
consequences of teenage substance
abuse. Disproportionate numbers of youth involved with alcohol and other drugs face an
increased risk of death through suicide, homicide, accident, and illness.
The Drug Abuse Warning Network (DAWN) study -- in a representative sample of
hospitals throughout the United States -- reports trends in people seeking emergency
department treatment related to illegal drug use or nonmedical use of legal drugs.
Preliminary 1994 estimates indicate drug-related emergency department episodes for
youth ages 12 to 17 increased by 17 percent from 1993 to 1994. This increase was
greater than for any of the older age groups reported. Significantly, emergency
department visits related to marijuana/hashish for youth ages 12 to 17 increased 50
percent between 1993 and 1994 (McCaig, 1995). Ninety-one youth between the ages of
12 and 17 died of drug abuse in 1993 (Office of Applied Studies, 1994).
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Transmission of HIV/AIDS primarily occurs through exposure to body fluids of an
infected person during sexual contact or through sharing of unsterile drug-injection
equipment. Another primary means of transmission is from mothers to infants during
pregnancy or the birth process. Many substance-abusing youth engage in behavior that
places them at risk of contracting HIV/AIDS or other sexually transmitted diseases. This
may include the actual use of psychoactive substances (particularly those that are
injected) or behavior resulting from poor judgment and impulse control while
experiencing the effects of mood-altering substances. Rates of AIDS diagnoses
currently are relatively low among teenagers, compared with most other age groups.
However, because the disease has a long latency period before symptoms appear, it is
likely that many young adults with AIDS were actually infected with HIV as adolescents.
Although alcohol-related traffic fatalities for youth have declined, young people are still
overrepresented in this area. In 1995 alone, more than 2,000 youth (ages 15 to 20)
were killed in alcohol-related car crashes (National Highway Traffic Safety
Administration, 1997).
These limited examples illustrate the catastrophic health-related consequences of
substance abuse among adolescents. Besides personal and family distress, additional
healthcare costs and loss of future productivity place burdens on the community.
Mental health
Mental health problems such as depression, developmental lags, apathy, withdrawal,
and other psychosocial dysfunctions frequently are linked to substance abuse among
adolescents. Substance-abusing youth are at higher risk than nonusers for mental
health problems, including depression, conduct problems, personality disorders, suicidal
thoughts, attempted suicide, and suicide. Marijuana use, which is prevalent among
youth, has been shown to interfere with short-term memory, learning, and psychomotor
skills. Motivation and psychosexual/emotional development also may be influenced
(Bureau of Justice Statistics, 1992).
Peers
Substance-abusing youth often are alienated from and stigmatized by their peers.
Adolescents using alcohol and other drugs also often disengage from school and
community activities, depriving their peers and communities of the positive contributions
they might otherwise have made.
Families
In addition to personal adversities, the abuse of alcohol and other drugs by youth may
result in family crises and jeopardize many aspects of family life, sometimes resulting in
family dysfunction. Both siblings and parents are profoundly affected by alcohol- and
drug-involved youth (Nowinski, 1990). Substance abuse can drain a family's financial
and emotional resources (Bureau of Justice Statistics, 1992).
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Social and Economic Consequences
The social and economic costs related to youth substance abuse are high. They result
from the financial losses and distress suffered by alcohol- and drug-related crime
victims, increased burdens for the support of adolescents and young adults who are not
able to become self-supporting, and greater demands for medical and other treatment
services for these youth (Gropper, 1985).
Delinquency
There is an undeniable link between substance abuse and delinquency. Arrest,
adjudication, and intervention by the juvenile justice system are eventual consequences
for many youth engaged in alcohol and other drug use. It cannot be claimed that
substance abuse causes delinquent behavior or delinquency causes alcohol and other
drug use. However, the two behaviors are strongly correlated and often bring about
school and family problems, involvement with negative peer groups, a lack of
neighborhood social controls, and physical or sexual abuse (Hawkins et al., 1987;
Wilson and Howell, 1993). Possession and use of alcohol and other drugs are illegal for
all youth. Beyond that, however, there is strong evidence of an association between
alcohol and other drug use and delinquent behavior of juveniles. Substance abuse is
associated with both violent and income-generating crimes by youth. This increases
fear among community residents and the demand for juvenile and criminal justice
services, thus increasing the burden on these resources. Gangs, drug trafficking,
prostitution, and growing numbers of youth homicides are among the social and criminal
justice problems often linked to adolescent substance abuse.
The DUF study found the highest association between positive drug tests of male
juvenile arrestees and their commission of drug-related crimes (e.g., sales, possession).
However, a substantial rate of drug use also was found among youth who committed
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violent, property, and other crimes (National Institute of Justice, 1996). These data are
depicted in figure 5.
Other data support the concern for drug-involved youth in the juvenile justice system.
The Survey of Youth in Custody, 1987 (Beck, Kline, and Greenfeld, 1988) found that
more than 39 percent of youth under age 18 were under the influence of drugs at the
time of their current offense. More than 57 percent reported using a drug in the previous
month. In another study of 113 delinquent youth in a State detention facility, 82 percent
reported being heavy (daily) users of alcohol and other drugs just prior to admission to
the facility, 14 percent were regular users (more than two times weekly), and 4 percent
reported occasional use (DeFrancesco, 1996).
A study conducted in 1988 in Washington, D.C., found youth who sold and used drugs
were more likely to commit crimes than those who only sold drugs or only used drugs.
Heavy drug users were more likely to commit property crimes than nonusers, and youth
who trafficked in drugs reported higher rates of crimes against persons. Youth in this
sample were most likely to commit burglary or sell drugs while using or seeking to
obtain drugs. About one-fourth of the youth also reported attacking another youth to
obtain drugs. However, among the youth in this sample, the majority who committed
crimes did not do so in connection with drugs (Altschuler and Brounstein, 1991). A
breakdown of crimes that youth have committed to obtain drugs follows:
Drug selling: 36 percent.
Serious assault: 24 percent.
Burglary: 24 percent.
Robbery: 19 percent.
The 1996-97 National Parents' Resource Institute for Drug Education (PRIDE) study
(1997) found a significant association between crimes committed by adolescents and
their use of alcohol and other drugs. Table 1 shows the percentage of 6th through 12th
grade students who reported they had used various substances and had been involved
in threatening or delinquent activities. The percentage of youth who were involved in
these activities and had not used alcohol or other drugs was substantially lower.
For those who work in the juvenile justice system, new data are constantly being
reported, but the story is an old one. Juvenile justice professionals encounter daily the
distress of youth, their families, and communities resulting from juvenile involvement in
substance abuse and delinquent behavior. These professionals also experience the
difficulties of trying to work successfully with these young people.
The projects described in the remainder of this Summary developed sound strategies
for identifying and intervening with youth who were involved in illicit drug use and who
encountered the juvenile justice system. The experiences and lessons learned by these
projects can be used by other agencies to replicate or adapt similar programs to meet
the needs of the youth they serve.
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III. The Influence of Substance Abuse on
Adolescent brain Development
BACKGROUND ON ADOLESCENT SUBSTANCE USE
Substance use during adolescence has been associated with alterations in brain
structure, function, and neurocognition. This review will present the current research
regarding typical adolescent brain development and the subtle but significant
abnormalities in indices of brain functioning associated with alcohol and drug use during
this critical developmental period. Studies using neuropsychological assessment and
structural and functional imaging will be discussed to help elucidate the relationship
between neurocognition with alcohol and marijuana use. Additionally, methodological
issues in neuroimaging and neuropsychological assessment research will be reviewed.
While several decades
of research with adults
have shown that
chronic heavy drinking
is associated with
adverse
consequences on the
adult brain, this
relationship has only
recently been
explored in the
adolescent brain.
Understanding the
effects of alcohol and
drug use on
adolescent
neurocognition is
crucial, being that
rates of use increase dramatically between ages 12 and 18. Epidemiological studies
have shown that past month alcohol use increases from 17% to 45% between 8 th and
12 th grade, and illicit drug use prevalence expands from 8% to 22%. Lifetime rates
indicate that 73% of youth have used alcohol and 48% have used illicit drugs by their
senior year of high school. In the past year, 23% of youth meet diagnostic criteria for a
substance use disorder (alcohol or drug abuse or dependence) by age 20.
While the developing brain may be more resilient to neurotoxic effects, exposure to
alcohol and drugs during a period of critical neurological development may interrupt the
natural course of brain maturation and key processes of brain development. In fact,
adolescence may be a period of heightened vulnerability for alcohol’s effect on the
brain. Cognitive deficits resulting from these alcohol and drug related neural insults
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have potentially harmful implications for subsequent academic, occupational, and social
functioning extending into adulthood. Therefore, neurocognitive sequelae from heavy
drinking and drug use are important to elucidate.
TYPICAL ADOLESCENT BRAIN DEVELOPMENT
Adolescence marks a period of rapid development between childhood and adulthood
involving complex social, biological, and psychological changes. The interactions of
these multidimensional factors have considerable implications for adolescent
development. Included in these alterations are substantial changes in the efficiency and
specialization of the adolescent brain, which is accomplished through synaptic
refinement and myelination. Synaptic refinement involves reductions in gray matter by
eliminating unnecessary neural connections. During adolescence, this synaptic pruning
occurs primarily in the prefrontal and temporal cortex and in subcortical structures such
as the striatum, thalamus, and nucleus accumbens. The adolescent brain also
undergoes increased myelination, which allows for improved integrity of white matter
fiber tracts and efficiency of neural conductivity. Higher-order association areas appear
to develop only after lower-order sensorimotor regions fully mature, with frontal lobes
being the final areas of the brain to complete development. Along with these
neuromaturational changes, it is suggested that increased myelination allows for
smoother, more efficient communication between frontal-subcortical brain regions,
allowing for better top-down cognitive control in adolescence.
In conjunction with these numerous brain transformations, shifting social influences and
peer group affiliation heavily impact adolescent behaviors. This may place youth at a
particularly heightened risk for initiating and continuing alcohol and drug use.
Specifically, transformations in the prefrontal regions and limbic systems are thought to
contribute to increased risk taking and novelty/sensation seeking behaviors. The
neuromaturation and neurochemical changes that are present during this period
correspond to a range of cognitive, emotional, and behavioral changes, and are
hypothesized to contribute to adolescents’ increased propensity for alcohol and drug
use.
ADOLESCENT SUBSTANCE USE AND NEUROCOGNITION
The current literature suggests that heavy drinking during adolescence does have a
subtle, but significant, deleterious effects on adolescent neurocognitive functioning.
Studies have found that adolescent heavy drinkers exhibit decrements in memory,
attention and speeded information processing, and executive functioning. In a study
comparing alcohol dependent and healthy control adolescents, Brown et al. found that
drinkers recalled 10% less verbal and nonverbal information than controls, even after
three weeks of monitored abstinence. A similar degree of reduction was found on
attentional and speeded information processing tasks in abstinent adolescent drinkers.
These findings are consistent with literature examining neurocognitive deficits in young
heavy drinkers, which found similar decreases on attention and information processing,
along with deficits in language competence and academic achievement. Deficits in
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executive functioning, specifically in future planning, abstract reasoning strategies, and
generation of new solutions to problems, have also been found.
While it has often been assumed that marijuana use is not linked to long-term cognitive
deficits, recent data suggest that even after four weeks of monitored abstinence,
adolescents who regularly smoke marijuana performed poorer on performance tests of
learning, cognitive flexibility, visual scanning, error commission, and working memory.
Further, the number of lifetime marijuana use episodes was significantly related to
overall poorer cognitive functioning, even after controlling for lifetime alcohol use.
We prospectively examined neuropsychological functioning in 26 youths with no
histories of alcohol or drug problems, and compared them to 47 youths with histories of
heavy adolescent alcohol, marijuana, and stimulant use. Follow-up neuropsychological
tests were given to the subjects seven different times across 8 years, on average
between the ages of 16 to 24. While there were no significant differences between
users and non-users on neurocognitive test scores at the first time point, heavy drinkers
performed worse on cognitive tasks at age 24 than light drinkers. In particular, those
who had a history of alcohol withdrawal symptoms (e.g., orthostatic hypotension,
nausea, insomnia, or irritability) were the most likely to have decreases in performance
scores, especially on tests of spatial functioning. Overall, heavy drinking during
adolescence was linked to a reduction in keeping up with age expectations.
In summary, adolescence is characterized by dramatic increases in rates of substance
use concurrent with ongoing neuromaturation. While neuropsychological studies have
shown that adolescent substance use is linked to poorer spatial, inhibitory, and learning
and memory functioning, neuroimaging techniques may elucidate the neural
mechanisms of these performance deficits.
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ADOLESCENT SUBSTANCE USE AND BRAIN STRUCTURE
Advances in neuroimaging have made it feasible to closely characterize the brain
structure and function of adolescent substance users and to pinpoint the circuitry and
regions that may subserve the neuropsychological deficits observed in adolescent
substance users.
Hippocampal Volume
Magnetic resonance imaging (MRI) was used to examine structural differences in the
hippocampus, an area of the brain crucial to intact memory functioning. Participants
were classified as: (1) light to non-drinkers (≤1 drink per month, ≤ 1 lifetime marijuana
use episode), (2) heavy drinking adolescents (history of consuming 4/5+ drinks in a
day), and (3) heavy marijuana users who also engaged in heavy episodic drinking.
Manual tracing techniques were employed by reliable raters, and revealed that heavy
drinkers had smaller left hippocampal volumes (p

Prefrontal Cortex Volume
During adolescence, the frontal lobe, an area of the brain associated with planning,
inhibition, emotion regulation, and integration of novel stimuli, goes through extensive
neuromaturation, increasing in efficiency and specialization. In a study comparing
prefrontal cortex volumes of adolescent heavy drinkers to non-drinkers and marijuana
and alcohol users, prefrontal volumes were smaller in heavy drinkers relative to controls
(p=.09) (see Figure 2). This difference was particularly pronounced in females (p

Quality of White Matter
Chronic alcoholic adults show clear abnormalities in brain white matter volume as well
as microstructural alterations in white matter tissue organization. Typically, less white
matter suggests dissipation of myelin-coated axons. Diffusion tensor imaging (DTI)
characterizes the integrity of water matter by examining the diffusion of water molecules
in white matter tissue. Therefore, DTI provides information on the organization of
localized white matter fiber tracts. Two commonly used scalar measurements are
fractional anisotropy (FA), which reflects white matter coherence by providing an
estimate of the directionally dependent movement of water molecules, and mean
diffusivity (MD), an index of the overall displacement of water molecules.
In a preliminary analysis, we looked at the effects of both binge drinking alone and with
combined marijuana use on white matter integrity. Forty-two participants (ages 16–19)
were identified as controls (n= 14), binge drinkers (≥ 4 drinks on an occasion for
females, ≥ 5 drinks on an occasion for males; n= 14), or binge drink+marijuana users
(n= 14). Adolescent participants received DTI with whole brain coverage. Diffusion
weighted data were collected on a 3-Tesla GE magnetic resonance scanner (repetition
time=12000 ms; echo time=93.4 ms; 36 × 3.0 mm thick axial slices; voxel resolution
1.875 × 1.875 × 3.0 mm 3 , b-value = 2000 s/mm 2 ). Diffusion-weighted images were
acquired in 15 directions, in addition to a normalization image (b=0) with no diffusion
encoding. Four volumes were acquired and averaged for each direction and the b = 0
volume. FA (or MD) maps from each participant were submitted to Tract-Based Spatial
Statistics (TBSS), which facilitated voxelwise between-group comparisons.
Significant group differences were found in eight white matter regions, including frontal
association fibers such as frontal-occipital and superior longitudinal fasciculi. Bingers
and binge+marijuana users displayed lower FA than controls (ps ≤ .016). Interestingly,
bingers demonstrated significantly lower FA than the binge+marijuana group (ps .014 to
.043). No significant MD differences were found in the 8 clusters identified by the FA
analyses. Our findings suggest poorer white matter integrity in adolescents with
histories of binge drinking than non-drinkers. However, teens with concomitant binge
drinking and marijuana use showed a lesser degree of reduced fiber tract coherence
than those engaging in binge drinking alone.
These findings are largely consistent with our previous structural imaging studies that
found small yet significant effects of marijuana use on adolescent brain structure and
function, and stronger associations between alcohol use and tissue status. In a study
that looked specifically at adolescents with alcohol use disorders, we found reduced
white matter microstructural integrity compared to demographically matched youths
without alcohol use disorders. Significantly lower FA was found in the splenium of the
corpus callosum, and trends for lower FA were also found in the rest of the corpus
callosum, suggesting possible alcohol-related white matter alterations. The callosal
fibers are a massive collection of white matter tissue that connect the left and right
hemispheres of the brain, and are important for efficient transfer of inform ation.
Microstructural changes in the corpus callosum may underlie neurocognitive changes
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associated with alcohol use during adolescent brain maturation. Notably, decreased
white-matter integrity was significantly related to longer duration of heavy alcohol use,
greater number of past alcohol withdrawal symptoms, and recent consumption of large
amounts of alcohol.
Overall, our findings of reduced FA suggest possible myelination alterations in brain
regions developing during adolescence, and underscore the impact of the effects of
alcohol on white matter maturation during adolescence. Our more recent findings
indicate that even subtle binge drinking behaviors can have a substantial impact on
tissue development, as adolescents with both alcohol use disorders as well as less
frequent or new-onset binge drinking habits were found to have altered white matter
integrity. Future studies will follow these cohorts over the adolescent years to see if
changes in substance use are followed by changes in indices of white matter quality.
Brain Blood Flow
Understanding cerebral blood flow (CBF) is important since inadequate blood flow can
damage brain tissue. CBF can also influence the blood oxygen dependent signal
interpreted in functional magnetic resonance imaging (fMRI). Moreover, chronic
alcoholics have been shown to have reduced blood flow into the brain. In a study
examining CBF in alcohol dependent young women (n=8), we found decreases as
compared to female light drinkers (n=8) using perfusion-weighted magnetic resonance
imaging. In these 18–25 year-olds, decreases were seen in six prefrontal and parietal
regions (η 2 = .47 to .83), and there were no regions in which perfusion was greater for
alcohol dependent participants compared to controls. These findings may help clarify
the metabolic changes behind differences in functional brain activity seen in
adolescents with histories of alcohol misuse.
ADOLESCENT SUBSTANCE USE AND BRAIN FUNCTIONING
In addition to alterations in brain structure, recent findings have suggested decrements
in brain functioning associated with adolescent substance use. Functional magnetic
resonance imaging (fMRI) investigates neural activity of the brain by measuring
changes in blood oxygen level dependent (BOLD) signal, which indicates areas of
increased activation in response to a mental task or stimulus. This technique is
noninvasive and does not require injections or radioactive materials, making it a safe
and appropriate technique for examining adolescent brain functioning.
Spatial Working Memory
Numerous studies involving adult alcoholics suggest neural disruption while executing
cognitive tasks; however, it is unclear to what extent drinking must progress, and at
what age, before abnormalities manifest. Our group found that adolescents who drank
heavily for one to two years showed abnormalities in brain response on cognitive tasks
measuring spatial working memory (SWM) as compared to light drinkers. While both the
heavy and light drinkers performed similarly on the task, heavy drinkers exhibited
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increased activation in the parietal lobe, with decreased activation in the occipital and
cerebellar regions, compared to light drinkers. Additionally, youth with more hangover
experiences and greater alcohol consumption showed greater abnormalities. These
results suggest that after as little as one to two years of heavy drinking, adolescents
may exhibit subtle neural reorganization that includes compensation, highlighting the
potential early influence of drinking on neurocognitive functioning during the escalation
of alcohol use disorders.
In another study by our lab, young adults who had engaged in four to five years of
heavy drinking showed poorer performance on the same SWM task during fMRI, in
addition to decreased activation in parietal and frontal regions. Together, these results
suggest that the adolescent brain may be able to compensate for subtle neural
abnormalities associated with drinking; however, repeated heavy drinking episodes may
interfere with the brain’s ability to make up for alcohol-related deficiencies in neural
functioning.
Additional studies from our laboratory (e.g., compared young adult marijuana users
(ages 16–18) after one month of abstinence to matched controls on the same SWM
task described in the
previous studies. Although
there were no differences
in task performance
between the marijuana
users and controls, the
marijuana users exhibited
increased activation in
parietal, temporal, and
frontal (including insula)
brain regions. The
marijuana users also
showed less activation in
cerebellum and occipital
cortices than controls.
Findings remained
significant after controlling for alcohol and other drug use, and also suggest
compensatory and possibly inefficient SWM-related neural response associated with
marijuana use.
Verbal Encoding
Decrements in verbal encoding abilities have also been observed in binge drinking
adolescents during fMRI tasks involving recall of learned word pairs. Compared to
nondrinkers, bingers showed less response in right superior frontal and bilateral
posterior parietal cortices, with more response in occipital cortex, during the verbal
encoding task. This suggests less utilization of working memory systems during
encoding for bingers compared to nondrinkers on tasks of encoding. In addition,
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drinkers encoded marginally fewer words than nondrinkers (p=.07), and had no
differential activation to novel stimuli. Together, these results suggest slightly poorer
initial verbal learning, disadvantaged verbal processing, and decelerated learning for
adolescents who engage in binge drinking compared to abstinent adolescents.
Further studies in our laboratory comparing verbal encoding abilities between
adolescents reporting marijuana use and matched controls have found no differences
on task performance. Yet, marijuana users evidence more frontal and less temporal
activation compared to matched controls. Although both groups performed similarly on
the fMRI task, adolescent marijuana users have shown poorer performance on sensitive
measures administered as part of an extensive neuropsychological test battery (e.g.,
California Verbal Learning Test-II, Wechsler Memory Scale-III Story Memory),
particularly on initial learning trials. Taken together, changes in brain activation in
adolescent marijuana users on a verbal encoding task may be indicative of less
allocation of attentional resources toward encoding the novel material.
Inhibition
In addition to decrements in spatial working memory and verbal encoding, modestly
decreased ability to inhibit behaviors has been found in binge drinking adolescents. A
pilot study from our group found greater BOLD response relative to controls in the
frontal areas and less activation in the cerebellar areas during a go/no-go task of
response inhibition administered during fMRI, despite similar task performance. On
response selection (“go”) trials, drinkers exhibited less BOLD response than controls in
the mid-cingulate, subcortical, and temporal areas. Better task accuracy was linked to
more frontal response during these trials among controls, but not among drinkers
(p

abstinence. Such increased neural processing effort to achieve inhibition may predate
the onset of regular use, or result from it.
Cue Reactivity
Adolescent response to alcohol advertising is of concern, as they are exposed to
alcohol-related ads on a daily basis in many countries. We have observed that heavy
drinking youth show greater brain activation while viewing alcohol advertisements than
they do to non-alcohol beverage ads. This substantially greater brain activation to
alcoholic beverage pictures was observed throughout the brain, particularly in the
prefrontal area, nucleus accumbens, hypothalamus, posterior cingulate, and temporal
lobe, and was prominent in the left hemisphere, limbic, and visual cortices. This
suggests that reward, visual attention limbic, appetitive, and episodic memory systems
were preferentially invoked in response to alcohol ads relative to non-alcohol ads in
heavy drinking teens. Only the inferior frontal gyrus showed more activation in light
drinkers during the task, potentially indicating a negative valence to these alcohol stimuli
in non-drinking teens. Overall, light drinkers showed more response to non-alcoholic
beverage pictures. These findings extend previous studies in adults, and link alcohol
advertisement exposure in youth to activation in reward, desire, positive emotion, and
episodic recall brain areas.
Predicting Relapse
Relapse is a common
clinical problem in
individuals with substance
dependence. Previous
studies have implicated a
multifactorial process
underlying relapse;
however, the contribution
of specific neural
substrates had yet to be
examined. We looked at
whether results from
functional imaging shortly
after drug cessation could
predict relapse in stimulant dependent individuals. The goals were to evaluate the
neurobiology of decision-making dysfunction in stimulant dependent subjects, and to
determine if functional imaging could be used as a tool to predict relapse.
Participants included treatment seeking methamphetamine dependent adult males
(N=46). All individuals underwent fMRI three to four weeks after cessation of substance
use. Of the 40 subjects who were followed a median of 370 days, 18 relapsed and 22
did not. The main outcome measure was BOLD activation during a simple two-choice
prediction task. During the prediction task, a house was presented, flanked by a person
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on its left and right. The participant decided on which side of the house a car would
appear. Each trial was self-paced to maximize self-determined action, thus the subject
determined the number of trials by the latency to select a response. Immediately
following the subject’s response, the car was presented for 300 ms on the far left or
right side. The screen provided the feedback whether the prediction was correct.
Unbeknownst to the participant, the computer determined the response based on the
participant’s selection. Three error rate block types included a high chance level (20% of
responses were “correct”), a 50% chance-level, and a low (80% of responses were
“correct”) chance level. The task captures the key elements of decision-making: the
probability of an outcome associated with an option, the positive or negative
consequence, and the magnitude of the consequence.
The fMRI activation patterns in right insular, posterior cingulate, and temporal cortex
correctly predicted 20 out of 22 subjects who did not relapse, and 17 out of 18 subjects
who did. A Cox regression analysis revealed that the combination of right middle frontal
gyrus, middle temporal gyrus, and posterior cingulate activation best predicted the time
to relapse. In total, this is the first investigation to show that fMRI can be used to predict
relapse in substance dependent individuals. It is likely that relapse corresponds with
less activation in structures that are critical for decision-making, and thus poor decisionmaking
sets the stage for relapse. The insular cortex may act through the interoceptive
system to influence ability to differentiate between good versus poor choices, while the
inferior parietal lobule may play a role in poor assessment of decision-making situations
and subsequent reliance on habitual behavior. Overall, substance dependent adults
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show brain patterns that can be used to predict whether and when relapse may occur.
Future studies are needed to determine if this is true for adolescents, and whether brain
activation patterns can be used to evaluate an individuals’ readiness for treatment
completion or treatment response.
Summary
Overall, changes in brain functioning in adolescents differ by substance use pattern.
Research has shown that heavy drinking during adolescence can lead to decreased
performance on cognitive tasks of memory, attention, spatial skills, and executive
functioning. These behavioral ramifications of heavy alcohol use may emerge as a
consequence of the reduced volume of important brain structures (e.g., hippocampus),
compromised quality of white matter, and abnormalities in activation during cognitive
tasks. Studies have also shown that marijuana use during adolescence can result in
decreases in cognitive functioning, particularly learning and sequencing scores. In
integrating and interpreting the results of adolescent marijuana studies from our
laboratory, it is important to note that the groups are generally equivalent on task
performance, and therefore the underlying brain responses in controls and users can be
largely assumed to represent activity to the same mental action. Corresponding
marijuana-related changes in cognition may be related to increases in gray matter
tissue volume, decreases in white matter microstructural integrity, and increases in
neuronal activation during cognitive tasks.
In sum, we can reasonably rule out recent use as accounting for the observed
differences between substance groups, given that participants in some studies have
been abstinent one month or greater. Substance using adolescents have been found to
differ from non-users on neuropsychological performance, brain tissue volume, white
matter integrity, and functional brain response. Longitudinal studies are essential to fully
understand how alcohol and marijuana use affect adolescent neurodevelopment.
METHODOLOGICAL CONSIDERATIONS
The cross-sectional nature of the majority of studies examining adolescent
neurocognitive functioning makes it difficult to determine the influence of alcohol and
drug use on adolescent neurocognition. Therefore, ongoing longitudinal neuroimaging
studies are essential to ascertain the degree to which substance intake is linked
temporally to adverse changes on indices of brain integrity, or whether neural
abnormalities reflect pre-existing patterns. In cross-sectional or longitudinal work,
several methodological features are critical to evaluate the potential influence of
adolescent substance use on neurocognition. These issues pertain to ensuring
participant compliance, accurately assessing potential confounds, and maximizing
participant follow-up.
Adolescent compliance as a research participant can be maximized by attending to
rapport, building trust, and ensuring privacy of self-report data to the extent that is
ethical and feasible to the setting. For behavioral tasks within or outside of imaging, it is
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critical to ensure participants comprehend task instructions, are fully trained on fMRI
tasks, and then are given reminders just prior to task administration. Motion during scan
acquisition is detrimental to the quality of imaging data, and is often worse in younger
adolescents than older teens or adults. Adolescent head motion can be minimized by
the following steps: discuss the importance and rationale for keeping the head still
multiple times before and at the scan appointment; model and practice how to say “yes”
and “no” when communicating with the research subject from the scanner; model and
practice techniques for relaxing and ensuring subjects are in a position suitable for longterm
comfort (e.g., legs are not crossed) before scanning begins; maximize participant
comfort by using soft cushions around the head and under the knees; and many
studies, especially those with younger participants, find practicing scanning in a less
expensive mock scanner results in improved participant comfort and more reliable data
during data acquisition.
Accurately measuring and
accounting for confounds
frequently present in adolescent
substance-using populations is
essential for elucidating the true
effect of substance use on
adolescent neurocognitive
functioning. Common confounds
in this population include head
injury, depression, ADHD,
conduct disorder, prenatal
exposure to neurotoxins, family
history-related effects, and
polysubstance involvement.
Conversely, excluding subjects for the aforementioned confounds may impede the
generalizability of results. The tradeoff between minimizing confounds and having
meaningful, ecologically valid results is an important study design decision, especially
given the high cost of fMRI sessions.
Accurately measuring abstinence is another important consideration in substancerelated
research protocols. If abstinence is required for participation (and compensation)
in a study, the dynamics of self-report could change. While biological data may help
confirm self-report, these measures are imperfect and do not pinpoint the quantity of
specific timing of substance intake. Regarding abstinence from cannabis, obtaining
serial quantitative THC metabolite levels, normalized to creatinine, is the best approach
for guarding against new use episodes.
Tracking participants over time is a critical part of many clinical issues when interested
in the degree to which a variable (e.g., alcohol or marijuana use) might result in neural
changes. Although some statistical approaches can help manage attrition, effective
tracking procedures are more desirable to ensure study integrity. To maximize
participant follow-up, frequent contact with participants must be maintained. Having a
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well-trained, friendly staff experienced with the population also helps retain participants
and parents, and ensures that all participants fully understand the tasks and
expectations during the study. Collecting comprehensive contact information can help
track adolescents over time in case they should relocate. Additionally, follow-up
measures and procedures should be as similar as possible to baseline, except to
mitigate learning and practice effects. For imaging studies, field map unwarping of EPIs
(e.g., fMRI and DTI) should also be considered, as this technique appears to produce
more consistent localization of activations. Finally, as technical problems are common,
back up plans for each piece of equipment used in the neuroimaging session should be
in place.
CONCLUSIONS
Current research suggests that substance use in adolescence leads to abnormalities in
brain functioning, including poorer neurocognitive performance, white matter quality,
changes in brain volume, and abnormal neuronal activation patterns. fMRI studies have
illuminated enhanced cue response in adolescent drinkers, and have shown the
potential to predict treatment outcomes in stimulant dependent adults.
A few questions still remain, such as whether heavy substance use during adolescence
causes cognitive impairments and changes in neurodevelopment, if and when are
critical periods of heightened vulnerability to such effects, and if observed abnormalities
remit with reduced use. We have the capability to design studies in which we restrict or
control for nicotine and most other drug use, but few adolescent drug users do not also
use alcohol. It is also important to understand if results generalize to youth with
psychiatric problems, other substance use histories, and low socioeconomic status, and
to further explore implications for changes in brain activation for learning and behavioral
control, along with mood and psychiatric illness. Harder parametric tasks that include
conditions on which behavior does differ between groups would help us better
understand the cognitive domains we have observed differences on. Lastly, we need to
better understand the biochemical changes that may mediate macrostructural,
microstructural, and functional neuronal changes in response to substance use, such as
cannabinoid receptor activity changes. Multimodal approaches to neuroimaging may
help us disentangle such questions (e.g., PET, spectroscopy).
Our group is currently conducting longitudinal studies of adolescent substance users as
well as youth at risk for substance problems due to family history or early conduct
disorder (minimal use at the time of the first imaging session). Follow-up scan data,
already underway, will elucidate if substance use during the follow-up interval predicts
changes in brain functioning. These investigations will ascertain if: (1) substance
(alcohol and marijuana, predominantly, given sample characteristics) use during
adolescence seems to cause detrimental changes in neurodevelopment, or if (2)
substance use does not account for the differences, the previously observed differences
would likely represent pre-existing markers of risk for heavy substance use during
adolescence.
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IV. The Effects of Drugs & Alcohol on the
Adolescent Brain
Overview
Though it has long been known that teenagers are prone to impulsive behavior, to
emotional rather than logical thinking, and to not fully considering the long-term
consequences of their actions, only recently has neuroscience and MRI technology
provided an understanding of why. The teenage brain, it turns out, is a brain still
developing. To understand the risks associated with psychoactive substances in
adolescents, it helps to understand that teenagers are not just less-experienced adults;
they are undergoing an important yet challenging developmental stage in which that
they are prone to errors of judgment, and sensitive to neurological assault by
psychoactive substances. More than any other age group adolescents are at risk for
substance addiction, and more than any other age group they risk permanent
intellectual and emotional damage due to the effects of drugs.
Normal Adolescent Brain Development
The human brain is sculpted by experience. At birth, the brain contains many more
neural connections than it could possible use, but these connections are unspecialized
and undeveloped. As time passes some connections are strengthened (such as the
nerves that process the sight of a mother's face or sound of a siblings' voice) and others
are pruned away.
The process of refinement and pruning continues throughout childhood, adolescence,
and even into early adulthood. The most marked development in adolescence is in the
brain's frontal lobe and outer mantle. The pre-frontal cortex, located in the frontal lobe,
executes such skills as setting priorities, formulating strategies, allocating attention and
controlling impulses; the outer mantle is involved with processing abstract information
and understanding rules, laws and codes of social interaction.
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The behaviors that accompany these changes are transparent. Teenagers are notorious
for their obsession with social interaction, for making up social rules and breaking them.
As teenagers grow into young adults they often exhibit a fascination with abstract
thinking on topics like history, culture and media, which demonstrates their growing
ability to understand the larger world. While the teenage brain is in some ways ill
equipped to make decisions and choices without the help of trusted adults, it is perfectly
designed for the types of intellectual and social challenges teenagers most need to
master.
Still, development of fully mature complex thinking takes a long time. MRI studies show
that the development of the prefrontal cortex and outer mantle of the brain continues
into the early 20s, and may not be completed until the mid 20s. As the wiring for logical
thought is used more and more over time the connections become more robust, and
when this process nears completion, parts of nerves become coated in a fatty layer
called a “myelin sheath.” Like insulation on a wire, this fatty layer allows the nerve
connections to process faster, making rational, reasoned decision-making quicker and
more automatic.
Effects of Drugs on the Developing Brain
There are many ways that psychoactive substances can alter or damage the
development of the adolescent brain. Firstly, psychoactive substances often target and
alter function of neurotransmitters, the chemical messengers that allow nerves to
communicate at their junctions. Interference with neurotransmitters can directly damage
fragile developing neural connections. Secondly, use of these substances alters
perception and may interfere with the developing perceptual skills. And finally, the
habits and choices associated with the use of drugs and alcohol slowly become
ingrained in the wiring of the brain. Repeated action becomes habit and the habits of
thought, perception, and reasoning developed in childhood and adolescence can stay
with a person throughout his or her lifetime.
Neurotransmitter Function
Alterations in neurotransmitter function are partially responsible for both the high
addiction potential and the devastating effects of substance use. The neurotransmitter
dopamine links the nerves in the outer mantle and prefrontal cortex of the brain and is
associated with the feelings of motivation and reward. When adolescents use the
problem solving circuitry of the brain, they experience feelings of both reward and
motivation. Over time teens become more and more motivated to think through
problems, and more likely to develop better solutions as they refine the neural circuitry
associated with these skills.
Methamphetamines and Cocaine are known to cause a flood of dopamine into the
brain. This is one reason for the extreme addiction potential of these drugs: their use is
associated with a tremendous sense of reward. It has been found, though, that cocaine
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addicts have a blunted perception for certain types of reward, and it is hypothesized that
cocaine, and by extension methamphetamines, over time override the brain's ability to
sense rewards accurately in day-to-day interactions. The effects of these drugs can be
devastating not only to intellectual development, but to the very ability of the user to feel
satisfaction from life.
Alterations in Perception
Perceptual changes caused by drugs can also have long-term complications for
adolescent development, since adolescent perceptive abilities are not fully mature. For
example, MRI studies show that adults tend to use the frontal lobes, or logical problem
solving, to determine facial expressions while adolescents use the amygdala, an area
which normally processes emotions such as fear and worry. It holds true in many
studies that where adults use problem solving areas of the brain to perceive the world
adolescents use the more primitive areas of the brain more associated with emotions,
and self-preservation; it also holds true that adult perception is generally more accurate.
Marijuana, like all drugs, changes perception. And like most drugs, it engenders
perception that is fearful, emotional, defensive, and often inaccurate. Though the short
term addiction potential of marijuana may be less than other drugs, the long-term impact
of chronic marijuana use can be profound. Determining the feelings and motives of
other people is necessary to function as an adult in society. If marijuana use is chronic
or constant enough to hinder perceptual maturation, an adolescent user may encounter
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misunderstood failures in school, work, and relationships, which in turn re-enforce the
desire to retreat to drugs.
Habit and the Hard Wiring of the Brain
As self-help gurus are quick to point out, if you do something for long enough it
becomes automatic. Nowhere does this wisdom more hold true than in adolescence.
Though teens may change clothes, ideas, friends and hobbies with maddening
frequency, they are developing ideas about themselves, their world and their place in it
that will follow them for the rest of their lives. Adults may spend years trying to create or
break even the simplest habit, yet most adults find that their most profound ideas about
themselves and the world were developed in high school or college. This is because, by
age 25 or so the brain is fully developed and building new neural connections is a much
slower process.
Conclusion
Early detection and treatment is essential to heading off the development of substance
addiction in adolescents. Given their brain development, teenagers cannot be expected
to understand the full range of consequences in their choices regarding drugs and
alcohol. The disease must be prevented, and where it cannot be prevented it must be
cured while there is still time for a full recovery.
Information Taken from The Adolescent Brain: A Work in Progress , Daniel R.
Weinberger, MD, Brita Elvevag, PhD, and Jay N. Giedd, MD, for The National Campaign
to Prevent Teen Pregnancy, 2005. …
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V. The Long-Term Effects of
Alcohol on Teenagers
Alcohol is one of the most commonly used and abused drugs by teenagers across the
United States. Drinking can have short-term effects on the teen’s life. But, also causes a
lot of long-term consequences as well. Drinking as a teen can actually be more
damaging, as the teen brain is in a crucial stage of development. Heavy or regular
drinking during this time can end up causing lifelong brain damage, impairment to brain
function, and it can put you at risk for developing a host of health problems. Starting to
drink as a teen also puts you at risk of developing alcoholism as an adult. A lot of adults
assume that alcohol affects teens in the same manner it does adults, however, this
simply isn’t true. Below we dive into the long-term effects of alcohol on teenagers.
1. Has a Negative
Influence on Adult
Brain Structure
New research
suggests that heavy
drinking as a teen
influences the
development of your
brain structure as an
adult. When you’re
younger the brain is
primarily focused on
growth and generating
new cells. Once you’re
an adolescent this
shifts towards creating
new neural pathways.
These new neural
pathways help to
relate information to
different parts of the
brain. Research
suggests that drinking
through the teen years
will reduce the ability
to complete memory
oriented tasks, and
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can even impair the development of the frontal regions of the brain.
2. Increases Your Risk of Adult Alcoholism
People who start drinking as teens greatly increase their chances of developing
alcoholism as an adult. Drinking when you are young increases your chances of
developing with a lifelong problem. In fact, teens who drink before the age of 15 are
40% more likely to develop alcohol dependency as an adult. The earlier a person
begins drinking the more likely they are to develop alcohol-related problems as an adult.
If you’re a parent of a teen who you suspect is drinking, it’s important to talk to them, or
get them the required help as soon as possible.
3. Frequent Alcohol Use Can Bring About Co-Occurring Disorders
Drinking alcohol on a regular basis has been linked to a number of disorders, including:
low self esteem
anxiety disorders
antisocial behavior
increased chances of dependency on other drugs
Frequent use of alcohol will bring out, or enable, any existing disorders. In order to
effectively deal with any issues with alcohol that might be present, you’ll also need to
treat any existing symptoms.
4. Can Develop Several Long Term Health Conditions
Chronic health issues may not be seen immediately, as they take much longer to show
up. However, heavy drinking as a teen will put at you an increased risk towards
developing serious health problems as an adult. Some of the health problems are as
follows:
liver cirrhosis
anemia
hypertension
pancreatitis
hepatitis
heart problems
cancer
Chronic alcohol use as a teen, especially, if the use is continued as an adult, will only
increase your chances of developing any of the above disorders. Alcohol wreaks havoc
on your health as an adult, and the problems you experience as you age will only
become amplified by teenage drinking.
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5. Short Term Impairment Can Have Long-Term Consequences
Even a one time drinking episode as a teen can have a negative influence on the rest of
your life. Since drinking greatly impairs your ability to make good decisions, you could
end up becoming serious injured, or arrested. Both of these events will negatively inhibit
your future. When you’re young drinking can seem like all fun and games, until you run
into a serious problem, like being arrested for drinking and driving, or sustaining a lifethreatening
injury while under the influence. If you’re the parent of a teen you suspect
might be drinking, it’s crucial you intervene and inform them about the dangers of
drinking, or get them the help and support they require.
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VI. Evidence-Based Approaches to Treating
Adolescent Substance Use Disorders
Research evidence supports the effectiveness of various substance abuse treatment
approaches for adolescents. Examples of specific evidence-based approaches are
described below, including behavioral and family-based interventions as well as
medications. Each approach is designed to address specific aspects of adolescent drug
use and its consequences for the individual, family, and society. In order for any
intervention to be effective, the clinician providing it needs to be trained and wellsupervised
to ensure that he or she adheres to the instructions and guidance described
in treatment manuals. Most of these treatments have been tested over short periods of
12–16 weeks, but for some adolescents, longer treatments may be warranted; such a
decision is made on a case-by-case
basis. The provider should use clinical
judgment to select the evidence-based
approach that seems best suited to the
patient and his or her family.*
Behavioral Approaches
Behavioral interventions help
adolescents to actively participate in
their recovery from drug abuse and
addiction and enhance their ability to
resist drug use. In such approaches,
therapists may provide incentives to
remain abstinent, modify attitudes and
behaviors related to drug abuse, assist families in improving their communication and
overall interactions, and increase life skills to handle stressful circumstances and deal
with environmental cues that may trigger intense craving for drugs. Below are some
behavioral treatments shown to be effective in addressing substance abuse in
adolescents (listed in alphabetical order).
Group Therapy for Adolescents
Adolescents can participate in group therapy and other peer support programs during
and following treatment to help them achieve abstinence. When led by well-trained
clinicians following well-validated Cognitive-Behavioral Therapy (CBT) protocols, groups
can provide positive social reinforcement through peer discussion and help enforce
incentives to staying off drugs and living a drug-free lifestyle.
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However, group treatment for adolescents carries a risk of unintended adverse effects:
Group members may steer conversation toward talk that glorifies or extols drug use,
thereby undermining recovery goals. Trained counselors need to be aware of that
possibility and direct group activities and discussions in a positive direction.
Adolescent Community Reinforcement Approach (A-CRA)
A-CRA is an intervention that seeks to help adolescents achieve and maintain
abstinence from drugs by replacing influences in their lives that had reinforced
substance use with healthier family, social, and educational or vocational reinforcers.
After assessing the adolescent’s needs and levels of functioning, the therapist chooses
from among 17 A-CRA procedures to address problem-solving, coping, and
communication skills and to encourage active participation in constructive social and
recreational activities.
Cognitive-Behavioral Therapy (CBT)
CBT strategies are based on the theory that learning processes play a critical role in the
development of problem behaviors like drug abuse. A core element of CBT is teaching
participants how to anticipate problems and helping them develop effective coping
strategies. In CBT, adolescents explore the positive and negative consequences of
using drugs. They learn to monitor their feelings and thoughts and recognize distorted
thinking patterns and cues that trigger their substance abuse; identify and anticipate
high-risk situations; and apply an array of self-control skills, including emotional
regulation and anger management, practical problem solving, and substance refusal.
CBT may be offered in outpatient settings in either individual or group sessions (see
"Group Therapy for Adolescents") or in residential settings.
Contingency Management (CM)
Research has demonstrated the effectiveness of treatment using immediate and
tangible reinforcements for positive behaviors to modify problem behaviors like
substance abuse. This approach, known as Contingency Management (CM), provides
adolescents an opportunity to earn low-cost incentives such as prizes or cash vouchers
(for food items, movie passes, and other personal goods) in exchange for participating
in drug treatment, achieving important goals of treatment, and not using drugs. The goal
of CM is to weaken the influence of reinforcement derived from using drugs and to
substitute it with reinforcement derived from healthier activities and drug abstinence. For
adolescents, CM has been offered in a variety of settings, and parents can be trained to
apply this method at home. CM is typically combined either with a psychosocial
treatment or a medication (where available). Recent evidence also supports the use of
Web-based CM to help adolescents stop smoking.
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Motivational Enhancement Therapy (MET)
MET is a counseling approach that helps adolescents resolve their ambivalence about
engaging in treatment and quitting their drug use. This approach, which is based on a
technique called motivational interviewing, typically includes an initial assessment of the
adolescent’s motivation to participate in treatment, followed by one to three individual
sessions in which a therapist helps the patient develop a desire to participate in
treatment by providing non-confrontational feedback. Being empathic yet directive, the
therapist discusses the need for treatment and tries to elicit self-motivational statements
from the adolescent to strengthen his or her motivation and build a plan for change. If
the adolescent resists, the therapist responds neutrally rather than by contradicting or
correcting the patient. MET, while better than no treatment, is typically not used as a
stand-alone treatment for adolescents with substance use disorders but is used to
motivate them to participate in other types of treatment.
Twelve-Step Facilitation Therapy
Twelve-Step Facilitation Therapy is designed to increase the likelihood that an
adolescent with a drug abuse problem will become affiliated and actively involved in a
12-step program like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Such
programs stress the participant’s acceptance that life has become unmanageable, that
abstinence from drug use is needed, and that willpower alone cannot overcome the
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problem. The benefits of 12-step participation for adults in extending the benefits of
addiction treatment appear to apply to adolescent outpatients as well, according to
recent research. Research also suggests adolescent-specific 12-step facilitation
strategies may help enhance outpatient attendance rates.
Behavioral interventions help adolescents to actively participate in their recovery from
drug abuse and addiction and enhance their ability to resist drug use.
Family-Based Approaches
Family-based approaches to treating adolescent substance abuse highlight the need to
engage the family, including parents, siblings, and sometimes peers, in the adolescent’s
treatment. Involving the family can be particularly important, as the adolescent will often
be living with at least one parent and be subject to the parent’s controls, rules, and/or
supports. Family-based approaches generally address a wide array of problems in
addition to the young person’s substance problems, including family communication and
conflict; other co-occurring behavioral, mental health, and learning disorders; problems
with school or work attendance; and peer networks. Research shows that family-based
treatments are highly efficacious; some studies even suggest they are superior to other
individual and group treatment approaches. Typically offered in outpatient settings,
family treatments have also been tested successfully in higher-intensity settings such as
residential and intensive outpatient programs. Below are specific types of family-based
treatments shown to be effective in treating adolescent substance abuse.
Brief Strategic Family Therapy (BSFT)
BSFT is based on a family systems approach to treatment, in which one member’s
problem behaviors are seen to stem from unhealthy family interactions. Over the course
of 12–16 sessions, the BSFT counselor establishes a relationship with each family
member, observes how the members behave with one another, and assists the family in
changing negative interaction patterns. BSFT can be adapted to a broad range of family
situations in various settings (mental health clinics, drug abuse treatment programs,
social service settings, families’ homes) and treatment modalities (as a primary
outpatient intervention, in combination with residential or day treatment, or as an
aftercare/continuing-care service following residential treatment).
Family Behavior Therapy (FBT)
FBT, which has demonstrated positive results in both adults and adolescents, combines
behavioral contracting with contingency management to address not only substance
abuse but other behavioral problems as well. The adolescent and at least one parent
participate in treatment planning and choose specific interventions from a menu of
evidence-based treatment options. Therapists encourage family members to use
behavioral strategies taught in sessions and apply their new skills to improve the home
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environment. They set behavioral goals for preventing substance use and reducing risk
behaviors for sexually transmitted diseases like HIV, which are reinforced through
a contingency management (CM) system. Goals are reviewed and rewards provided at
each session.
Involving the family can be particularly important in adolescent substance abuse
treatment.
Functional Family Therapy (FFT)
FFT combines a family systems view of family functioning (which asserts that unhealthy
family interactions underlie problem behaviors) with behavioral techniques to improve
communication, problem-solving, conflict resolution, and parenting skills. Principal
treatment strategies include (1) engaging families in the treatment process and
enhancing their motivation for change and (2) modifying family members’ behavior
using CM techniques, communication and problem solving, behavioral contracts, and
other methods.
Undertreating a substance use disorder will increase the risk of relapse.
Multidimensional Family Therapy (MDFT)
MDFT is a comprehensive family- and
community-based treatment for substanceabusing
adolescents and those at high risk for
behavior problems such as conduct disorder
and delinquency. The aim is to foster family
competency and collaboration with other
systems like school or juvenile justice.
Sessions may take place in a variety of
locations, including in the home, at a clinic, at
school, at family court, or in other community
locations. MDFT has been shown to be
effective even with more severe substance
use disorders and can facilitate the
reintegration of substance abusing juvenile
detainees into the community.
Multisystemic Therapy (MST)
MST is a comprehensive and intensive familyand
community-based treatment that has
been shown to be effective even with adolescents whose substance abuse problems
are severe and with those who engage in delinquent and/or violent behavior. In MST,
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the adolescent’s substance abuse is viewed in terms of characteristics of the adolescent
(e.g., favorable attitudes toward drug use) and those of his or her family (e.g., poor
discipline, conflict, parental drug abuse), peers (e.g., positive attitudes toward drug use),
school (e.g., dropout, poor performance), and neighborhood (e.g., criminal subculture).
The therapist may work with the family as a whole but will also conduct sessions with
just the caregivers or the adolescent alone.
Addiction Medications
Several medications have been found to be effective in treating addiction to opioids,
alcohol, or nicotine in adults, although none of these medications have been approved
by the FDA to treat adolescents. In most cases, only preliminary evidence exists for the
effectiveness and safety of these medications in people under 18, and there is no
evidence on the neurobiological impact of these medications on the developing brain.
However, despite the relative lack of evidence, some health care providers do use
medications “off-label” when treating adolescents (especially older adolescents) who
are addicted to opioids, nicotine, or (less commonly) alcohol. Newer compounds
continue to be studied for possibly treating substance use disorders in adults and
adolescents, but none other than those listed here have shown conclusive results.
Note that there are currently no FDA-approved medications to treat addiction to
cannabis, cocaine, or methamphetamine in any age group.
Opioid Use Disorders
Buprenorphine reduces or eliminates opioid withdrawal symptoms, including drug
cravings, without producing the “high” or dangerous side effects of heroin and other
opioids. It does this by both activating and blocking opioid receptors in the brain (i.e., it
is what is known as a partial opioid agonist). It is available for sublingual (under-thetongue)
administration both in a stand-alone formulation (called Subutex ® ) and in
combination with another agent called naloxone. The naloxone in the combined
formulation (marketed as Suboxone ® ) is included to deter diversion or abuse of the
medication by causing a withdrawal reaction if it is intravenously injected.Physicians
with special certification may provide office-based buprenorphine treatment for
detoxification and/or maintenance therapy. It is sometimes prescribed to older
adolescents on the basis of two research studies indicating its efficacy for this
population, even though it is not approved by the FDA for pediatric use.*
Adolescent drug abuse treatment is most commonly offered in outpatient settings.
Methadone also prevents withdrawal symptoms and reduces craving in opioid-addicted
individuals by activating opioid receptors in the brain (i.e., a full opioid agonist). It has a
long history of use in treatment of opioid dependence in adults, and is available in
specially licensed methadone treatment programs. In select cases and in some States,
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opioid-dependent adolescents between the ages of 16 and 18 may be eligible for
methadone treatment, provided they have two documented failed treatments of opioid
detoxification or drug-free treatment and have a written consent for methadone signed
by a parent or legal guardian.
Naltrexone is approved for the prevention of relapse in adult patients following
complete detoxification from opioids. It acts by blocking the brain’s opioid receptors (i.e.,
an opioid antagonist), preventing opioid drugs from acting on them and thus blocking
the high the user would normally feel and/or causing withdrawal if recent opioid use has
occurred. It can be taken orally in tablets or as a once-monthly injection given in a
doctor’s office (a preparation called Vivitrol ® ).
Alcohol Use Disorders
Acamprosate (Campral ® ) reduces withdrawal symptoms by normalizing brain systems
disrupted by chronic alcohol consumption in adults.
Disulfiram (Antabuse ® ) inhibits an enzyme involved in the metabolism of alcohol,
causing an unpleasant reaction if alcohol is consumed after taking the medication.
Naltrexone decreases alcohol-induced euphoria and is available in both oral tablets
and long-acting injectable preparations (as in its use for the treatment of opioid
addiction, above).
Nicotine Use Disorders
Bupropion, commonly prescribed for depression, also reduces nicotine cravings and
withdrawal symptoms in adult smokers.
Nicotine Replacement Therapies (NRTs) help smokers wean off cigarettes by
activating nicotine receptors in the brain. They are available in the form of a patch, gum,
lozenge, nasal spray, or inhaler.
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Varenicline reduces nicotine cravings and withdrawal in adult smokers by mildly
stimulating nicotine receptors in the brain.
* According to the FDA label, “SUBOXONE and SUBUTEX are not recommended for
use in pediatric patients. The safety and effectiveness of SUBOXONE and SUBUTEX in
patients below the age of 16 have not been established.”
‡ Medication-assisted therapies are rarely used to treat adolescent alcohol use
disorders.
Recovery Support Services
To reinforce gains made in treatment and to improve their quality of life more generally,
recovering adolescents may benefit from recovery support services, which include
continuing care, mutual help groups (such as 12-step programs), peer recovery support
services, and recovery high schools. Such programs provide a community setting where
fellow recovering persons can share their experiences, provide mutual support to each
other’s struggles with drug or alcohol problems, and in other ways support a substancefree
lifestyle. Note that recovery support services are not substitutes for treatment. Also,
the existing research evidence for these approaches (with the exception of Assertive
Continuing Care) is preliminary; anecdotal evidence supports the effectiveness of peer
recovery support services and recovery high schools, for example, but their efficacy has
not been established through controlled trials.
Assertive Continuing Care (ACC)
ACC is a home-based continuing-care approach delivered by trained clinicians to
prevent relapse, and is typically used after an adolescent completes therapy utilizing
the Adolescent Community Reinforcement Approach (A-CRA). Using positive and
negative reinforcement to shape behaviors, along with training in problem-solving and
communication skills, ACC combines A-CRA and assertive case management services
(e.g., use of a multidisciplinary team of professionals, round-the-clock coverage,
assertive outreach) to help adolescents and their caregivers acquire the skills to engage
in positive social activities.
Mutual Help Groups
Mutual help groups such as the 12-step programs Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) provide ongoing support for people with addictions to
alcohol or drugs, respectively, free of charge and in a community setting. Participants
meet in a group with others in recovery, once a week or more, sharing their experiences
and offering mutual encouragement. Twelve-step groups are guided by a set of
fundamental principles that participants are encouraged to adopt––including
acknowledging that willpower alone cannot achieve sustained sobriety, that surrender to
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the group conscience must replace self-centeredness, and that long-term recovery
involves a process of spiritual renewal.
Peer Recovery Support Services
Peer recovery support services, such as recovery community centers, help individuals
remain engaged in treatment and/or the recovery process by linking them together both
in groups and in one-on-one relationships with peer leaders who have direct experience
with addiction and recovery. Depending on the needs of the adolescent, peer leaders
may provide mentorship and coaching and help connect individuals to treatment, 12-
step groups, or other resources. Peer leaders may also facilitate or lead communitybuilding
activities, helping recovering adolescents build alternative social networks and
have drug- and alcohol-free social options.
Recovery High Schools
Recovery high schools are schools specifically designed for students recovering from
substance abuse issues. They are typically part of another school or set of alternative
school programs within the public school system, but recovery school students are
generally separated from other students by means of scheduling and physical barriers.
Such programs allow adolescents newly in recovery to be surrounded by a peer group
supportive of recovery efforts and attitudes. Recovery schools can serve as an adjunct
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to formal substance abuse treatment, with students often referred by treatment
providers and enrolled in concurrent treatment for other mental health problems.
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References
1. http://www.nccp.org/publications/pub_1008.html
2. https://www.ojjdp.gov/pubs/drugid/ration-03.html
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827693/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827693/
5. http://www.samafoundation.org/the-effects-of-drugs-and-alcohol-on-theadolescent-brain.html
6. https://www.nextgenerationvillage.com/the-long-term-effects-of-alcohol-onteenagers/
7. https://www.drugabuse.gov/publications/principles-adolescent-substance-usedisorder-treatment-research-based-guide/evidence-based-approaches-totreating-adolescent-substance-use-disorders
8. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/podata_1_17_14.pdf
9. http://www.fcccp.org/wp-content/uploads/fcccp.org/2010/12/Red-Flags-
Resources-Second-Edition-2010.pdf
10. https://www.psychologytoday.com/blog/in-flux/201407/10-relationship-red-flags
11. https://www.childtrends.org/wp-content/uploads/2013/09/Illicit-drug-use-Highlight-
9.13.pdf
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Page 70 of 96

Attachment A
Use of Illicit Drugs: Child Trends
Page 71 of 96

Publication # 2013‐11
September 2013
Adolescent Health Highlight:
Use of Illicit Drugs
By David Murphey, Ph.D., Megan Barry, B.A., Brigitte Vaughn, M.S., Lina
Guzman, Ph.D. and Mary Terzian, Ph.D.
Adolescence is a time when many young people express their autonomy
by taking risks. Risk‐taking is a normal and positive development on the
path to adulthood, but it also carries potential danger. One of the most
common, and most dangerous, of adolescents’ risky behaviors is using
illicit drugs. Illicit drugs include marijuana/hashish, cocaine (including
crack), heroin, hallucinogens, inhalants, or psychotherapeutic
medications not taken under a health provider’s supervision. 2
This Adolescent Health Highlight presents statistical information about
the extent, types, and patterns of adolescents’ use of illicit drugs;
discusses their effects on adolescents’ health and well‐being; shares
findings from research about factors that can help adolescents avoid
substance use and abuse; and presents strategies for preventing illicit
drug use among adolescents and treating those with drug problems. (As
used in this Highlight, the illicit drugs category does not include alcohol
and tobacco).
Types and patterns of illicit drug use
Marijuana (and hashish, a product derived from marijuana, and included
here in all discussions of marijuana use) is by far the most commonly
used illicit drug among adolescents. However, adolescents use a wide
range of illicit drugs—some newly developed, some “rediscovered.”
Child Trends

ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
Unfortunately, word
about “new”
substances to get
high with tends to
travel much faster
among adolescents
than does news
about the harm
associated with
these substances.
Unfortunately, word about “new” substances to get high with tends to travel much faster
among adolescents than does news about the harm associated with these substances. 1 Thus, it
can be challenging to stay on top of all the varieties of illicit drugs adolescents are currently
using. Moreover, some adolescents use multiple illicit drugs, either concurrently or over the
course of their adolescent years. 1
There are additional difficulties associated with collecting data on adolescents’ illicit drug use.
Nearly all such data rely on adolescents’ own accounts, and, because of the sensitive nature of
this topic, they may underreport their own drug use. 5 Still, in 2011, half of adolescents (50
percent) reported having used an illicit drug at least once by the 12 th grade. Among 12 th ‐graders,
46 percent reported using marijuana; 22 percent reported using a prescription‐type
psychotherapeutic drug (including amphetamines, sedatives, tranquilizers, and narcotics other
than heroin) without medical supervision; and about 8 percent reported using inhalants or
hallucinogens, at least once in their lifetime (see Figure 1). 1 About one in four 12 th ‐graders (25
percent) reported having used one or more illicit drugs in the past 30 days. 1 In 2011, the
substances that adolescents in grades 8 through 12 most frequently reported having used
during the previous 30 days were marijuana, amphetamines, inhalants, and hallucinogens
(including ecstasy and LSD). 1
FIGURE 1: Lifetime prevalence of drug use among 12th graders, 2011
60
50
40
50%
46%
30
20
22%
10
8% 8%
0
Any illicit drug Marijuana Prescription
Drugs
Inhalants
Hallucinogens
Source: Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future: National
results on adolescent drug use: Overview of key findings, 2011. National Institute on Drug Abuse.
The proportion of 12 th ‐grade students reporting the use, in the previous 30 days, of illicit drugs
other than marijuana decreased from 10 percent in 2000 to 9 percent in 2011. Over the same
period, the proportion of 10 th ‐graders reporting using these drugs decreased from 9 percent to 5
percent (see Figure 2). 1
Child Trends
Page 2

ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
FIGURE 2: Used a drug other than marijuana in the past month, by grade, 2000 and 2011
12
10
9%
10%
9%
Marijuana is the
most commonly used
illicit drug among
adolescents. It is
most often smoked
in rolled cigarettes
(“joints”) or in pipes,
but can also be
ingested with food.
8
6
4
2
0
5%
10th Graders
12th Graders
2000
2011
Source: Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future: National
results on adolescent drug use: Overview of key findings, 2011. National Institute on Drug Abuse.
Some adolescents
misuse prescription
medications,
particularly
psychotherapeutic
drugs that include
amphetamines (such
as Ritalin and
Adderall); sedatives;
tranquilizers; and
narcotics (such as
Vicodin and
OxyContin).
Marijuana. As noted, marijuana is the most commonly used illicit drug among adolescents. It is
most often smoked in rolled cigarettes (“joints”) or in pipes, but it can also be ingested with
food. The proportion of adolescents who use marijuana has ebbed and flowed over the years.
After staying fairly steady for much of the early 2000s, daily use rates for 10 th ‐ and 12 th ‐graders
in 2011 showed small, but statistically significant, increases from 2009 (See Figure 3). 1 About
one in seven adolescents in 8 th , 10 th and 12 th grades combined in 2011 reported having used
marijuana in the past 30 days. 1
Prescription drug misuse. Some adolescents misuse prescription medications, particularly
psychotherapeutic drugs, which include amphetamines (such as Ritalin and Adderall); sedatives;
tranquilizers; and narcotics (such as Vicodin and OxyContin). About one in five 12 th ‐graders in
2011 reported having used one of these drugs without medical supervision at some time in his
or her life. A much smaller percentage (about three percent for amphetamines, the most
commonly used prescription drug) reported having used one or more of these prescription
medications in the past 30 days in 2011. 1
Child Trends
Page 3

ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
FIGURE 3: Daily marijuana use, by grade, 2009 and 2011
8
7
7%
About one in nine
adolescents reports
having used
inhalants at some
point in his or her
life.
6
5
4
3
2
1
3%
4%
5%
2009
2011
0
10th Graders
12th Graders
Source: Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future: National
results on adolescent drug use: Overview of key findings, 2011. National Institute on Drug Abuse.
Inhalants. Many household substances (such as glues, aerosols, butane, and solvents) can be
inhaled to give a user a “high.” About one in nine adolescents reports having used inhalants at
some point in his or her life. These substances tend to be used primarily by younger
adolescents. 1
Hallucinogens. Drugs known for their hallucinogenic properties include LSD, MTF, mescaline,
concentrated THC, peyote, PCP, psilocybin, and DMT. Past‐year reported use of hallucinogens by
8 th , 10 th , and 12 th grade students has been fairly steady in recent years, at between two and six
percent. 1
“Ecstasy.” Sometimes referred to as MDMA, “E,” and “X,” and one of several so‐called “club
drugs,” Ecstasy is the most commonly used hallucinogenic drug, with five percent of both 10 th ‐
and 12 th ‐graders reporting use in the past year. 1
Other illicit drugs. Among the illicit drugs that are used less commonly by 8 th , 10 th , and 12 th
grade students are cocaine, heroin, methamphetamine, and steroids (less than one percent for
each, for use in the past 30 days). 1
In general, male
adolescents are
somewhat more
likely than are their
female counterparts
to use illicit drugs.
Differences in illicit drug use by adolescent group
In general, male adolescents are somewhat more likely than are their female counterparts to
use illicit drugs. Patterns of use change over the grades, but by 12th grade, white adolescents
are more likely than are their black or Hispanic peers to have used any illicit drug within the past
year. 1 Few other demographic patterns are consistent across types of illicit drugs and across
grade levels. Illicit substance use seems to be something many adolescents engage in
occasionally, and a few engage in once a month or more often. 1
According to a recent study, nonmedical prescription drug misuse is more prevalent among
adolescents who live in rural areas. Among those living in rural areas, adolescents were more at
risk of misusing prescription medications if their health status was poor, if they suffered from
Child Trends
Page 4

ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
depression, and if they used other drugs and alcohol. Adolescents living in rural areas were less
likely to misuse prescription medications if they were enrolled in school and living in a twoparent
household. 6
Adolescents who use
illicit drugs have
higher death rates
than do their peers,
because of increased
risk of injuries (such
as those resulting
from car crashes),
suicide, homicide,
and illness.
Effects of illicit drugs on adolescents
Adolescents may be especially vulnerable to the damaging effects of drug use, because their
brains are still developing. 7 Use of illicit drugs is associated with many harmful behaviors and
can cause both short‐ and long‐term health problems. It is difficult to generalize about what
level of use is harmful, because effects vary by individual, and many illicit drugs have no
standardized “dosage.” However, adolescents who use illicit drugs are more likely than other
adolescents to engage in risky sexual behavior, 8 or be involved in delinquency and crime. 9,10
Additionally, students using illicit drugs often have problems in school, although it is not easy to
determine which comes first—the drug use, or the school problems. These school problems
include low attendance, poor academic performance, and a greater likelihood of dropping out
or being expelled. 11,12 Furthermore, illicit drug use can affect relationships with family and
friends by causing adolescents to be unreliable, forgetful, dishonest, or violent; it can also put
them at increased risk for being a victim of violence. 13
Numerous physical problems are associated with illicit drug use, depending on the type of drug
used. These problems can include, in the short term, lung failure, heart attack, and heart failure,
and in the long term, obesity, lung and cardiovascular disease, stroke, and cancer. 13 Illicit drug
use also increases the risk of contracting HIV, hepatitis, and other diseases. 13 Adolescents who
use illicit drugs have higher death rates than do their peers, because of increased risk of injuries
(such as those resulting from car crashes), suicide, homicide, and illness. 13 Many mental health
disorders are also linked to illicit drug use, including depression, anxiety, paranoia,
hallucinations, developmental delays, delusions, and mood disturbances. 13,14
To encourage safe
choices, parents
should explain
expectations
clearly, describe
the consequences of
breaking the rules,
and follow through
consistently when
necessary.
Defining features that help protect adolescents from substance abuse
Researchers have identified several “protective factors”—conditions and characteristics that
make it more likely that adolescents will remain substance‐free (defined as no use of cigarettes,
alcohol, or illicit drugs). These factors include strong positive connections with parents and
other family members, the presence of parents in the home at key times of the day, and
reduced access to illegal substances in the home. A strong connection to school and a deep
religious commitment also can help adolescents avoid substance use. 3 For example, students
who plan on completing four years of college are much more likely than are other students to
report being substance‐free. 4
The proportion of 12 th ‐graders who reported being substance‐free in the last 30 days increased
from 26 percent in 1976 to 51 percent in 2010 (the latest year for which we have these data).
The proportion of 10 th ‐graders abstaining from substances remained at 64 percent. 4 These
numbers would be higher if alcohol use were not included. Although all the reasons for the
increase in the percentage of adolescents who are substance‐free are not known, prevention
activities, particularly those related to reducing cigarette smoking, have likely played a role. 15
Approaches to preventing and treating illicit drug use
Several strategies have been shown to prevent illicit drug use; most of them overlap with what
is known about evidence‐based substance abuse prevention in general. For example, one
effective strategy is to implement family‐strengthening interventions during the elementary
school years, to enhance parenting skills, reduce parental substance use (if present), and
Child Trends
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ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
Typical signs and
symptoms of illicit
drug use include
mood swings,
weight loss, a drop
in grades, possession
of drug
paraphernalia, or
increased problem
behaviors.
improve parent‐child relationships. As children enter adolescence, school‐based drug
prevention programs that focus on life‐skills training can prepare them to resist social pressures
and participate successfully in family, school, and community activities. 16 In 2011, more than
one in four (26 percent) high school students reported being offered, sold, or given an illegal
drug on school property. 17 School‐ or community‐based parent training programs can help
support the growth of adolescents’ positive skills and behaviors, so that they will not be drawn
to drugs.
There are many ways for parents to help prevent adolescent drug use. An important first step is
to maintain an open and caring relationship with their adolescent. Adolescents who feel that
they can trust and communicate with their parents are more likely to follow family rules. To
encourage safe choices, parents should explain their expectations clearly, describe the
consequences of breaking the rules, and follow through consistently when necessary. More
specifically, when it comes to preventing drug use, parents should: a) explain why drug use is
harmful; b) communicate their expectations and rules relating to the use of drugs; c) check in
with their adolescent on a regular basis; d) get to know their adolescents’ friends; and e)
communicate with their adolescents to find out whether they are making safe choices. 18
Lastly, it is important to teach parents, administrators, and teachers about signs of illicit drug
use, so that adolescents using drugs can be identified and offered treatment. Typical signs and
symptoms of illicit drug use include mood swings, weight loss, a drop in grades, possession of
drug paraphernalia, or the onset of, or increase in, problem behaviors. 19 Some telltale signs are
associated with the use of specific drugs. For example, signs of marijuana use include bloodshot
eyes and appearing dizzy or uncoordinated; and signs of inhalant use may include aggressive
behavior or outbursts, nausea, poor coordination, slurred or unintelligible speech, and muscle
weakness. 20,21
The Child Trends
DataBank includes
brief summaries of
well‐being
indicators, including
several that are
related to
adolescents’ use of
illicit drugs.
When adolescents display signs of substance use, treatment should be sought to keep problems
from worsening. Treatments that provide family therapy and support, and that involve multiple
service systems, have been found to be effective, as have interventions such as cognitivebehavioral
therapy, motivational interviewing, and/or contingency management (a form of
behavioral therapy that gives participants vouchers or special privileges when they attend a
program regularly or follow treatment plans). 22 In selecting an appropriate treatment, it is
important to consider other problems that may accompany drug abuse, such as mental illness or
delinquent behavior. Drug abuse treatments for adolescents who are also juvenile offenders
may differ from treatments for adolescents with accompanying mental health disorders.
Resources
The Child Trends DataBank includes brief summaries of well‐being indicators, including several
that are related to adolescents’ use of illicit drugs:
Illicit Drug Use: http://www.childtrends.org/?indicators=illicit‐drug‐use
Marijuana Use: http://www.childtrends.org/?indicators=marijuana‐use
Steroid Use: http://www.childtrends.org/?indicators=steroid‐use
Substance‐Free Youth: http://www.childtrends.org/?indicators=substance‐free‐youth
The Childs Trends LINKS (Lifecourse Interventions to Nurture Kids Successfully) database
summarizes evaluations of out‐of‐school time programs that work (or do not) to enhance
children's development. The LINKS Database is user‐friendly and directed especially to
policymakers, program providers, and funders.
Child Trends
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ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
To learn how to stay
drug‐free,
adolescents can visit
http://www.abovet
heinfluence.com/,
the adolescentgeared
Web site of
The National Youth
Anti‐Drug Media
Campaign.
Programs related to prevention of abuse of marijuana, illicit/prescription drugs, or all
substances are summarized.
Evaluations of programs proven to work (or do not) in illicit drug use prevention,
cessation, and intervention can be found in the article What works for preventing and
stopping substance use in adolescents: Lessons from experimental evaluations of
programs and interventions.
Other selected resources:
The Office of National Drug Control Policy (http://ondcp.gov) publishes the presidential
Administration’s National Drug Control Policy, as well as information on how parents
should dispose of prescription drugs, and steps that parents can take to prevent
adolescent drug abuse.
The National Institute on Drug Abuse (NIDA) has a number of different resources on
illicit drug use for adolescents and practitioners. For practitioners, NIDA’s DrugFacts
page (http://www.drugabuse.gov/publications/term/160/DrugFacts) reports
on adolescents’ trends in drug abuse.
Adolescents (and others) who need help with a drug problem can call 1‐800‐662‐HELP.
To find a local treatment facility, visit the Substance Abuse and Mental Health Services
Administration’s Substance Abuse Treatment Facility Locator at
http://findtreatment.samhsa.gov/.
Parents looking for strategies to prevent, or stop, illicit drug use by their adolescent can
visit http://www.drugfree.org/
Adolescents looking for more information on the science behind drug abuse, and the
effects of drug use on the body and brain, can visit the NIDA for Teens site
(http://teens.drugabuse.gov).
To learn how to stay drug‐free, adolescents can visit
http://www.abovetheinfluence.com, the adolescent‐geared Web site of the National
Youth Anti‐Drug Media Campaign.
Acknowledgements
The authors would like to thank Jennifer Manlove at Child Trends for her careful review of and helpful comments on this brief.
Editor: Harriet J. Scarupa
Child Trends
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ADOLESCENT HEALTH HIGHLIGHT
Use of Illicit Drugs
September 2013
References
1
Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future, national results on adolescent drug use:
overview of key findings, 2011. Ann Arbor: Institute for Social Research, The University of Michigan. Retrieved June 14, 2013, from
http://monitoringthefuture.org/pubs/monographs/mtf‐overview2011.pdf
2
U.S. Department of Health and Human Services. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I summary of
national findings. Retrieved June 14, 2013, from http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9ResultsP.pdf
3
Blum, R. W., & Rinehart, P. M. (1997). Reducing the risk: connections that make a difference in the lives of youth. Bethesda, MD: National Institute
of Child Health and Human Development (NIH).
4
Child Trends. (2010). Child Trends databank: substance‐free youth. Retrieved June 14, 2013, from
http://www.childtrends.org/?indicators=substance‐free‐youth
5
Delaney‐Black, V., Chiodo, L. M., Hannigan, J. H., Greenwald, M. K., Janisse, J., Patterson, G., et al. (2010). Just say “I don’t”: lack of concordance
between teen report and biological measures of drug use. Pediatrics, 126, 887‐893.
6
Havens, J. R., Young, A. M., & Havens, C. E. (2010). Nonmedical prescription drug use in a nationally representative sample of adolescents. Archives
of Pediatric and Adolescent Medicine, 217.
7
Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Science, 1124, 111‐126.
8
Kaiser Family Foundation. (2002). Substance use and risky sexual behavior. Washington, DC: Kaiser Family Foundation. Retrieved June 14, 2013,
from http://kaiserfamilyfoundation.files.wordpress.com/2002/01/3214.pdf
9
Huizinga, D., Loeber, R., Thornberry, T. P., & Cothern, L. (2000). Co‐occurrence of delinquency and other problem behaviors. Washington, D.C.: U.S.
Department of Justice Office of Juvenile Justice and Delinquency Prevention. Retrieved June 14, 2013, from
http://www.ncjrs.gov/html/ojjdp/jjbul2000_11_3/contents.html
10
Windle, M., & Mason, W. A. (2004). General and specific predictors of behavioral and emotional problems among adolescents. Journal of
Emotional and Behavioral Disorders, 12(1), 49‐62.
11
McCluskey, C. P., Krohn, M. D., Lizotte, A. J., & Rodriguez, M. L. (2002). Early substance use and school achievement: an examination of Latino,
white, and African American youth. Journal of Drug Issues, 32(3), 921‐943.
12
National Center on Addiction and Substance Abuse at Columbia University. (2001). Malignant neglect: substance abuse and America's schools.
New York, NY: Columbia University. Retrieved June 14, 2013, from http://www.omegalabs.net/media/documents/pdf/MalNeglect.pdf
13
Above the Influence, & National Youth Anti‐Drug Media Campaign. FAQs about drug use. Retrieved June 14, 2013, from
http://www.abovetheinfluence.com/facts/faqs
14
Crowe, A. H., & Bilchik, S. (1998). Drug identification and testing summary. Washington, D.C.: Office of Juvenile Justice and Delinquency
Prevention. Retrieved June 14, 2013, from https://www.ncjrs.gov/html/ojjdp/167889/index.html
15
Centers for Disease Control and Prevention. (2002). Trends in cigarette smoking among high school students—United States, 1991‐2001. MMWR,
51(19), 409‐412. Retrieved June 14, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5119a1.htm
16
Bandy, T., & Moore, K. A. (2008). What works for preventing and stopping substance use in adolescents: lessons from experimental evaluations of
programs and interventions. Washington, D.C.: Child Trends. Retrieved June 14, 2013, from http://www.childtrends.org/wpcontent/uploads/2008/05/Child_Trends‐2008_05_20_FS_WhatWorksSub.pdf
17
Centers for Disease Control and Prevention. (2012). Youth risk behavior surveillance‐United States, 2011. Morbidity and Mortality Weekly Report,
61(4). Retrieved June 14, 2013, from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf
18
Centers for Disease Control and Prevention. (2010). Monitoring your teen's activities: what parents and families should know. Retrieved June 14,
2013, from http://www.cdc.gov/HealthyYouth/adolescenthealth/pdf/parental_monitoring_factsheet.pdf
19
The Partnership at Drugree.org. Time to act! How to tell if your teen is using and taking action to intervene. Retrieved June 14, 2013, from
http://timetoact.drugfree.org/index.html
20
National Institue on Drug Abuse. (2011). Marijuana: facts parents need to know. Retrieved June 14, 2013, from
http://www.drugabuse.gov/publications/marijuana‐facts‐parents‐need‐to‐know
21
Drug Enforcement Administration. Drugs of Abuse. Retrieved August 30, 2013, from http://www.justice.gov/dea/pr/multimedialibrary/publications/drug_of_abuse.pdf#page=72
22
Budney, A. J., Roffman, R., Stephens, R. S., & Walker, D. (2007). Marijuana dependence and its treatment. Addiction Science & Clinical Practice,
4(1).
Child Trends
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Page 72 of 96

Attachment B
Principles of Adolescent Substance
Use Disorder Treatment
Page 73 of 96

Principles of Adolescent
Substance Use Disorder Treatment:
A Research-Based Guide

Principles of Adolescent
Substance Use Disorder Treatment:
A Research-Based Guide
This publication is in the public domain and may be used or reproduced in
its entirety without permission from NIDA. Citation of the source is appreciated.

NIDA wishes to thank the following individuals for their
helpful comments during the review of this publication:
Tina Burrell, M.A., Washington State Department of Social and Health Services
Connie Cahalan, Missouri Department of Mental Health
Barbara Cimaglio, Vermont Department of Health
Michael L. Dennis, Ph.D., Chestnut Health Systems
Rochelle Head-Dunham, M.D., Louisiana Department of Health and Hospitals
Scott W. Henggeler, Ph.D., Medical University of South Carolina
Sharon Levy, M.D., M.P.H., Children’s Hospital Boston
Kenneth J. Martz, Psy.D., CAS, Pennsylvania Department of Drug and Alcohol Programs
Kathy Paxton, M.S., West Virginia Bureau for Behavioral Health and Health Facilities
Paula D. Riggs, M.D., University of Colorado School of Medicine

Contents
FROM THE DIRECTOR.............................................................................................................................................1
I. INTRODUCTION ................................................................................................................................................2
II. PRINCIPLES OF ADOLESCENT SUBSTANCE USE DISORDER TREATMENT..............................................8
1. Adolescent substance use needs to be identified and addressed as soon as possible................................9
2. Adolescents can benefit from a drug abuse intervention even if they are not addicted to a drug.................9
3. Routine annual medical visits are an opportunity to ask adolescents about drug use..................................9
4. Legal interventions and sanctions or family pressure may play an important role in getting
adolescents to enter, stay in, and complete treatment..................................................................................9
5. Substance use disorder treatment should be tailored to the unique needs of the adolescent......................9
6. Treatment should address the needs of the whole person, rather than just focusing on his
or her drug use............................................................................................................................................10
7. Behavioral therapies are effective in addressing adolescent drug use.......................................................10
8. Families and the community are important aspects of treatment................................................................10
9. Effectively treating substance use disorders in adolescents requires also identifying and
treating any other mental health conditions they may have........................................................................10
10. Sensitive issues such as violence and child abuse or risk of suicide should be identified
and addressed............................................................................................................................................. 11
11. It is important to monitor drug use during treatment.................................................................................... 11
12. Staying in treatment for an adequate period of time and continuity of care afterward are important.......... 11
13. Testing adolescents for sexually transmitted diseases like HIV, as well as hepatitis B and C,
is an important part of drug treatment......................................................................................................... 11
III. FREQUENTLY ASKED QUESTIONS ...............................................................................................................12
1. Why do adolescents take drugs? ...............................................................................................................13
2. What drugs are most frequently used by adolescents? .............................................................................13
3. How do adolescents become addicted to drugs, and which factors increase risk?....................................14
4. Is it possible for teens to become addicted to marijuana?..........................................................................14
5. Is abuse of prescription medications as dangerous as other forms of illegal drug use?.............................15
6. Are steroids addictive and can steroid abuse be treated?..........................................................................15
7. How do other mental health conditions relate to substance use in adolescents?.......................................16
8. Does treatment of ADHD with stimulant medications like Ritalin ® and Adderall ® increase
risk of substance abuse later in life?...........................................................................................................16
9. What are signs of drug use in adolescents, and what role can parents play in getting treatment?............16
10. How can parents participate in their adolescent child’s treatment? ...........................................................17
11. What role can medical professionals play in addressing substance abuse
(including abuse of prescription drugs) among adolescents?.....................................................................17
12. Is adolescent tobacco use treated similarly to other drug use?..................................................................18
13. Are there medications to treat adolescent substance abuse? ...................................................................18
14. Do girls and boys have different treatment needs? ....................................................................................18
15. What are the unique treatment needs of adolescents from different racial/ethnic backgrounds?...............19
16. What role can the juvenile justice system play in addressing adolescent drug abuse?..............................19
17. What role do 12-step groups or other recovery support services play in addiction
treatment for adolescents?..........................................................................................................................19

IV. TREATMENT SETTINGS..................................................................................................................................20
Outpatient/Intensive Outpatient.........................................................................................................................21
Partial Hospitalization........................................................................................................................................21
Residential/Inpatient Treatment.........................................................................................................................21
V. EVIDENCE-BASED APPROACHES TO TREATING ADOLESCENT SUBSTANCE
USE DISORDERS.............................................................................................................................................22
BEHAVIORAL APPROACHES...........................................................................................................................23
Adolescent Community Reinforcement Approach (A-CRA)..........................................................................23
Cognitive-Behavioral Therapy (CBT)............................................................................................................24
Contingency Management (CM)...................................................................................................................24
Motivational Enhancement Therapy (MET) .................................................................................................24
Twelve-Step Facilitation Therapy..................................................................................................................24
FAMILY-BASED APPROACHES........................................................................................................................25
Brief Strategic Family Therapy (BSFT).........................................................................................................25
Family Behavior Therapy (FBT)....................................................................................................................25
Functional Family Therapy (FFT)..................................................................................................................26
Multidimensional Family Therapy (MDFT)....................................................................................................26
Multisystemic Therapy (MST).......................................................................................................................26
ADDICTION MEDICATIONS.............................................................................................................................26
Opioid Use Disorders....................................................................................................................................27
Alcohol Use Disorders..................................................................................................................................27
Nicotine Use Disorders.................................................................................................................................28
RECOVERY SUPPORT SERVICES..................................................................................................................28
Assertive Continuing Care (ACC).................................................................................................................28
Mutual Help Groups......................................................................................................................................29
Peer Recovery Support Services..................................................................................................................29
Recovery High Schools.................................................................................................................................29
TREATMENT REFERRAL RESOURCES................................................................................................................31
REFERENCES.........................................................................................................................................................32

From the Director
Since its first edition in 1999, NIDA’s Principles of Drug Addiction Treatment
has been a widely used resource for health care providers, families, and others
needing information on addiction and treatment for people of all ages. But recent
research has greatly advanced our understanding of the particular treatment
needs of adolescents, which are often different from those of adults. I thus am
very pleased to present this new guide, Principles of Adolescent Substance Use
Disorder Treatment, focused exclusively on the unique realities of adolescent
substance use—which includes abuse of illicit and prescription drugs, alcohol,
and tobacco—and the special treatment needs for people aged 12 to 17.
The adolescent years are a key window for both substance use and the
development of substance use disorders. Brain systems governing emotion and
reward-seeking are fully developed by this time, but circuits governing judgment
and self-inhibition are still maturing, causing teenagers to act on impulse, seek new sensations, and be
easily swayed by their peers—all of which may draw them to take risks such as trying drugs of abuse.
What is more, because critical neural circuits are still actively forming, teens’ brains are particularly
susceptible to being modified by those substances in a lasting way—making the development of a
substance use disorder much more likely.
Addiction is not the only danger. Abusing drugs during adolescence can interfere with meeting crucial
social and developmental milestones and also compromise cognitive development. For example, heavy
marijuana use in the teen years may cause a loss of several IQ points that are not regained even if users
later quit in adulthood. Unfortunately, that drug’s popularity among teens is growing—possibly due in part
to legalization advocates touting marijuana as a “safe” drug. Nor do most young people appreciate the
grave safety risks posed by abuse of other substances like prescription opioids and stimulants or newly
popular synthetic cannabinoids (“Spice”)—and even scientists still do not know much about how abusing
these drugs may affect the developing brain.
These unknowns only add to the urgency of identifying and intervening in substance use as early as
possible. Unfortunately, this urgency is matched by the difficulty of reaching adolescents who need help.
Only 10 percent of adolescents who need treatment for a substance use disorder actually get treatment.
Most teens with drug problems don’t want or think they need help, and parents are frequently blind to
indications their teenage kids may be using drugs—or they may dismiss drug use as just a normal part of
growing up.
Historically the focus with adolescents has tended to be on steering young people clear of drugs
before problems arise. But the reality is that different interventions are needed for adolescents at
different places along the substance use spectrum, and some require treatment, not just prevention.
Fortunately, scientific research has now established the efficacy of a number of treatment approaches
that can address substance use during the teen years. This guide describes those approaches, as well
as presents a set of guiding principles and frequently asked questions about substance abuse and
treatment in this age group. I hope this guide will be of great use to parents, health care providers, and
treatment specialists as they strive to help adolescents with substance use problems get the help they
need.
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 1

I. Introduction
2 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

People are most likely to begin
abusing drugs*—including
tobacco, alcohol, and illegal
and prescription drugs—
during adolescence and young
adulthood. ‡ By the time they are seniors,
almost 70 percent of high school students will
have tried alcohol, half will have taken an illegal
drug, nearly 40 percent will have smoked a
cigarette, and more than 20 percent will have
used a prescription drug for a nonmedical
purpose. 1 There are many reasons adolescents
use these substances, including the desire
for new experiences, an attempt to deal with
problems or perform better in school, and simple
peer pressure. Adolescents are “biologically
wired” to seek new experiences and take
risks, as well as to carve out their own identity.
Trying drugs may fulfill all of these normal
developmental drives, but in an unhealthy
way that can have very serious long-term
consequences.
Many factors influence whether an adolescent
tries drugs, including the availability of drugs
within the neighborhood, community, and school
and whether the adolescent’s friends are using
them. The family environment is also important:
Violence, physical or emotional abuse, mental
illness, or drug use in the household increase
the likelihood an adolescent will use drugs.
Finally, an adolescent’s inherited genetic
vulnerability; personality traits like poor impulse
control or a high need for excitement; mental
The adolescent brain is often likened
to a car with a fully functioning gas
pedal (the reward system) but weak
brakes (the prefrontal cortex).
The brain continues to develop through early adulthood. Mature brain regions at each
developmental stage are indicated in blue. The prefrontal cortex (red circles), which governs
judgment and self-control, is the last part of the brain to mature.
Source: PNAS 101:8174–8179, 2004.
health conditions such as depression, anxiety,
or ADHD; and beliefs such as that drugs are
“cool” or harmless make it more likely that an
adolescent will use drugs. 2
The teenage years are a critical window of
vulnerability to substance use disorders,
because the brain is still developing
and malleable (a property known as
neuroplasticity), and some brain areas are
less mature than others. The parts of the
brain that process feelings of reward and
pain—crucial drivers of drug use—are the first
to mature during childhood. What remains
incompletely developed during the teen years
are the prefrontal cortex and its connections
to other brain regions. The prefrontal cortex is
responsible for assessing situations, making
sound decisions, and controlling our emotions
and impulses; typically this circuitry is not
mature until a person is in his or her mid-20s
(see figure, above).
The adolescent brain is often likened to a car
with a fully functioning gas pedal (the reward
system) but weak brakes (the prefrontal
cortex). Teenagers are highly motivated to
pursue pleasurable rewards and avoid pain,
*
In this guide, the terms drugs and substances are used interchangeably to refer to tobacco, alcohol, illegal drugs, and prescription medications used
for nonmedical reasons.
‡ Specifying the period of adolescence is complicated because it may be defined by different variables, and policymakers and researchers may
disagree on the exact age boundaries. For purposes of this guide, adolescents are considered to be people between the ages of 12 and 17.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 3

ut their judgment and decision-making
skills are still limited. This affects their ability
to weigh risks accurately and make sound
decisions, including decisions about using
drugs. For these reasons, adolescents are
a major target for prevention messages
promoting healthy, drug-free behavior and
giving young people encouragement and skills
to avoid the temptations of experimenting with
drugs. 3
Most teens do not escalate from trying drugs
to developing an addiction or other substance
use disorder;* however, even experimenting
with drugs is a problem. Drug use can be
part of a pattern of risky behavior including
unsafe sex, driving while intoxicated, or other
hazardous, unsupervised activities. And in
cases when a teen does develop a pattern of
repeated use, it can pose serious social and
health risks, including:
• school failure
• problems with family and other relationships
• loss of interest in normal healthy activities
• impaired memory
• increased risk of contracting an infectious
disease (like HIV or hepatitis C) via risky
sexual behavior or sharing contaminated
injection equipment
• mental health problems—including
substance use disorders of varying severity
• the very real risk of overdose death
How drug use can progress to addiction.
Different drugs affect the brain differently, but
a common factor is that they all raise the level
of the chemical dopamine in brain circuits that
control reward and pleasure.
The brain is wired to encourage life-sustaining
and healthy activities through the release
of dopamine. Everyday rewards during
adolescence—such as hanging out with
friends, listening to music, playing sports,
Despite popular belief, willpower alone
is often insufficient to overcome an
addiction. Drug use has compromised
the very parts of the brain that make it
possible to “say no.”
and all the other highly motivating experiences for
teenagers—cause the release of this chemical in
moderate amounts. This reinforces behaviors that
contribute to learning, health, well-being, and the
strengthening of social bonds.
Drugs, unfortunately, are able to hijack this process.
The “high” produced by drugs represents a flooding
of the brain’s reward circuits with much more
dopamine than natural rewards generate. This
creates an especially strong drive to repeat the
experience. The immature brain, already struggling
with balancing impulse and self-control, is more
likely to take drugs again without adequately
considering the consequences. 4 If the experience
is repeated, the brain reinforces the neural links
between pleasure and drug-taking, making the
association stronger and stronger. Soon, taking
the drug may assume an importance in the
adolescent’s life out of proportion to other rewards.
The development of addiction is like a vicious
cycle: Chronic drug use not only realigns a person’s
priorities but also may alter key brain areas
necessary for judgment and self-control, further
reducing the individual’s ability to control or stop
their drug use. This is why, despite popular belief,
willpower alone is often insufficient to overcome
an addiction. Drug use has compromised the very
parts of the brain that make it possible to “say no.”
Not all young people are equally at risk for
developing an addiction. Various factors including
inherited genetic predispositions and adverse
experiences in early life make trying drugs and
developing a substance use disorder more likely.
Exposure to stress (such as emotional or physical
abuse) in childhood primes the brain to be sensitive
*
For purposes of this guide, the term addiction refers to compulsive drug seeking and use that persists even in the face of devastating consequences;
it may be regarded as equivalent to a severe substance use disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5, 2013). The spectrum of substance use disorders in the DSM-5 includes the criteria for the DSM-4 diagnostic categories of abuse and
dependence.
4 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

80
Adolescents Differ from Adults in Substances Most Abused
12 – 17
Percent of those who received past-year treatment
70
60
50
40
30
20
10
0
42.9
42.6
66.5
65.5
33.1
17.1
38.7
57.2
46.3
Alcohol Marijuana Prescription
Drugs
8.6
12.6
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2013.
18.3
3.0
12.4
11.7
11.1
18 – 25
26+
9.9
8.7
6.7
4.6
3.3
Cocaine Heroin Hallucinogens Inhalants
to stress and seek relief from it throughout
life; this greatly increases the likelihood of
subsequent drug abuse and of starting drug use
early. 5 In fact, certain traits that put a person
at risk for drug use, such as being impulsive
or aggressive, manifest well before the first
episode of drug use and may be addressed
by prevention interventions during childhood. 6
By the same token, a range of factors, such
as parenting that is nurturing or a healthy
school environment, may encourage healthy
development and thereby lessen the risk of later
drug use.
Drug use at an early age is an important
predictor of development of a substance use
disorder later. The majority of those who have
a substance use disorder started using before
age 18 and developed their disorder by age 20. 7
The likelihood of developing a substance use
disorder is greatest for those who begin use in
their early teens. For example, 15.2 percent of
people who start drinking by age 14 eventually
develop alcohol abuse or dependence (as
compared to just 2.1 percent of those who wait
until they are 21 or older), 8 and 25 percent of
those who begin abusing prescription drugs at
age 13 or younger develop a substance use
disorder at some time in their lives. 9 Tobacco,
alcohol, and marijuana are the first addictive
substances most people try. Data collected
in 2012 found that nearly 13 percent of those
with a substance use disorder began using
marijuana by the time they were 14. 10
When substance use disorders occur in
adolescence, they affect key developmental
and social transitions, and they can interfere
with normal brain maturation. These potentially
lifelong consequences make addressing
adolescent drug use an urgent matter. Chronic
marijuana use in adolescence, for example, has
been shown to lead to a loss of IQ that is not
recovered even if the individual quits using in
adulthood. 11 Impaired memory or thinking ability
and other problems caused by drug use can
derail a young person’s social and educational
development and hold him or her back in life.
The serious health risks of drugs compound
the need to get an adolescent who is abusing
drugs into treatment as quickly as possible.
Also, adolescents who are abusing drugs are
likely to have other issues such as mental health
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 5

problems accompanying and possibly contributing
to their substance use, and these also need to
be addressed. 12 Unfortunately, less than one
third of adolescents admitted to substance abuse
treatment who have other mental health issues
receive any care for their conditions. 13
Adolescents’ drug use and treatment needs
differ from those of adults. Adolescents in
treatment report abusing different substances than
adult patients do. For example, many more people
aged 12–17 received treatment for marijuana
use than for alcohol use in 2011 (65.5 percent
versus 42.9 percent), whereas it was the reverse
for adults (see figure, page 5). When adolescents
do drink alcohol, they are more likely than adults
to binge drink (defined as five or more drinks in a
row on a single occasion). 14 Adolescents are less
likely than adults to report withdrawal symptoms
when not using a drug, being unable to stop
using a drug, or continued use of a drug in spite
of physical or mental health problems; but they
are more likely than adults to report hiding their
substance use, getting complaints from others
about their substance use, and continuing to use
in spite of fights or legal trouble.
Adolescents also may be less likely than adults
to feel they need help or to seek treatment on
their own. Given their shorter histories of using
drugs (as well as parental protection), adolescents
may have experienced relatively few adverse
consequences from their drug use; their incentive
to change or engage in treatment may correspond
to the number of such consequences they have
experienced. 15 Also, adolescents may have more
difficulty than adults seeing their own behavior
patterns (including causes and consequences of
their actions) with enough detachment to tell they
need help.
Only 10 percent of 12- to 17-year-olds needing
substance abuse treatment actually receive any
services. 16 When they do get treatment, it is often
for different reasons than adults. By far, the largest
proportion of adolescents who receive treatment
are referred by the juvenile justice system (see
figure, page 7). Given that adolescents with
substance use problems often feel they do
not need help, engaging young patients in
treatment often requires special skills and
patience.
Many treatment approaches are available to
address the unique needs of adolescents.
The focus of this guide is on evidence-based
treatment approaches―those that have been
scientifically tested and found to be effective
in the treatment of adolescent substance
abuse. Whether delivered in residential or
inpatient settings or offered on an outpatient
basis, effective treatments for adolescents
primarily consist of some form of behavioral
therapy. Addiction medications, while effective
and widely prescribed for adults, are not
generally approved by the U.S. Food and
Drug Administration (FDA) for adolescents.
However, preliminary evidence from controlled
trials suggest that some medications may
assist adolescents in achieving abstinence,
so providers may view their young patients’
needs on a case-by-case basis in developing a
personalized treatment plan.
Whatever a person’s age, treatment is not “one
size fits all.” It requires taking into account the
needs of the whole person—including his or
her developmental stage and cognitive abilities
and the influence of family, friends, and others
in the person’s life, as well as any additional
mental or physical health conditions. Such
issues should be addressed at the same time
as the substance use treatment. When treating
adolescents, clinicians must also be ready
and able to manage complications related to
their young patients’ confidentiality and their
dependence on family members who may or
may not be supportive of recovery.
Supporting Ongoing Recovery—Sustaining
Treatment Gains and Preventing Relapse
Enlisting and engaging the adolescent in
treatment is only part of a sometimes long and
complex recovery process. 17 Indeed, treatment
is often seen as part of a continuum of care.
When an adolescent requires substance
6 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

200
Number of Adolescents Aged 12–17 Admitted to Publicly Funded
Substance Abuse Treatment Facilities on an Average Day, by Principal
Source of Referral: Treatment Episode Data Set 2008*
150
184
100
50
63
46 43
28
18
0
Juvenile
Justice
System
Self or
Others
Community
Organizations
Schools
Source: 2008 SAMHSA Treatment Episode Data Set (TEDS)
Treatment
Providers
Other
Health
Care
Professionals
abuse treatment, follow-up care and recovery
support (e.g., mutual-help groups like 12-step
programs) may be important for helping teens
stay off drugs and improving their quality of life.
When substance use disorders are identified
and treated in adolescence—especially if they
are mild or moderate—they frequently give
way to abstinence from drugs with no further
problems. Relapse is a possibility, however, as
it is with other chronic diseases like diabetes
or asthma. Relapse should not be seen as a
sign that treatment failed but as an occasion
to engage in additional or different treatment.
Averting and detecting relapse involves
monitoring by the adolescent, parents, and
teachers, as well as follow-up by treatment
providers. Although recovery support programs
are not a substitute for formal evidence-based
treatment, they may help some adolescents
maintain a positive and productive drug-free
lifestyle that promotes meaningful and beneficial
relationships and connections to family, peers,
and the community both during treatment and
after treatment ends. Whatever services or
programs are used, an adolescent’s path to
recovery will be strengthened by support from
family members, non-drug-using peers, the
school, and others in his or her life.
*
“Treatment providers” in this chart refers to “alcohol/drug abuse care providers.” Treatment providers can and do refer people to treatment if, for
example, a person is transferring from one level of treatment to another and the original facility does not provide the level of treatment that the person
needs, or if a person changes facilities for some other reason. “Other health care professionals” refers to physicians, psychiatrists, or other licensed
health care professionals or general hospitals, psychiatric hospitals, mental health programs, or nursing homes.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 7

II.
Principles of Adolescent
Substance Use Disorder
Treatment
8 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

1. Adolescent substance use needs to
be identified and addressed as soon
as possible. Drugs can have long-lasting
effects on the developing brain and
may interfere with family, positive peer
relationships, and school performance.
Most adults who develop a substance use
disorder report having started drug use in
adolescence or young adulthood, so it is
important to identify and intervene in drug
use early.
2. Adolescents can benefit from a drug
abuse intervention even if they are
not addicted to a drug. 18 Substance use
disorders range from problematic use to
addiction and can be treated successfully
at any stage, and at any age. For young
people, any drug use (even if it seems
like only “experimentation”), is cause for
concern, as it exposes them to dangers
from the drug and associated risky
behaviors and may lead to more drug use
in the future. Parents and other adults
should monitor young people and not
underestimate the significance of what may
appear as isolated instances of drug taking.
4.
3. Routine annual medical visits are
an opportunity to ask adolescents
about drug use. Standardized screening
tools are available to help pediatricians,
dentists, emergency room doctors,
psychiatrists, and other clinicians determine
an adolescent’s level of involvement (if
any) in tobacco, alcohol, and illicit and
nonmedical prescription drug use. 19 When
an adolescent reports substance use,
the health care provider can assess its
severity and either provide an onsite brief
intervention or refer the teen to a substance
20, 21
abuse treatment program.
Legal interventions and sanctions or
family pressure may play an important
role in getting adolescents to enter, stay
in, and complete treatment. Adolescents
with substance use disorders rarely feel
they need treatment and almost never
seek it on their own. Research shows that
treatment can work even if it is mandated or
entered into unwillingly. 22
5. Substance use disorder treatment
should be tailored to the unique
needs of the adolescent. Treatment
planning begins with a comprehensive
assessment to identify the person’s
strengths and weaknesses to be
addressed. Appropriate treatment considers
an adolescent’s level of psychological
development, gender, relations with family
and peers, how well he or she is doing in
school, the larger community, cultural and
ethnic factors, and any special physical or
behavioral issues.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 9

Legal
Services
Components of Comprehensive
Drug Abuse Treatment
Family
Services
Vocational
Services
Assessment
Evidence-Based Treatment
Substance Use Monitoring
Clinical and Case Management
Recovery Support Programs
Continuing Care
HIV/AIDS
Services
Educational
Services
Mental
Health
Services
Medical
Services
The best treatment programs provide a combination of therapies
and other services to meet the needs of the individual patient.
6. Treatment should address the needs
of the whole person, rather than
just focusing on his or her drug
use. The best approach to treatment
includes supporting the adolescent’s
larger life needs, such as those related
to medical, psychological, and social
well-being, as well as housing, school,
transportation, and legal services.
Failing to address such needs
simultaneously could sabotage the
adolescent’s treatment success.
Many adolescents who abuse drugs
have a history of physical, emotional,
and/or sexual abuse or other trauma.
7. Behavioral therapies are effective
in addressing adolescent drug use.
Behavioral therapies, delivered by trained
clinicians, help an adolescent stay off drugs
by strengthening his or her motivation to
change. This can be done by providing
incentives for abstinence, building skills
to resist and refuse substances and deal
with triggers or craving, replacing drug use
with constructive and rewarding activities,
improving problem-solving skills, and
facilitating better interpersonal relationships.
8. Families and the community are
important aspects of treatment. The
support of family members is important
for an adolescent’s recovery. Several
evidence-based interventions for adolescent
drug abuse seek to strengthen family
relationships by improving communication
and improving family members’ ability to
support abstinence from drugs. In addition,
members of the community (such as school
counselors, parents, peers, and mentors)
can encourage young people who need help
to get into treatment—and support them
along the way.
9. Effectively treating substance use
disorders in adolescents requires
also identifying and treating any other
mental health conditions they may have.
Adolescents who abuse drugs frequently
also suffer from other conditions including
depression, anxiety disorders, attentiondeficit
hyperactivity disorder (ADHD),
oppositional defiant disorder, and conduct
problems. 23 Adolescents who abuse drugs,
particularly those involved in the juvenile
justice system, should be screened for other
psychiatric disorders. Treatment for these
problems should be integrated with the
treatment for a substance use disorder.
10 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

10. Sensitive issues such as violence
and child abuse or risk of
suicide should be identified and
addressed. Many adolescents who
abuse drugs have a history of physical,
emotional, and/or sexual abuse or
other trauma. 24 If abuse is suspected,
referrals should be made to social
and protective services, following local
regulations and reporting requirements.
11. It is important to monitor drug use
during treatment. Adolescents recovering
from substance use disorders may
experience relapse, or a return to drug
use. Triggers associated with relapse
vary and can include mental stress and
social situations linked with prior drug
use. It is important to identify a return
to drug use early before an undetected
relapse progresses to more serious
consequences. A relapse signals the need
for more treatment or a need to adjust the
individual’s current treatment plan to better
meet his or her needs.
12. Staying in treatment for an adequate
period of time and continuity of care
afterward are important. The minimal
length of drug treatment depends on
the type and extent of the adolescent’s
problems, but studies show outcomes are
better when a person stays in treatment for
3 months or more. 25 Because relapses often
occur, more than one episode of treatment
may be necessary. Many adolescents
also benefit from continuing care following
treatment, 26 including drug use monitoring,
follow-up visits at home, 27 and linking the
family to other needed services.
A relapse signals the need for more
treatment or a need to adjust the
individual’s current treatment plan.
13. Testing adolescents for sexually
transmitted diseases like HIV, as well
as hepatitis B and C, is an important
part of drug treatment. Adolescents
who use drugs—whether injecting or
non-injecting—are at an increased risk
for diseases that are transmitted sexually
as well as through the blood, including
HIV and hepatitis B and C. All drugs
of abuse alter judgment and decision
making, increasing the likelihood that an
adolescent will engage in unprotected
sex and other high-risk behaviors
including sharing contaminated drug
injection equipment and unsafe tattooing
and body piercing practices––potential
routes of virus transmission. Substance
use treatment can reduce this risk both
by reducing adolescents’ drug use (and
thus keeping them out of situations in
which they are not thinking clearly) and
by providing risk-reduction counseling to
help them modify or change their highrisk
behaviors. 28,29
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 11

III. FREQUENTLY ASKED QUESTIONS
12 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

1. Why do adolescents
take drugs?
Adolescents experiment with drugs or continue
taking them for several reasons, including:
• To fit in: Many teens use drugs “because
others are doing it”—or they think others
are doing it—and they fear not being
accepted in a social circle that includes
drug-using peers.
• To feel good: Abused drugs interact with
the neurochemistry of the brain to produce
feelings of pleasure. The intensity of this
euphoria differs by the type of drug and how
it is used.
• To feel better: Some adolescents suffer
from depression, social anxiety, stressrelated
disorders, and physical pain. Using
drugs may be an attempt to lessen these
feelings of distress. Stress especially plays
a significant role in starting and continuing
drug use as well as returning to drug use
(relapsing) for those recovering from an
addiction.
• To do better: Ours is a very competitive
society, in which the pressure to perform
athletically and academically can be
intense. Some adolescents may turn to
certain drugs like illegal or prescription
stimulants because they think those
substances will enhance or improve their
performance.
• To experiment: Adolescents are often
motivated to seek new experiences,
particularly those they perceive as thrilling
or daring.
2. What drugs are most
frequently used by
adolescents?
Alcohol and tobacco are the drugs most
commonly abused by adolescents, followed by
marijuana. The next most popular substances
differ between age groups. Young adolescents
tend to favor inhalant substances (such as
breathing the fumes of household cleaners,
glues, or pens; see “The Dangers of Inhalants,”
page 15), whereas older teens are more likely
to use synthetic marijuana (“K2” or “Spice”) and
prescription medications—particularly opioid
pain relievers like Vicodin ® and stimulants like
Adderall ® . In fact, the Monitoring the Future
survey of adolescent drug use and attitudes
shows that prescription and over-the-counter
medications account for a majority of the drugs
most commonly abused by high-school seniors.
Percent of High School Seniors Using in the Past Year
Most Commonly Abused Drugs by
High School Seniors (Other than
Tobacco and Alcohol)
40
35
30
25
20
15
10
5
0
Marijuana
36.4
Amphetamines A
8.7
Synthetic Marijuana
7.9
Prescription Painkillers*
7.1
■ Illegal Drugs
■ Prescription or OTC Drugs
Cough Medicine
5.0
Sedatives
Tranquilizers
Hallucinogens
MDMA (Ecstasy)
Salvia
A
The top drug used in this category is Adderall (7.4%)
*The top drugs used in this category are Vicodin (5.3%) and OxyContin (3.6%)
Source: Monitoring the Future National Results on Adolescent
Drug Use: Summary of Key Findings, 2013.
4.8
4.6
4.5
4.0
3.4
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 13

3. How do adolescents
become addicted to
drugs, and which factors
increase risk?
Addiction occurs when repeated use of drugs
changes how a person’s brain functions over
time. The transition from voluntary to compulsive
drug use reflects changes in the brain’s natural
inhibition and reward centers that keep a
person from exerting control over the impulse
to use drugs even when there are negative
consequences—the defining characteristic of
addiction.
Some people are more vulnerable to this
process than others, due to a range of possible
risk factors. Stressful early life experiences such
as being abused or suffering other forms of
trauma are one important risk factor. Adolescents
with a history of physical and/or sexual abuse
are more likely to be diagnosed with substance
use disorders. 30 Many other risk factors,
including genetic vulnerability, prenatal exposure
to alcohol or other drugs, lack of parental
supervision or monitoring, and association with
drug-using peers also play an important role. 31
At the same time, a wide range of genetic and
environmental influences that promote strong
psychosocial development and resilience may
work to balance or counteract risk factors,
making it ultimately hard to predict which
individuals will develop substance use
disorders and which won’t.
4. Is it possible for teens
to become addicted to
marijuana?
Yes. Contrary to common belief, marijuana is
addictive. Estimates from research suggest that
about 9 percent of users become addicted to
marijuana; this number increases among those
who start young (to about 17 percent, or 1 in
6) and among daily users (to 25–50 percent). 32
Thus, many of the nearly 7 percent of highschool
seniors who (according to annual survey
data) 33 report smoking marijuana daily or almost
daily are well on their way to addiction, if not
already addicted, and may be functioning at a
sub-optimal level in their schoolwork and in
other areas of their lives.
Long-term marijuana users who try to quit
report withdrawal symptoms including irritability,
sleeplessness, decreased appetite, anxiety, and
drug craving, all of which can make it difficult
to stay off the drug. Behavioral interventions,
including Cognitive-Behavioral Therapy and
Contingency Management (providing tangible
incentives to patients who remain drug-free)
have proven to be effective in treating marijuana
addiction (see Page 24 for descriptions of
these treatments). Although no medications
are currently available to treat marijuana
addiction, it is possible that medications to ease
marijuana withdrawal, block its intoxicating
effects, and prevent relapse may emerge from
recent discoveries about the workings of the
endocannabinoid system, a signaling system in
the body and brain that uses chemicals related
to the active ingredients in marijuana.
Legalization of marijuana for adult recreational
use and for medicinal purposes is currently
the subject of much public debate. Whatever
the outcome, public health experts are worried
about use increasing among adolescents,
since marijuana use as a teen may harm the
developing brain, lower IQ, and seriously impair
the ability to drive safely, especially when
combined with alcohol.
Parents seeking more information about the
effects of marijuana on teens are encouraged
to see information offered on NIDA’s Web
site: http://www.drugabuse.gov/drugs-abuse/
marijuana.
14 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

The Dangers of Inhalants
Various household products, including
cleaning fluids, glues, lighter fluid, aerosol
sprays, and office supplies like markers
and correction fluid, have fumes that are
sometimes breathed to obtain a brief,
typically alcohol-like high. Because of their
ready availability, these are frequently
among the earliest substances youth abuse;
they are generally less popular among older
teens, who have greater access to other
substances like alcohol or marijuana.
Although the high from inhalants typically
wears off quickly, immediate health
consequences of inhalant abuse may be
severe: In addition to nausea or vomiting,
users risk suffocation and heart failure—
called “sudden sniffing death.” Serious
long-term consequences include liver and
kidney damage, hearing loss, bone marrow
damage, and brain damage. Although
addiction to inhalants is not very common, it
can occur with repeated abuse.
Early abuse of inhalants may also be a
warning sign for later abuse of other drugs.
One study found that youth who used
inhalants before age 14 were twice as likely
to later use opiate drugs. 34 So it is important
for parents to safeguard household products
and be alert to signs that their younger
teens may be abusing these substances.
5. Is abuse of prescription
medications as
dangerous as other
forms of illegal drug use?
Psychoactive prescription drugs, which include
opioid pain relievers, stimulants prescribed for
ADHD, and central nervous system depressants
prescribed to treat anxiety or sleep disorders, are
all effective and safe when taken as prescribed
by a doctor for the conditions they are intended
to treat. However, they are frequently abused—
that is, taken in other ways, in other quantities,
or by people for whom they weren’t prescribed—
and this can have devastating consequences.
In the case of opioid pain relievers such
as Vicodin ® or OxyContin ® , there is a great
risk of addiction and death from overdose
associated with such abuse. Especially when
pills are crushed and injected or snorted, these
medications affect the brain and body very much
like heroin, including euphoric effects and a
hazardous suppression of breathing (the reason
for death in cases of fatal opioid overdose).
In fact, some young people who develop
prescription opioid addictions shift to heroin
because it may be cheaper to obtain. 35
ADHD medications such as Adderall ® (which
contains the stimulant amphetamine) are
increasingly popular among young people who
take them believing it will improve their school
performance. This too is a dangerous trend.
Prescription stimulants act in the brain similarly
to cocaine or illegal amphetamines, raising heart
rate and blood pressure, as well as producing
an addictive euphoria. Other than promoting
wakefulness, it is unclear that such medications
actually provide much or any cognitive benefit,
however, beyond the benefits they provide when
taken as prescribed to those with ADHD. 36
6. Are steroids addictive
and can steroid abuse be
treated?
Some adolescents—mostly male—abuse
anabolic-androgenic steroids in order to improve
their athletic performance and/or improve their
appearance by helping build muscles. Steroid
abuse may lead to serious, even irreversible,
health problems including kidney impairment,
liver damage, and cardiovascular problems that
raise the risk of stroke and heart attack (even
in young people). An undetermined percentage
of steroid abusers may also become addicted
to the drugs—that is, continuing to use them
despite physical problems and negative effects
on social relations—but the mechanisms
causing this addiction are more complex than
those for other drugs of abuse.
Steroids are not generally considered
intoxicating, but animal studies have shown that
chronic steroid use alters the same dopamine
reward pathways in the brain that are affected
by other substances. Other factors such as
underlying body image problems also contribute
to steroid abuse. 37 Moreover, when people stop
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 15

using steroids, they can experience withdrawal
symptoms such as hormonal changes that
produce fatigue, loss of muscle mass and sex
drive, and other unpleasant physical changes.
One of the more dangerous withdrawal
symptoms is depression, which has led to
suicide in some people discontinuing steroids.
Steroid abuse is also frequently complicated
by abuse of other substances taken either as
part of a performance-enhancing regimen (such
as stimulants) or to help manage pain-, sleep-,
or mood-related side effects (such as opioids,
cannabis, and alcohol). 38
Because of this complicated mix of issues,
treatment for steroid abuse necessarily involves
addressing all related mental and physical
health issues and substance use disorders
simultaneously. This may involve behavioral
treatments as well as medications to help
normalize the hormonal system and treat
any depression or pain issues that may be
present. If symptoms are severe or prolonged,
hospitalization may be needed.
7. How do other mental
health conditions relate
to substance use in
adolescents?
Drug use in adolescents frequently overlaps with
other mental health problems. For example, a
teen with a substance use disorder is more likely
to have a mood, anxiety, learning, or behavioral
disorder too. Sometimes drugs can make
accurately diagnosing these other problems
complicated. Adolescents may begin taking
drugs to deal with depression or anxiety, for
example; on the other hand, frequent drug use
may also cause or precipitate those disorders.
Adolescents entering drug abuse treatment
should be given a comprehensive mental health
screening to determine if other disorders are
present. Effectively treating a substance use
disorder requires addressing drug abuse and
other mental health problems simultaneously.
Addiction occurs when repeated use
of drugs changes how a person’s
brain functions over time.
8. Does treatment of
ADHD with stimulant
medications like Ritalin ®
and Adderall ® increase
risk of substance abuse
later in life?
Prescription stimulants are effective at treating
attention disorders in children and adolescents,
but concerns have been raised that they could
make a young person more vulnerable to
developing later substance use disorders. On
balance, the studies conducted so far have
found no differences in later substance use for
ADHD-affected children who received treatment
versus those that did not. This suggests that
treatment with ADHD medication does not affect
(either negatively or positively) an individual’s
risk for developing a substance use disorder. 39
9. What are signs of drug
use in adolescents,
and what role can
parents play in getting
treatment?
If an adolescent starts behaving differently for
no apparent reason––such as acting withdrawn,
frequently tired or depressed, or hostile–it could
be a sign he or she is developing a drug-related
problem. Parents and others may overlook such
signs, believing them to be a normal part of
puberty.
Other signs include:
• a change in peer group
• carelessness with grooming
• decline in academic performance
• missing classes or skipping school
• loss of interest in favorite activities
• changes in eating or sleeping habits
• deteriorating relationships with family
members and friends
Parents tend to underestimate the risks or
seriousness of drug use. The symptoms listed
here suggest a problem that may already have
become serious and should be evaluated to
determine the underlying cause—which could
be a substance abuse problem or another
16 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

11. What role can medical
professionals play in
addressing substance
abuse (including abuse of
prescription drugs) among
adolescents?
mental health or medical disorder. Parents who
are unsure whether their child is abusing drugs
can enlist the help of a primary care physician,
school guidance counselor, or drug abuse
treatment provider.
Parents seeking treatment for an adolescent
child are encouraged to see NIDA’s booklet,
Seeking Drug Abuse Treatment: Know What to
Ask (http://www.drugabuse.gov/publications/
seeking-drug-abuse-treatment) and see the
Treatment Referral Resources section of this
guide (page 31).
10. How can parents
participate in their
adolescent child’s
treatment?
Parents can actively support their child and
engage with him or her during the treatment and
recovery process. Apart from providing moral
and emotional support, parents can also play a
crucial role in supporting the practical aspects
of treatment, such as scheduling and making
appointments, as well as providing needed
structure and supervision through household
rules and monitoring. Also, several evidencebased
treatments for adolescents specifically
address drug abuse within the family context.
Family-based drug abuse treatment can help
improve communication, problem-solving,
and conflict resolution within the household.
Treatment professionals can help parents
and other family members identify ways they
can support the changes the adolescent
achieves through treatment (see “Family-Based
Approaches,” pages 25–26).
Medical professionals have an important role to
play in screening their adolescent patients for
drug use, providing brief interventions, referring
them to substance abuse treatment if necessary,
and providing ongoing monitoring and follow-up.
Screening and brief interventions do not have to be
time-consuming and can be integrated into general
medical settings.
• Screening. Screening and brief assessment
tools administered during annual routine
medical checkups can detect drug use before
it becomes a serious problem. The purpose
of screening is to look for evidence of any use
of alcohol, tobacco, or illicit drugs or abuse of
prescription drugs and assess how severe the
problem is. Results from such screens can
indicate whether a more extensive assessment
and possible treatment are necessary (see
“Screening Tools and Brief Assessments Used
with Adolescents,” below). 40 Screening as a
part of routine care also helps to reduce the
stigma associated with being identified as
having a drug problem.
Screening Tools and Brief
Assessments Used with
Adolescents
Screening tools are available and outlined
in the American Academy of Pediatrics
(AAP) publications, Tobacco, Alcohol, and
Other Drugs: The Role of the Pediatrician in
Prevention, Identification, and Management
of Substance Abuse 41 and Substance Use
Screening, Brief Intervention and Referral to
Treatment for Pediatricians. 42
In addition, the Alcohol Screening and Brief
Intervention for Youth: A Practitioner’s Guide
developed by the National Institute on Alcohol
Abuse and Alcoholism provides information
on identifying adolescents at high risk for
alcohol abuse. 43
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 17

• Brief Intervention. Adolescents who report
using drugs can be given a brief intervention
to reduce their drug use and other risky
behaviors. Specifically, they should be
advised how continued drug use may harm
their brains, general health, and other areas
of their life, including family relationships
and education. Adolescents reporting no
substance use can be praised for staying
away from drugs and rescreened during their
next physical.
• Referral. Adolescents with substance
use disorders or those that appear to be
developing a substance use disorder may
need a referral to substance abuse treatment
for more extensive assessment and care.
• Follow-up. For patients in treatment, medical
professionals can offer ongoing support of
treatment participation and abstinence from
drugs during follow-up visits. Adolescent
patients who relapse or show signs of
continuing to use drugs may need to be
referred back to treatment.
• Before prescribing medications that can
potentially be abused, clinicians can assess
patients for risk factors such as mental illness
or a family history of substance abuse,
consider an alternative medication with less
abuse potential, more closely monitor patients
at high risk, reduce the length of time between
visits for refills so fewer pills are on hand,
and educate both patients and their parents
about appropriate use and potential risks
of prescription medications, including the
dangers of sharing them with others.
12. Is adolescent tobacco use
treated similarly to other
drug use?
Yes. People often don’t think of tobacco use as a
kind of “drug abuse” that requires treatment, and
motives for quitting smoking may be somewhat
different than motives for quitting other drugs.
But tobacco use has well-known health risks––
especially when begun in the teen years––and
the highly addictive nicotine in tobacco can make
treatment a necessity to help an adolescent quit.
Laboratory research also suggests that nicotine
may increase the rewarding and addictive effects
of other drugs, making it a potential contributor to
other substance use disorders.
Common treatment approaches like Cognitive-
Behavioral Therapy are now being used
to help adolescents quit smoking (and quit
using other drugs) by helping them “train their
brains” so they learn to recognize and control
their cravings and better deal with life stress.
Other therapies like Contingency Management
and Motivational Enhancement use incentives
and motivation techniques to help teens
reduce or stop smoking. 44 (See page 24 for
descriptions of these treatments.)
Tobacco use often accompanies other drug
use and needs to be addressed as part of
other substance use disorder treatment. In
a recent survey, nearly 55 percent of current
adolescent cigarette smokers (ages 12 to 17)
were also illicit drug users (by comparison,
only about 6 percent of those who did
not smoke used any illicit drugs). 45 Also,
cigarette smoking can be an indicator of other
psychiatric disorders, which can be identified
through comprehensive screening
by a treatment provider.
13. Are there medications
to treat adolescent
substance abuse?
Several medications are approved by the
FDA to treat addiction to opioids, alcohol, and
nicotine in individuals 18 and older. In most
cases, little research has been conducted
to evaluate the safety and efficacy of these
medications for adolescents; however,
some health care providers do use these
medications “off-label,” especially in older
adolescents (see “Addiction Medications,”
pages 26–28).
14. Do girls and boys have
different treatment
needs?
Adolescent girls and boys may have different
developmental and social issues that may
call for different treatment strategies or
emphases. For example, girls with substance
use disorders may be more likely to also have
mood disorders such as depression or to have
experienced physical or sexual abuse. Boys
with substance use disorders are more likely
18 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

to also have conduct, behavioral, and learning
problems, which may be very disruptive to their
school, family, or community. Treatments should
take into account the higher rate of internalizing
and traumatic stress disorders among adolescent
girls, the higher rate of externalizing disruptive
disorders and juvenile justice problems among
adolescent boys, and other gender differences
that may play into adolescent substance use
disorders.
15. What are the unique
treatment needs of
adolescents from
different racial/ethnic
backgrounds?
Treatment providers are urged to consider the
unique social and environmental characteristics
that may influence drug abuse and treatment
for racial/ethnic minority adolescents, such as
stigma, discrimination, and sparse community
resources. With the growing number of immigrant
children living in the United States, issues of
culture of origin, language, and acculturation
are important considerations for treatment. The
demand for bilingual treatment providers to work
with adolescents and their families will also be
increasing as the diversity of the U.S. population
increases.
16. What role can the
juvenile justice system
play in addressing
adolescent drug abuse?
Involvement in the juvenile justice system is
unfortunately a reality for many substanceabusing
adolescents, but it presents a valuable
opportunity for intervention. Substance use
treatment can be incorporated into the juvenile
justice system in several ways. These include:
• screening and assessment for drug abuse
upon arrest
• initiation of treatment while awaiting trial
• access to treatment programs in the community
in lieu of incarceration (e.g., juvenile treatment
drug courts) 46,47
• treatment during incarceration followed by
community-based treatment after release
Coordination and collaboration between juvenile
justice professionals, drug abuse treatment
providers, and other social service agencies
are essential in getting needed treatment to
adolescent offenders, about one half of whom
have substance use disorders. 48
17. What role do 12-step
groups or other recovery
support services play in
addiction treatment for
adolescents?
Adolescents may benefit from participation
in self- or mutual-help groups like 12-step
programs or other recovery support services,
which can reinforce abstinence from drug use
and other changes made during treatment, as
well as support progress made toward important
goals like succeeding in school and reuniting
with family. Peer recovery support services and
recovery high schools provide a community
setting where fellow recovering adolescents can
share their experiences and support each other
in living a drug-free life.
It is important to note that recovery support
services are not a substitute for drug abuse
treatment. Also, there is sometimes a risk in
support-group settings that conversation among
adolescents can turn to talk extolling drug use;
group leaders need to be aware of such a
possibility and be ready to direct the discussion
in more positive directions if necessary.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 19

IV. TREATMENT SETTINGS
20 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Treatment for substance use disorders
is delivered at varying levels of care
in many different settings. Because
no single treatment is appropriate
for every adolescent, treatments
must be tailored for the individual. Based on
the consensus of drug treatment experts, the
American Society of Addiction Medicine (ASAM)
has developed guidelines for determining the
appropriate intensity and length of treatment for
adolescents with substance abuse problems,
based on an assessment involving six areas: 49
(1) Level of intoxication and potential for
withdrawal
(2) Presence of other medical conditions
(3) Presence of other emotional, behavioral, or
cognitive conditions
(4) Readiness or motivation to change
(5) Risk of relapse or continued drug use
(6) Recovery environment (e.g., family, peers,
school, legal system)
With a substance use disorder—as with any
other medical condition—treatment must
be long enough and strong enough to be
effective. Just as an antibiotic must be taken for
sufficient time to kill a bacterial infection, even
though symptoms may already have subsided,
substance abuse treatment must continue for
a sufficient length of time to treat the disease.
Undertreating a substance use disorder—
providing lower than the recommended level
of care or a shorter length of treatment than
recommended—will increase the risk of relapse
and could cause the patient, his or her family
members, or the referring juvenile justice system
to lose hope in the treatment because they will
see it as ineffective.
This section will review the settings in which
adolescent drug abuse treatment most often
occurs.
Outpatient/Intensive Outpatient
Adolescent drug abuse treatment is most
commonly offered in outpatient settings. When
delivered by well-trained clinicians, this can
be highly effective. Outpatient treatment is
traditionally recommended for adolescents
with less severe addictions, few additional
mental health problems, and a supportive living
environment, although evidence suggests that
more severe cases can be treated in outpatient
settings as well. Outpatient treatment varies in
the type and intensity of services offered and
may be delivered on an individual basis or in
a group format (although research suggests
group therapy can carry certain risks; see
“Group Therapy for Adolescents,” page 23).
Low- or moderate-intensity outpatient care
is generally delivered once or twice a week.
Intensive outpatient services are delivered more
frequently, typically more than twice a week for
at least 3 hours per day. Outpatient programs
may offer drug abuse prevention programming
(focused on deterring further drug use) or other
behavioral and family interventions. 50,51
Partial Hospitalization
Adolescents with more severe substance use
disorders but who can still be safely managed
in their home living environment may be
referred to a higher level of care called partial
hospitalization or “day treatment.” This setting
offers adolescents the opportunity to participate
in treatment 4–6 hours a day at least 5 days a
week while living at home. 52
Residential/Inpatient Treatment
Residential treatment is a resource-intense high
level of care, generally for adolescents with
severe levels of addiction whose mental health
and medical needs and addictive behaviors
require a 24-hour structured environment to
make recovery possible. These adolescents
may have complex psychiatric or medical
problems or family issues that interfere with
their ability to avoid substance use. One wellknown
long-term residential treatment model
is the therapeutic community (TC). TCs use
a combination of techniques to “resocialize”
the adolescent and enlist all the members of
the community, including residents and staff,
as active participants in treatment. Treatment
focuses on building personal and social
responsibility and developing new coping skills.
Such programs offer a range of family services
and may require family participation if the TC is
sufficiently close to where the family lives. Shortterm
residential programs also exist. 53
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 21

V. EVIDENCE-BASED
APPROACHES TO
TREATING ADOLESCENT
SUBSTANCE USE
DISORDERS
22 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

Research evidence supports the
effectiveness of various substance
abuse treatment approaches for
adolescents. Examples of specific
evidence-based approaches
are described below, including behavioral
and family-based interventions as well as
medications. Each approach is designed
to address specific aspects of adolescent
drug use and its consequences for the
individual, family, and society. In order for
any intervention to be effective, the clinician
providing it needs to be trained and wellsupervised
to ensure that he or she adheres
to the instructions and guidance described in
treatment manuals. Most of these treatments
have been tested over short periods of
12–16 weeks, but for some adolescents,
longer treatments may be warranted; such a
decision is made on a case-by-case basis.
The provider should use clinical judgment
to select the evidence-based approach that
seems best suited to the patient and his or
her family.*
BEHAVIORAL APPROACHES
Behavioral interventions help adolescents
to actively participate in their recovery from
drug abuse and addiction and enhance their
ability to resist drug use. In such approaches,
therapists may provide incentives to remain
abstinent, modify attitudes and behaviors
related to drug abuse, assist families in
improving their communication and overall
interactions, and increase life skills to
handle stressful circumstances and deal
with environmental cues that may trigger
intense craving for drugs. Below are some
behavioral treatments shown to be effective in
addressing substance abuse in adolescents
(listed in alphabetical order).
Group Therapy for Adolescents
Adolescents can participate in group
therapy and other peer support programs
during and following treatment to help them
achieve abstinence. When led by welltrained
clinicians following well-validated
Cognitive-Behavioral Therapy (CBT)
protocols (see page 24), groups can provide
positive social reinforcement through peer
discussion and help enforce incentives
to staying off drugs and living a drug-free
lifestyle.
However, group treatment for adolescents
carries a risk of unintended adverse effects:
Group members may steer conversation
toward talk that glorifies or extols drug
use, thereby undermining recovery goals.
Trained counselors need to be aware of that
possibility and direct group activities and
discussions in a positive direction.
Adolescent Community
Reinforcement Approach (A-CRA)
A-CRA is an intervention that seeks to help
adolescents achieve and maintain abstinence
from drugs by replacing influences in their
lives that had reinforced substance use with
healthier family, social, and educational or
vocational reinforcers. After assessing the
adolescent’s needs and levels of functioning,
the therapist chooses from among 17 A-CRA
procedures to address problem-solving, coping,
and communication skills and to encourage
active participation in constructive social and
recreational activities. 54
*
The treatments listed in this book are not intended to be a comprehensive list of efficacious evidence-based treatment approaches for adolescents.
NIDA continues supporting research developing new approaches to address adolescent drug abuse.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 23

Cognitive-Behavioral Therapy (CBT)
CBT strategies are based on the theory that
learning processes play a critical role in the
development of problem behaviors like drug
abuse. A core element of CBT is teaching
participants how to anticipate problems and
helping them develop effective coping strategies.
In CBT, adolescents explore the positive and
negative consequences of using drugs. They
learn to monitor their feelings and thoughts and
recognize distorted thinking patterns and cues
that trigger their substance abuse; identify and
anticipate high-risk situations; and apply an
array of self-control skills, including emotional
regulation and anger management, practical
problem solving, and substance refusal. CBT
may be offered in outpatient settings in either
individual or group sessions (see “Group
Therapy for Adolescents,” page 23) or in
residential settings. 55
Contingency Management (CM)
Research has demonstrated the effectiveness
of treatment using immediate and tangible
reinforcements for positive behaviors to modify
problem behaviors like substance abuse. This
approach, known as Contingency Management
(CM), provides adolescents an opportunity
to earn low-cost incentives such as prizes or
cash vouchers (for food items, movie passes,
and other personal goods) in exchange for
participating in drug treatment, achieving
important goals of treatment, and not using
drugs. The goal of CM is to weaken the influence
of reinforcement derived from using drugs and
to substitute it with reinforcement derived from
healthier activities and drug abstinence. For
adolescents, CM has been offered in a variety
of settings, and parents can be trained to apply
this method at home. CM is typically combined
either with a psychosocial treatment or a
medication (where available). Recent evidence
also supports the use of Web-based CM to help
adolescents stop smoking. 56
Motivational Enhancement Therapy
(MET)
MET is a counseling approach that helps
adolescents resolve their ambivalence about
engaging in treatment and quitting their drug
use. This approach, which is based on a
technique called motivational interviewing,
typically includes an initial assessment of
the adolescent’s motivation to participate in
treatment, followed by one to three individual
sessions in which a therapist helps the patient
develop a desire to participate in treatment by
providing non-confrontational feedback. Being
empathic yet directive, the therapist discusses
the need for treatment and tries to elicit selfmotivational
statements from the adolescent
to strengthen his or her motivation and build
a plan for change. If the adolescent resists,
the therapist responds neutrally rather than by
contradicting or correcting the patient. MET,
while better than no treatment, is typically not
used as a stand-alone treatment for adolescents
with substance use disorders but is used to
motivate them to participate in other types of
treatment. 57
Twelve-Step Facilitation Therapy
Twelve-Step Facilitation Therapy is designed to
increase the likelihood that an adolescent with
a drug abuse problem will become affiliated
and actively involved in a 12-step program
like Alcoholics Anonymous (AA) or Narcotics
Anonymous (NA). Such programs stress the
participant’s acceptance that life has become
unmanageable, that abstinence from drug use
is needed, and that willpower alone cannot
overcome the problem. The benefits of 12-
step participation for adults in extending the
benefits of addiction treatment appear to apply
to adolescent outpatients as well, according
to recent research. Research also suggests
adolescent-specific 12-step facilitation strategies
may help enhance outpatient attendance rates. 58
Behavioral interventions help adolescents to actively participate in their
recovery from drug abuse and addiction and enhance their ability to resist
drug use.
24 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

FAMILY-BASED APPROACHES
Family-based approaches to treating
adolescent substance abuse highlight
the need to engage the family, including
parents, siblings, and sometimes peers,
in the adolescent’s treatment. Involving
the family can be particularly important,
as the adolescent will often be living with
at least one parent and be subject to the
parent’s controls, rules, and/or supports.
Family-based approaches generally address
a wide array of problems in addition to the
young person’s substance problems, including
family communication and conflict; other cooccurring
behavioral, mental health, and
learning disorders; problems with school or
work attendance; and peer networks. Research
shows that family-based treatments are highly
efficacious; some studies even suggest they are
superior to other individual and group treatment
approaches. 59 Typically offered in outpatient
settings, family treatments have also been tested
successfully in higher-intensity settings such as
residential and intensive outpatient programs.
Below are specific types of family-based
treatments shown to be effective in treating
adolescent substance abuse.
Brief Strategic Family Therapy (BSFT)
BSFT is based on a family systems approach
to treatment, in which one member’s problem
behaviors are seen to stem from unhealthy
family interactions. Over the course of 12–16
sessions, the BSFT counselor establishes a
relationship with each family member, observes
how the members behave with one another,
and assists the family in changing negative
Involving the family can be
particularly important in
adolescent substance abuse
treatment.
interaction patterns. BSFT can be adapted to
a broad range of family situations in various
settings (mental health clinics, drug abuse
treatment programs, social service settings,
families’ homes) and treatment modalities (as a
primary outpatient intervention, in combination
with residential or day treatment, or as an
aftercare/continuing-care service following
residential treatment). 60
Family Behavior Therapy (FBT)
FBT, which has demonstrated positive results
in both adults and adolescents, combines
behavioral contracting with contingency
management to address not only substance
abuse but other behavioral problems as
well. The adolescent and at least one parent
participate in treatment planning and choose
specific interventions from a menu of evidencebased
treatment options. Therapists encourage
family members to use behavioral strategies
taught in sessions and apply their new skills
to improve the home environment. They set
behavioral goals for preventing substance
use and reducing risk behaviors for sexually
transmitted diseases like HIV, which are
reinforced through a contingency management
(CM) system (see description on page 24).
Goals are reviewed and rewards provided at
each session. 61
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 25

Multidimensional Family Therapy
(MDFT)
MDFT is a comprehensive family- and
community-based treatment for substanceabusing
adolescents and those at high risk for
behavior problems such as conduct disorder
and delinquency. The aim is to foster family
competency and collaboration with other
systems like school or juvenile justice. Sessions
may take place in a variety of locations,
including in the home, at a clinic, at school, at
family court, or in other community locations.
MDFT has been shown to be effective even with
more severe substance use disorders and can
facilitate the reintegration of substance abusing
juvenile detainees into the community. 63
Functional Family Therapy (FFT)
FFT combines a family systems view of family
functioning (which asserts that unhealthy
family interactions underlie problem behaviors)
with behavioral techniques to improve
communication, problem-solving, conflict
resolution, and parenting skills. Principal
treatment strategies include (1) engaging
families in the treatment process and enhancing
their motivation for change and (2) modifying
family members’ behavior using CM techniques,
communication and problem solving, behavioral
contracts, and other methods. 62
Undertreating a substance use
disorder will increase the risk of
relapse.
Multisystemic Therapy (MST)
MST is a comprehensive and intensive familyand
community-based treatment that has been
shown to be effective even with adolescents
whose substance abuse problems are severe
and with those who engage in delinquent and/
or violent behavior. In MST, the adolescent’s
substance abuse is viewed in terms of
characteristics of the adolescent (e.g., favorable
attitudes toward drug use) and those of his or
her family (e.g., poor discipline, conflict, parental
drug abuse), peers (e.g., positive attitudes
toward drug use), school (e.g., dropout, poor
performance), and neighborhood (e.g., criminal
subculture). The therapist may work with the
family as a whole but will also conduct sessions
with just the caregivers or the adolescent
alone. 64
ADDICTION MEDICATIONS
Several medications have been found to
be effective in treating addiction to opioids,
alcohol, or nicotine in adults, although none of
these medications have been approved by the
FDA to treat adolescents. In most cases, only
preliminary evidence exists for the effectiveness
and safety of these medications in people
under 18, and there is no evidence on the
neurobiological impact of these medications
26 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

on the developing brain. However, despite
the relative lack of evidence, some health
care providers do use medications “off-label”
when treating adolescents (especially older
adolescents) who are addicted to opioids,
nicotine, or (less commonly) alcohol. Newer
compounds continue to be studied for possibly
treating substance use disorders in adults and
adolescents, but none other than those listed
here have shown conclusive results.
Note that there are currently no FDA-approved
medications to treat addiction to cannabis,
cocaine, or methamphetamine in any age
group.
Opioid Use Disorders
Buprenorphine reduces or eliminates opioid
withdrawal symptoms, including drug cravings,
without producing the “high” or dangerous side
effects of heroin and other opioids. It does this
by both activating and blocking opioid receptors
in the brain (i.e., it is what is known as a partial
opioid agonist). It is available for sublingual
(under-the-tongue) administration both in a
stand-alone formulation (called Subutex ® )
and in combination with another agent called
naloxone. The naloxone in the combined
formulation (marketed as Suboxone ® ) is
included to deter diversion or abuse of the
medication by causing a withdrawal reaction
if it is intravenously injected. 65 Physicians with
special certification may provide office-based
buprenorphine treatment for detoxification
and/or maintenance therapy. 66 It is sometimes
prescribed to older adolescents on the basis
of two research studies indicating its efficacy
for this population, 67,68 even though it is not
approved by the FDA for pediatric use.*
Methadone also prevents withdrawal
symptoms and reduces craving in opioidaddicted
individuals by activating opioid
receptors in the brain (i.e., a full opioid agonist).
Adolescent drug abuse treatment is
most commonly offered in outpatient
settings.
It has a long history of use in treatment of
opioid dependence in adults, and is available
in specially licensed methadone treatment
programs. In select cases and in some States,
opioid-dependent adolescents between the ages
of 16 and 18 may be eligible for methadone
treatment, provided they have two documented
failed treatments of opioid detoxification or
drug-free treatment and have a written consent
for methadone signed by a parent or legal
guardian. 69
Naltrexone is approved for the prevention of
relapse in adult patients following complete
detoxification from opioids. It acts by blocking
the brain’s opioid receptors (i.e., an opioid
antagonist), preventing opioid drugs from acting
on them and thus blocking the high the user
would normally feel and/or causing withdrawal if
recent opioid use has occurred. It can be taken
orally in tablets or as a once-monthly injection
given in a doctor’s office (a preparation called
Vivitrol ® ). 70
Alcohol Use Disorders ‡
Acamprosate (Campral ® ) reduces withdrawal
symptoms by normalizing brain systems
disrupted by chronic alcohol consumption in
adults.
Disulfiram (Antabuse ® ) inhibits an enzyme
involved in the metabolism of alcohol, causing an
unpleasant reaction if alcohol is consumed after
taking the medication. 71
* According to the FDA label, “SUBOXONE and SUBUTEX are not recommended for use in pediatric patients. The safety and effectiveness of
SUBOXONE and SUBUTEX in patients below the age of 16 have not been established.”
‡ Medication-assisted therapies are rarely used to treat adolescent alcohol use disorders.
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 27

Naltrexone decreases alcohol-induced euphoria
and is available in both oral tablets and longacting
injectable preparations (as in its use for
the treatment of opioid addiction, above).
Nicotine Use Disorders
Bupropion, commonly prescribed for
depression, also reduces nicotine cravings and
withdrawal symptoms in adult smokers. 72
Nicotine Replacement Therapies (NRTs)
help smokers wean off cigarettes by activating
nicotine receptors in the brain. They are
available in the form of a patch, gum, lozenge,
nasal spray, or inhaler. 73
Varenicline reduces nicotine cravings and
withdrawal in adult smokers by mildly stimulating
nicotine receptors in the brain. 74
RECOVERY SUPPORT SERVICES
To reinforce gains made in treatment and to
improve their quality of life more generally,
recovering adolescents may benefit from
recovery support services, which include
continuing care, mutual help groups (such
as 12-step programs), peer recovery support
services, and recovery high schools. Such
programs provide a community setting where
fellow recovering persons can share their
experiences, provide mutual support to each
other’s struggles with drug or alcohol problems,
and in other ways support a substance-free
lifestyle. Note that recovery support services are
not substitutes for treatment. Also, the existing
research evidence for these approaches (with
the exception of Assertive Continuing Care) is
preliminary; anecdotal evidence supports the
effectiveness of peer recovery support services
and recovery high schools, for example, but
their efficacy has not been established through
controlled trials.
Assertive Continuing Care (ACC)
ACC is a home-based continuing-care
approach delivered by trained clinicians to
prevent relapse, and is typically used after
an adolescent completes therapy utilizing
the Adolescent Community Reinforcement
Approach (A-CRA, see page 23). Using positive
and negative reinforcement to shape behaviors,
along with training in problem-solving and
28 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

communication skills, ACC combines A-CRA
and assertive case management services
(e.g., use of a multidisciplinary team of
professionals, round-the-clock coverage,
assertive outreach) to help adolescents and
their caregivers acquire the skills to engage in
positive social activities. 75
Mutual Help Groups
Mutual help groups such as the 12-step
programs Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) provide ongoing
support for people with addictions to alcohol
or drugs, respectively, free of charge and in
a community setting. Participants meet in a
group with others in recovery, once a week or
more, sharing their experiences and offering
mutual encouragement. Twelve-step groups
are guided by a set of fundamental principles
that participants are encouraged to
adopt––including acknowledging that willpower
alone cannot achieve sustained sobriety,
that surrender to the group conscience must
replace self-centeredness, and that longterm
recovery involves a process of spiritual
renewal. 76
Peer Recovery Support Services
Peer recovery support services, such as
recovery community centers, help individuals
remain engaged in treatment and/or the
recovery process by linking them together
both in groups and in one-on-one relationships
with peer leaders who have direct experience
with addiction and recovery. Depending on
the needs of the adolescent, peer leaders
may provide mentorship and coaching and
help connect individuals to treatment, 12-
step groups, or other resources. Peer leaders
may also facilitate or lead community-building
activities, helping recovering adolescents build
alternative social networks and have drug- and
alcohol-free social options. 77
Recovery High Schools
Recovery high schools are schools specifically
designed for students recovering from
substance abuse issues. They are typically part
of another school or set of alternative school
programs within the public school system,
but recovery school students are generally
separated from other students by means
of scheduling and physical barriers. Such
programs allow adolescents newly in recovery
to be surrounded by a peer group supportive of
recovery efforts and attitudes. Recovery schools
can serve as an adjunct to formal substance
abuse treatment, with students often referred by
treatment providers and enrolled in concurrent
treatment for other mental health problems. 78
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 29

30 • Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide

TREATMENT
REFERRAL
RESOURCES
Substance Abuse and Mental Health Services Administration
(SAMHSA) Treatment Locator: 1-800-662-HELP or search
www.findtreatment.samhsa.gov
The “Find A Physician” feature on the American Society
of Addiction Medicine (ASAM) Web site:
http://community.asam.org/search/default.asp?m=basic
The Patient Referral Program on the American Academy
of Addiction Psychiatry Web site:
http://www.aaap.org/patient-referral-program
The Child and Adolescent Psychiatrist Finder on the American
Academy of Child and Adolescent Psychiatry Web site:
http://www.aacap.org/cs/root/child_and_adolescent_
psychiatrist_finder/child_and_adolescent_psychiatrist_finder
Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 31

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Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide • 35

NIH Publication Number 14-7953
January 2014
Feel free to reprint this publication.

Attachment C
Red Flags & Resources
(2 nd ed.)
Page 75 of 96

Red Flags and Resources
How to spot the red flags of risky behaviors
and find the support you need in Franklin and
Grand Isle Counties, Vermont.
Alburgh Bakersfield Berkshire Enosburgh Fairfax Fairfield Fletcher Franklin Georgia Grand Isle
Highgate Isle La Motte Montgomery North Hero Richford South Hero Sheldon St. Albans Swanton
Northwestern Vermont Second Edition

Funding for the publication of Red Flags and Resources Northwest Vermont Second Edition was made possible in part by the
Office of National Drug Control Policy (ONDCP) and the Substance Abuse and Mental Health Services Administration (SAMHSA)
through the Drug Free Communities Support Program.

Red Flags and Resources
Northwestern Vermont Second Edition
How to spot the red flags of risky behaviors
and find the support you need in Franklin and
Grand Isle Counties, Vermont.

Emotional Health ........................................................................................ 25
Stress and Anxiety ............................................................................. 26
Depression and Suicide ..................................................................... 28
Eating Disorders ................................................................................ 30
Obesity .............................................................................................. 32
Relationships and Personal Safety .............................................................. 35
Bullying.............................................................................................. 36
Harassment ....................................................................................... 38
Abusive Relationships ........................................................................ 40
Internet Safety ................................................................................... 42
Sexual Behavior ................................................................................. 44
For More Information ................................................................................. 46
Editorial and Financial Contributors ........................................................... 47
For more information about positive youth development, visit the Search Institute online at www.search_institute.org.
Table of Contents
Introduction .................................................................................................. 1
Nurturing Healthy Families ........................................................................... 3
Substance Use and Abuse ............................................................................. 5
Alcohol ................................................................................................ 6
Tobacco ............................................................................................... 8
Marijuana .......................................................................................... 10
Prescription Drugs and Over-the-Counter Drugs ............................... 12
Inhalants ........................................................................................... 14
Cocaine.............................................................................................. 16
Heroin ............................................................................................... 18
Club Drugs: Ecstasy, Methamphetamines .......................................... 20
Steroids ............................................................................................. 22

Adolescence is a time of exploration, and for some, it’s a time of risk-taking. Some risk-taking helps teens learn about
what they value, whom they like, and what they want in life. But some of the choices teens face pose significant risks.
As teens take that natural step away from parental influence and direction, adults are challenged to be supportive and
well-informed, to maintain perspective, and to keep a sense of humor. Red Flags and Resources is intended to help
adults and teens better understand risky behaviors, what they can do to counter them, and how to get help when they
need it.
The topics reflect what
teens themselves tell us
about the drugs and
alcohol available in our
area and about behaviors
they engage in.
1
This information comes
from the Vermont Youth
Risk Behavior Survey, which
is based on a confidential
questionnaire completed
by students every two years
in middle and high schools
throughout Vermont.
Red Flags and Resources

The authors of Red Flags and Resources embrace the idea of positive youth development, a view of young people as assets to
their communities, not problems waiting to happen. When young people
grow up with strong connections to their communities, they make
decisions about how to act and who they will become, not by chance,
but by relying on a web of influences and personal strengths. Parents,
you can enhance these values by:
Supporting your child and his friends. They need to be surrounded by
people who love, care for, appreciate, and accept them.
Empowering them to feel valued and respected so they can contribute
to their families, schools, and community.
Establishing boundaries and expectations that encourage youth to do
their best. Introducing your child and her friends to new skills, interests, and
opportunities outside school and home.
Encouraging your child to engage in a variety of learning
experiences and instilling a lifelong commitment to learning.
Exposing your child to the value of caring for others.
Teaching the skills needed to make sound decisions and develop positive
social competencies.
Building your child’s self-worth and helping him establish a sense of
purpose in life.
For more information about positive youth development, visit the Search Institute online at www.search_institute.org.
2

Nurturing Healthy Families 3
When families provide
safe havens for
emotional growth
and health,
children learn to
meet the challenges
of adolescence
and young adulthood.
Healthy families foster resilience—the capacity to deal competently day after day with
the choices and demands each family member encounters. Resilience enables us to
focus on personal strengths to overcome adversity.
In their book Raising Resilient Children (Contemporary Books, 2001), Robert Brooks and
Sam Goldstein suggest five essential strategies for nurturing resilient children:
Be empathic in order to teach empathy.
Empathy is putting yourself in another person’s shoes, understanding how this
person feels. Teens are constantly learning how to do this, and adults need to
remember to try to see the world through their children’s eyes. By demonstrating
empathy, you are teaching a skill that is vital to satisfying relationships.
Teach responsibility.
Teens develop a sense of accomplishment and pride when given responsibilities
that contribute to their home and school. This “required helpfulness” reinforces
self-esteem as children experience the positive difference they make.
Teach problem solving skills.
View problems as opportunities. Empower your teen to discover his own good
solutions to problems as they occur in his daily living.
Offer realistic encouragement and positive feedback.
Help teens identify their own strengths and learn how to use them to build good
relationships and solve problems.
Help children learn to deal with mistakes.
Teach teens to see mistakes as learning experiences rather than failures.

4
Teens may act as though they don’t want to talk with parents, but in surveys, most of them say they really do.

S U B S T A N C E U S E A N D A B U SE
5
What is experimentation? When does it become “use,” and when does use become “abuse?”
The answers to these questions depend not on
how many times a person uses a substance, but
on why he or she uses a substance and what
problems occur as a result. Genetics, family
history, social influence, and emotional health all
play a role in how far and how fast an individual
does—or does not—move forward on a useabuse
continuum.
Some use the following terms to categorize use
and to assess risk:
Non-use The individual does not use
substances at all. One can still be affected by
other peoples’ use.
Experimentation The individual uses
alcohol and other substances rarely or
occasionally, and in limited amounts. At this
stage, the motivation for use is likely curiosity.
Use The individual has made a choice to use
substances more than once and often denies the
risks associated with use, such as legal
problems, physical risks, and social, emotional,
and sexual safety. Substance use does not
usually interfere with daily functioning; as a
result, parents may not be aware that a teen is
using. The motivation for use is often
recreational. Use can quickly progress to abuse.
Abuse The individual’s interests, friendships, and
activities may revolve around using substances. Use
continues in spite of negative health, academic, and
legal consequences. At this stage, teens are often in
denial of their increasing dependence on
substances. There may be long periods of non-use
between periods of heavy use.
Addiction Substance use is no longer a choice.
Addiction is a chronic and often progressive
disease, and intervention is required.
It’s important that parents and teens talk together
about the risks entailed in substance use. Talk
openly about healthy choices, peer pressure, refusal
skills, and family values and expectations about
substance use. Start when children are young and
continue having conversations during the
adolescent years. (But if you haven’t done so, don’t
worry. Start now.) School and community groups
make information available, but this is not a
substitute for discussion in your own family.
Some things to remember:
• Fewer teens use substances than is commonly
perceived. In the Vermont Youth Risk Behavior
Survey of area teens, when they are asked how
many of their peers they think abuse alcohol or
other substances, they consistently overestimate
how many actually report doing so. In fact, teens
who don’t use substances are still the majority.
• If there is a family history of substance abuse,
there may be a greater likelihood that a teen will be
susceptible.
Alcohol, Page 6
Tobacco, Page 8
Marijuana, Page 10
Prescription Drugs and
Over-the-Counter Drugs,
page 12
Inhalants, page 14
Cocaine, page 16
Heroin, page 18
Club Drugs: Ecstasy, page 20
Methamphetamine, page 22
Steroids, page 24

6
Alcohol
WHAT IS BINGE DRINKING?
lcohol is the drug most commonly used by young people. A growing body of research suggests that teens’ brains, which are still
A developing, are more susceptible to harmful effects from alcohol, both short- and long-term. Alcohol can weaken judgment and
self-control. Drinking can cause people to behave in ways contrary to their usual good judgment, such as experimenting with other
drugs, unplanned sexual activity, and dangerous driving. Alcohol slows, and with heavy use can even stop breathing and other
involuntary reflexes. Alcohol can have a greater effect on teens taking antidepressants and other medications; one drink coupled with
medication can have the effect of three to four drinks. It is illegal for adults to serve or sell alcohol to anyone under the age of 21,
except to their own children. It is also unlawful for adults knowingly to allow children who are not their own to consume alcohol on
their premises. Serious legal consequences can result from underage alcohol possession and use, including arrest, fines, and loss of
driver’s licenses. Driving under the influence of alcohol can result in imprisonment.
AlcoPops and Energy Drinks
Y
oung people are heavy consumers and drivers of the market for non-alcoholic energy
drinks. Alcohol companies appear to be mimicking the marketing strategies for energy
drinks, effectively capitalizing on the popularity of energy drinks among youth to sell their products.
The premixed alcoholic energy drinks, also known as ‘alcopops’ are sold in cans that look
virtually identical to their non-alcoholic cousins, confusing consumers, retailers, parents, law
Although there is debate regarding the benefits of energy drink and caffeine consumption, there is
consensus among health researchers that caffeine consumption can have adverse health
consequences, particularly at high doses. Non-alcoholic energy drinks have 2-3 times the caffeine
content of soda and have caused dangerous reactions, some requiring emergency room visits.
Mixing alcohol with energy drinks presents several potential health and safety risks. While young
people may think that caffeine, a stimulant, masks the intoxicating effects of alcohol, research
shows this is not the case. As a result, people drinking these products may mistakenly believe
they are less impaired than they are, and engage in dangerous activities such as driving under the
influence.
Binge drinking is the rapid intake of a quantity of alcohol that causes severe
intoxication and possibly alcohol poisoning. The definition is different for
each person, depending on bodyweight and other individual factors. For
instance, five drinks may be the point at which a 200-pound male
experiences alcohol poisoning, but two or three may be the limit for a 105-
pound girl.
Recent brain research indicates that adolescents may be able to drink more
alcohol than adults before feeling its effects. This makes alcohol particularly
dangerous for young drinkers, who may be tempted to drink quantities that
can cause serious harmful effects.
Prevention groups are working with lawmakers in Vermont
to investigate whether alcoholic energy drinks are appropriately
classified as malt beverages instead of distilled spirits
under applicable state laws.
ALCOHOL POISONING
Alcohol poisoning occurs when the alcohol level
in the bloodstream is so high that it affects
breathing, heart rate, and other body functions.
It is not just intoxication, but it may follow quickly
afterward, which makes it particularly difficult to
recognize. Vomiting may or may not occur with
alcohol poisoning. Speech may be slurred or
incoherent. The person may lack
coordination.Alcohol poisoning can be
deadly.
Symptoms
Drinking to the point of passing out or
semi-consciousness with slow respirations
Cold, clammy, pale or bluish skin, perhaps a
Alcopops are sweetened alcoholic
beverages that are usually
sold in single serving bottles or
cans. These drinks resemble
fruit juices, teas, and energy
drinks that are already popular
with youth.
The marketing of these
products employs
methods which reach and
appeal to youth, while prices
remain low due to tax classification
as beer even though half
the alcohol in alcopops is
derived from distilled spirits.
Because they don’t taste ,
smell, or look like alcohol,
alcopops serve as a transition
or bridge from soft drinks to alcohol
and fuel underage drinking.
particularly among girls.
If you observe any of these
symptoms, call 911 immediately.
Stay with the person until medical
help arrives. Never leave the person
alone to “sleep it off.” He or she
might not wake

RED FLAGS
Physical
Hangover symptoms: headache, thirst,
stomach aches, vomiting, bloodshot eyes
Unexpected or frequent use of mouthwash,
breath mint or spray, or peanut butter
Smelling of alcohol
Changes in sleeping and/or eating habits,
constant fatigue
Poor hygiene
Memory lapses, poor concentration, lack of
coordination, slurred speech
Diluted alcohol or alcohol missing from the
home
Having a fake ID
Money problems
Emotional
Some of these may indicate a problem with
alcohol, but some may be part of normal teenage
behavior. If several of these indicators occur at the
same time, suddenly, or if they are extreme, it is
time to intervene.
Anger, irritability, and defensiveness
Depression
Low grades and disciplinary problems at school
Absence from school, work, or favorite
activities
Sudden change of friends and reluctance to
introduce them to the family
A“nothing matters” attitude; lack of
involvement in former interests; general low
energy
Secretive behavior, lying; avoiding family when
returning home
Drinking alone, any time of day
Responses
For teens
If you are concerned for yourself or a
friend, find an adult with whom you can
talk—a parent, a school counselor, a
teacher, your doctor, or other caring adult.
Respect your individuality and your life;
take seriously the risks of alcohol use.
Educate yourself so you can make
informed decisions.
Don’t get into a car being driven by a
person who has been drinking.
RESOURCES
Prevention
Franklin County
Caring Communities
www.fcccp.org
802 527-5049
Grand Isle County
Clean Team
www.gicct.org
802 309-2515
Rural Partnerships
www.ruralpartnerships.org
802 393-5383
Vermont Department of Health
www.healthvermont.org
Substance Abuse Prevention
Consultant
802 524-7918
Treatment
For adults
Family health-care provider
School guidance counselor, student
assistance professional, nurse, or
social worker
Northwestern Counseling
& Support Services (adolescents)
802 524-6554
www.ncssinc.org
Teen Alcohol Safety Program (TASP)
Grand Isle County
Court Diversion
802 372-4955 or 802 796-3549
Howard Center (adults)
www.howardcenter.org
802 488-6265
Be awake and alert when your teen comes
home at night and remain calm if you find she
has been drinking.
Discuss your observations with your teen the
next day, when he is not under the influence.
Try to make it easy for your teen to talk
honestly with you. Maintain mutual respect.
Be available to your teen if a safe driver is
needed, no questions asked.
If you need help talking to a teen or deciding
what to do, speak to an addiction counselor or
therapist.
Recovery and Aftercare
Alcoholics Anonymous
www.aavt.org
802 524-5444
AlAnon
www.vermontalanonalateen.org
866 972-5266
Northwestern Counseling
& Support Services (NCSS)
802 524-6554
www.ncssinc.org
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
7

8
RED FLAGS
Tobacco
Frequent use of breath
mints, gum, perfumed
products
Frequent trips outside, even
in cold weather
Clothing, breath, and hair
smelling of smoke
Stained clothing
Yellowed or stained teeth
and fingers
Frequent cough and cold
symptoms
Shortness of breath and lack
of energy
Unaccounted-for spending
and other money concerns
Denial and secrecy
Tobacco is a drug legally sold in products such as cigarettes, cigars, and smokeless
tobacco (chew/spit tobacco, pipes, snuff). It is illegal to give or sell tobacco to
minors. All tobacco products contain nicotine, which is a highly addictive chemical.
Smoked nicotine enters the bloodstream rapidly, causing dependence and a
cycle of craving and difficult withdrawal. Smoking limits the amount of oxygen in
the blood, reducing stamina for sports and other physical activities. Nicotine is
also absorbed readily when tobacco is chewed. With regular use, levels of nicotine
accumulate in the body during the day and persist over night. Daily smokers
or chewers are exposed to the effects of nicotine 24 hours a day.
Chewing tobacco can cause damage to gum tissue and even loss of teeth. It also
reduces a person's ability to taste and smell. Most importantly, smokeless tobacco
contains chemicals that can cause cancers of the mouth, pharynx, larynx, and
esophagus. This can even happen in very young users of chewing tobacco. In
fact, most people who develop these cancers were users of chewing tobacco.
Researchers have identified more than 250 chemicals in tobacco smoke that are
toxic or cause cancer in humans and animals. These include ammonia, arsenic,
cyanide, acetone, formaldehyde, and carbon monoxide. Some of these may affect
development and can cause life threatening disease. The health risks include
lung cancer as well as cancers of the throat, tongue, mouth, larynx, esophagus,
pancreas, cervix, kidney, and bladder. Other damaging physical effects include
heart disease, stroke, and respiratory illnesses, such as emphysema, bronchitis,
and serious asthma episodes.
Tobacco is the leading preventable cause of death in the United States. More
people die from tobacco related illnesses than from AIDS, car accidents, illegal
drugs and suicides combined.

RESOURCES 9
Family health-care provider
School guidance counselor, nurse, student
assistance professional, Tobacco Prevention
Coordinator or social worker
Vermont Quit Line
www.tobaccostories.org
800 784-8669
800 QUIT NOW
Franklin Grand Isle Tobacco Prevention
Coalition
802 524-1296
Vermont Quit Net
vt.quitnet.com
802 524-8831
Responses
For teens
Educate yourself about nicotine dependency, withdrawal, and other
health risks.
Seek support from a friend in order to resist the social pressures to
use tobacco.
If you or someone you care about smokes or chews tobacco, make
a plan for stopping. Success is more likely when you have support.
For adults
If you are concerned about a young person using tobacco, have an open, nonjudgmental
conversation about that decision. Express confidence in the young
person’s ability to quit and offer motivation for quitting.
Help the teen make a plan, which might include professional support and
medical care.
Offer resources, such as groups, skilled counselors, and medical intervention.
Be ready to modify the plan if relapse occurs.

continued...
10
Marijuana
T
he term marijuana refers to the leaves and flowering buds of
cannabis sativa, the hemp plant. Marijuana can be smoked
(joints, pipes, bongs, blunts) but is sometimes used as an ingredient
in food or brewed in tea. Marijuana smoke has a very distinctive
sweet, pungent smell that may remain on the clothing after use. The
dried leaves are gray green although new varieties can have purple
and reddish color leaves.
Like tobacco, marijuana can contain poisons and carcinogens increasing
the risk of chronic cough, bronchitis, emphysema and
cancers of the head, neck and lungs. The marijuana sold today is
generally much more potent, with higher THC concentration than
that available in decades past. THC, short for tetrahydrocannabinol,
is a chemical compound found in the cannabis plant which causes
the “high” associated with marijuana.
Marijuana impairs short-term memory and comprehension, and reduces
coordination and concentration. This can affect academic
performance, athletic ability, social skills, and the ability to drive a
car. Marijuana impacts areas of the brain that control motivation and
recall, and impacts the body’s immune system, circulatory system
and weight. The high occurs within minutes of smoking. Effects usually
last 3 to 4 hours but may persist or recur for 12 to 24 hours.
Long term use may result in damage to the brain.
More young people use marijuana than any other illicit drug, according
to the Vermont Youth Risk Behavior Survey. Long-term studies
of high school students and their patterns of drug use show that
very few young people use other drugs without first trying marijuana,
alcohol, or tobacco.
RED FLAGS
motivation, reduced physical strength
Change in study habits, declining grades, difficulty thinking
or problem-solving
Change in friends and social life; frequent comings and
goings; sneaking out of house
Loss of interest in usual activities, loss of energy and
An unusually “mellow” mood
Creating a psychedelic atmosphere in room décor with
light and music

Responses RESOURCES 11
Parents. The Anti-Drug
www.theantidrug.com
For teens
Educate yourself about the risks of
using marijuana.
Practice how to say no if offered
marijuana.
If you or someone you care about is
using marijuana, talk with a trusted
adult and ask for help.
If you or a friend is experiencing
adverse effects from use of
marijuana, get medical help
immediately. Call 911.
For adults
Educate your teen about the risks of marijuana
use. Research indicates that the more parents
talk with children about marijuana, the less likely
teens will be to use it.
Teach your teen how to refuse when offered
marijuana.
If you find your teen is using marijuana, be calm
and nonjudgmental. Try to help them
understand their reasons for using, and help
them develop a plan for stopping.
Seek professional guidance.
Family health-care providers
School guidance counselor, student assistance
professional, social worker, or nurse
Northwestern Counseling
& Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
www.howardcenter.org
802 488-6265
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
RED FLAGS
Marijuana paraphernalia such as matches, lighters, clove cigarettes, rolling papers,
scales, roach clips, water pipes, and bongs
Leaving for school early without a good reason
Bloodshot eyes and/or frequent use of eye drops
Chronic coughing, phlegm
Use of incense, fragrant candles, room or car fresheners, mouthwash, and fabric
softener
Open windows, even in winter
Anxiety and panic attacks
Money problems
National Institute on Drug Abuse
www.teens.drugabuse.gov
National Clearinghouse for Alcohol and
Drug Information
www.health.org
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance Abuse
Knowledge Base
www.adolescent-substance-abuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com

“Opiate abuse
and addiction is
one of our
most serious
challenges in
Vermont. It calls
for an integrated
approach
encompassing
public health, law
enforcement and
addiction
treatment all
working
together.”
— Barbara Cimaglio
Deputy Commissioner
Alcohol & Drug
Abuse Programs
Vermont Department
of Health
Dextromethorphan (DXM), an ingredient in many cough and cold medicines, induces a high when taken in amounts greater than directed
on the bottle or package. DXM can cause nausea, vomiting, life-threatening seizures, hallucinations, and even death.
12
Prescription Drugs &
Over-the-Counter Drugs
PRESCRIPTION DRUGS
Prescription drug misuse is the use of prescription medication in a manner that is not directed
by a health care professional. The addictive potential for some of these drugs is the
same as that for heroin or methamphetamine. According to the 2009 Vermont Youth Risk
Behavior Survey, 17.5 percent of students in grades 8-12 in Franklin and Grand Isle counties
have reported using a prescription drug not meant for them at least once in their lifetime.
Emergency department mentions of prescription narcotics has jumped significantly in
our area.
Powerful painkillers or opiates like morphine, codeine, OxyContin, Vicodin, and Percocet
can be used to obtain a high when used in higher-than-prescribed doses. OxyContin is sold as a time-release tablet
meant to be swallowed whole. It is prescribed for continuous relief of moderate to severe pain. Breaking or crushing
the tablet destroys the time-release function. The medicine is then swallowed, snorted, smoked, or injected to produce
an immediate high. A large single dose can cause severe respiratory depression and death. Long term misuse
leads to physical dependence and in some cases, addiction.
Central nervous system depressants are prescribed to treat anxiety and sleep disorders. Abuse of tranquilizers and
sedatives (such as Valium, Xanax, Ativan, and Phenobarbital) can lead to respiratory difficulties, sleeplessness,
coma, and death. Depressants slow down normal brain function and can cause a drowsy, uncoordinated feeling.
Abuse can also lead to dependency and addiction.
Abuse of stimulants, such as amphetamines, in low doses can cause anxiety. High doses, snorting, or injection can
cause hallucinations, severe depression, and physical and psychological dependence. Methylphenidate, the compound
found in Ritalin and other medications for ADHD, is also being misused by some to study late at night and
abused by some for its short-lasting high. These drugs raise blood pressure and heart rate. High doses can cause
dangerously high body temperature and cardiac arrest brought on by an abnormal heartbeat.
OTC DRUGS
Just because a drug is sold over the counter, without a prescription, doesn’t mean it is safe if misused. OTC
medicines commonly abused for stimulant or sedative effects include cough syrups, mouthwashes, antihistamines,
decongestants, and cold medicines. Robitussin, Listerine, Benadryl, Sudafed, Coricidin, NoDoz, and NyQuil are often
abused and are readily available.

Responses RESOURCES
13
For adults
Know what’s in your medicine cabinet.
Discard outdated or unused
medicines.
If there is medicine in your home that
could be misused, monitor its use.
Consult your healthcare provider for
help.
RED FLAGS
For stimulants, both
prescription and OTC
Irritability, extreme anger,
aggressive and threatening
behavior
Paranoid ideas, hallucinations
Excessive weight loss
Bookmarked web sites about
“robotripping,” or DXM
Packages of cough medicines
containing dextromethorphan
Presence of sleep masks or
cotton balls, indicating
possible use for sensory deprivation
to enhance
DXM high
For teens
Educate yourself about the risks of
misusing or abusing prescription
and over-the-counter drugs.
If you or someone you care about is
misusing them, talk with a trusted
adult and ask for help.
If you or a friend is experiencing
adverse effects from use of these
drugs, get medical help immediately.
Call 911.
Don’t take medicine that isn’t
prescribed for you.
Be aware that pain relief
prescriptions often contain more
doses than are actually needed for
recovery; use only as necessary
For sedatives and tranquilizers
Abnormally reduced anxiety
Unusual feelings of well-being
Lowered inhibitions
Slowed pulse and breathing
Poor concentration, confusion, impaired
coordination, memory, and judgment
Fatigue
Slurred speech
Dizziness
Family health-care providers
School guidance counselor, SAP,
nurse, or social worker
Northwestern Counseling
& Support Services (adolescents)
NCSS
802 524-6554
www.ncssinc.org
Howard Center (adults)
802 488-6265
www.howardcenter.org
Chronic Pain/Narcotics Community
Forum. For more information call Dr
Ed Haak, DO Northwestern Medical
Center 802-524-5911, ext 4363
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
Nar-Anon
802 363-6046
www.naranonvt.com
Narcotics Anonymous
24 Hour Champlain Valley Helpline
802 862-4516 www.cvana.org
For analgesics
and pain relievers
Northern New England Poison Center
1 800 222 1222
www.nnepc.org
Vermont Dept. of Health
healthvermont.gov/adap/adap.aspx
National Clearing House for Alcohol
and Drug Information
800-729-6686
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance Abuse
Knowledge Base
www.adolescent-substanceabuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com
Parents. The Anti-Drug
www.theantidrug.com
National Institute on Drug Abuse
www.teens.drugabuse.gov
beyond acute phase of recovery
Continued use of prescribed pain medication
Drowsiness and lethargy
Slurred speech
Nausea
Constipation, gas pains
Euphoria

14
I nhalants are a diverse group of chemical poisons that can be “sniffed” or
“huffed” (inhaled through the mouth) to produce an immediate rush or high. A common
misconception is that it is a childish fad to be equated with youthful experiments
with cigarettes. Inhalant abuse is deadly serious and one of the most dangerous of
“experimental behaviors.” Sniffing volatile solvents can cause severe damage to the
brain and nervous system. By starving the body of oxygen or forcing the heart to beat
more rapidly and erratically, inhalants can kill sniffers, most of whom are adolescents.
Inhalant use can result in Sudden Sniffing Death Syndrome from a single episode of
inhalant use, whether used for the first time or not.
Inhalants include spray paints, glue, and cleaning fluids. These commonplace products
are readily available to young people. 46 states have enacted legislation designed to
prevent products that are commonly used as inhalants from being sold to minors.
Health-risk surveys indicate the use of inhalants has risen among younger teens.
All inhalants can produce intoxication, dependence, abuse or death.
Euphoric effects occur within seconds and may last from minutes to hours. The high is
followed by depression and sleepiness. Because it is hard for a user to know how much
of the chemical he is taking in, it is easy to overdose.
Intoxication can lead to lethargy, slowed thinking and movements, muscle weakness,
depressed reflexes, coma, and death. Inhalants impair judgment and coordination.
Recurrent use may result in psychological problems, such as severe depression and
academic difficulties. Chronic abuse can cause severe, long-term damage to the brain,
liver, and kidneys.
Inhalants
INHALANTS INCLUDE:
Industrial or household solvents or solvent-containing products, including paint thinners and
removers, degreasers, dry-cleaning fluids, gasoline, and glue
Art or office supply solvents, including correction fluids, felt tip-marker fluid, and computer-key cleaners
Gases used in household or commercial products, including butane lighters, propane tanks, whipping
cream aerosols and dispensers (whippets), and dust off products
Aerosol items such as spray paints, hair or deodorant sprays, and fabric protector sprays
Room deodorizers, perfume, and antifreeze
RED FLAGS
Discarded bags, rags, gauze, and soft drink
cans that could be used to contain
substances for sniffing
Odors of these products
Unexplained facial rash, runny nose,
frequent sniffing, sneezing, nosebleeds,
frequent unexplained coughing
Blisters or soreness around the nose or
mouth
Extreme mood swings
Unusual, harsh breath odor
Nausea, vomiting
Numb or tingling hands and feet
Uncontrolled laughter
Irritability and anger, violent outbursts
Reduced physical or mental abilities
Call 911 immediately if you observe
these symptoms of inhalant intoxication:
Slurred speech
Tremors
Confusion
Combativeness
Hallucinations
Convulsions
Blurred vision, glazed eyes, dilated pupils
Unsteady gait
Euphoria
Bizarre risk taking
Involuntary passing of feces or urine

RESOURCES Responses 15
Family health-care providers
School guidance counselor, student
assistance professional, nurse
or social worker
Northwestern Counseling
& Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
www.howardcenter.org
802 488-6265
Friends of Recovery
800 769-2798
National Inhalant Prevention Coalition
www.inhalants.org
Parents. The Anti-Drug.
www.theantidrug.com
National Institute on Drug Abuse
www.teens.drugabuse.gov
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
Troubled Teens, Help for Parents
www.4troubledteens.com
ASK — Adolescent Substance Abuse
Knowledge Base
www.adolescent-substanceabuse.com
Air blast
Ames (amyl nitrite)
Amys (amyl nitrite)
Aroma of men (isobutyl nitrite)
Bagging (using inhalants)
Bolt (isobutyl nitrite)
Boppers (amyl nitrite)
Buzz bomb (nitrous oxide)
Climax (isobutyl nitrite)
Discorama
Glading (using inhalants)
Gluey (one who sniffs or inhales
glue)
Hardware (isobutyl nitrite)
Hippie crack
Honey oil
Huff
Huffing (sniffing an inhalant)
Slang
Kick
Laughing gas (nitrous oxide)
Medusa
Moon gas
Oz
Pearls (amyl nitrite)
Poor mans pot
Poppers (isobutyl nitrite,
amyl nitrite)
Quicksilver (isobutyl nitrite)
Rush (isobutyl nitrite)
Shoot the breeze (nitrous oxide)
Snappers (isobutyl nitrite)
Snorting (using inhalant)
Thrust (isobutyl nitrite)
Toncho (octane booster)
Whippets (nitrous oxide)
Whiteout (isobutyl nitrite)
For teens
Educate yourself about the risks of
using inhalants. Know that any
experimentation with inhalants is
extremely risky.
If you observe any of the acute
symptoms listed in the red box at left,
in yourself or others after using
inhalants, get help immediately.
If you or someone you care about is
using inhalants, talk with a trusted
adult and ask for help.
For adults
Educate yourself about inhalants.
Know what’s in your own kitchen,
laundry area, and garage.
Make sure your teen knows the
dangers of inhalants.
If you think your teen is using
inhalants, talk with him/her in a
supportive, firm manner.
Speak with an addictions counselor,
therapist, or pediatrician.
If you observe any of the conditions in
the box at left, call 911 or take the teen
to an emergency room immediately.

Cocaine is a powerfully addictive stimulant derived from
the coca plant. Slang terms for cocaine include coke, C,
snow, nose candy, sugar, blow, toot, bump, Charlie,
white lady, dust, base, free, rock, and crack. Cocaine
produces feelings of exhilaration, euphoria, and
confidence.
Cocaine is a fine white powder with a bitter taste.
It can be sniffed, snorted, injected, or smoked.
When snorted, the effect lasts 15 to 30 minutes.
Repeated snorting damages the membranes of
the nose.
“Crack” is a smokeable form of cocaine made into lumps, or “rocks.” Smoking crack delivers large amounts of
the drug to the bloodstream, causing an immediate and very intense effect lasting 5 to 10 minutes. Frequent
or heavy use can cause compulsive behaviors, extreme anxiety, paranoia, and hallucinations. Smoking
cocaine can damage the lungs and cause weight loss, depression, and fatigue.
Cocaine use impairs judgment, which may lead to unwise decisions about sexual activity and thus exposure
to HIV/AIDS and other sexually transmitted diseases as well as vulnerability to rape and unplanned
pregnancy. It can lead to dependency and withdrawal. Combining cocaine and alcohol can be deadly.The
body converts the two drugs to coaethylene which has a longer duration in the brain and is more toxic than
either drug alone. It is the most common two drug combination that results in drug related death.
16
Cocaine

National Clearinghouse for
Alcohol and Drug Information
www.health.org
National Institute on Drug
Abuse
www.teens.drugabuse.org
Parents. The Anti-Drug
www.antidrug.com
RED FLAGS
Euphoria with enhanced vigor
and/or dulling of mood
Blurred vision, dilated pupils
Tremors and twitching
Gregariousness, grandiosity
Hyperactivity, restlessness
Hyper-vigilance
Anxiety, tension, or anger
Repetitive behaviors
Impaired judgment
Rapid heartbeat, chills, nausea,
vomiting, weakness, chest pain
or pressure
Responses
For teens
Educate yourself about the risks of using
cocaine.
If you or someone you care about is
using cocaine, talk with a trusted adult
and ask for help.
If you or a friend is experiencing adverse
effects from use of cocaine, get medical
help immediately. Call 911.
For adults
Educate yourself about cocaine and its risks.
Be open and honest with your teen. Don’t let
anger or fear overwhelm your ability to
communicate.
Tell the teen what you see that worries you;
be specific.
Assure your teen that expert help is available
and that you want to be part of the solution.
Ask your health professional for help.
17
If you believe a teen is experiencing adverse
effects, call 911 or take him to a hospital
emergency department immediately.
RESOURCES
Your family health-care provider
School guidance counselor, nurse,
or social worker
Northwestern Counseling
& Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
www.howardcenter.org
802 488-6265
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
Nar-Anon
802 363-6046
www.naranonvt.com
Narcotics Anonymous
24 Hour Champlain Valley Helpline
802 862-4516
www.cvana.org
Partnership for a Drug-Free
America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance
Abuse Knowledge Base
www.adolescent-substance-abuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com

18
RED FLAGS
Heroin
Staggering walk
Impaired judgment, attention, and memory
Agitation
Euphoria followed by apathy
Constricted pupils
Slurred speech
Drowsiness
Ignoring potentially harmful or painful events
Severe itching
Loss of appetite
pium, specifically its derivative morphine, is used to make heroin. Opium
O comes from the opium poppy cultivated for this purpose. Opium consists
of morphine, codeine, thebaine and other substances. Heroin is highly
addictive. It is usually a white or brown powder. Slang names for heroin are
brown sugar, dope, H, horse, junk, skag, skunk, smack, black tar, mud, and
white horse. Heroin can be sniffed, snorted, smoked, or injected.
Heroin enters the brain rapidly and produces an immediate rush, or pleasurable
feeling, often accompanied by a warm flushing of the skin, dry mouth,
and heavy feeling in the extremities.
The greatest risk of heroin use is addiction. Heroin overdose is a particular
risk because the amount and purity of the drug cannot be known. Long-term
effects can include diseases such as hepatitis B and C, HIV, and AIDS, as
well as arthritis.
Effects as a user withdraws from heroin:
Anxiety
Restlessness
Achy feeling, often in back and legs
Irritability
Increased sensitivity to pain
Nausea, vomiting, diarrhea
Tears, runny nose
Dilated pupils
Sweating, fever
Insomnia
Responses
For teens
Educate yourself about the risks of
using heroin.
If you or someone you care about is
using heroin, talk with a trusted adult
and ask for help.
If you or a friend is experiencing
adverse effects from use of heroin,
get medical help immediately. Call
911.
For adults
Learn about the dangers of heroin.
If you believe your teen may have used heroin, be
open and honest; don’t let anger or fear get in the
way.
Tell your teen what you see that worries you; be
specific.
Assure him that expert help is available and that
you want to be part of the solution.
Ask a health professional for help.

If you believe a teen has overdosed, call 911 or take the teen directly to a hospital emergency department.
19
RESOURCES
Your family health-care
provider
School guidance counselor,
student assistance professional,
nurse, or social worker
Northwestern Counseling
& Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
www.howardcenter.org
802 488-6265
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
Nar-Anon
802 363-6046
www.naranonvt.com
National Clearinghouse for
Alcohol and Drug Information
www.health.org
National Institute on Drug Abuse
www.teens.drugabuse.org
Parents. The Anti-Drug.
www.antidrug.com
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance
Abuse Knowledge Base
www.adolescent-substanceabuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com
Narcotics Anonymous
24 Hour Champlain Valley Helpline
802 862-4516
www.cvana.org

CLUB DRUGS:
Ecstasy and Methamphetamine
20
cstasy, methamphetamine, GHB,
E Rohypnol, and LSD are known as club
drugs because of their popularity at all-night
parties, known as raves or trances, at dance
clubs, and bars. They distort perception and
enhance tactile experiences. The use of these
drugs can cause serious health problems and
even death. Two of the most prevalent and
dangerous are ecstasy and
methamphetamine.
Ecstasy (MDMA) is an illegal drug with both
stimulant and hallucinogenic qualities. It is a
synthetic compound manufactured in illegal
laboratories and may contain unknown toxins.
Look-alike and more dangerous drugs may be
sold as ecstasy. Street names include Adam,
XTC, hug, beans, love drug, E, M, and roll. It
has a potent effect on the brain neurotransmitter
serotonin, which plays an important role in
regulating mood, aggression, sexual activity,
sensitivity to pain, and other behaviors. It reduces
inhibitions, eliminates anxiety, and produces
feelings of empathy to others. In addition,
the drug reportedly suppresses the need
to eat, drink, or sleep enabling users to endure
all-night parties.
Over 15 years of research conducted on
animals has proven that MDMA damages
specific neurons in the brain. Because of
the difficulty of conducting similar research
on humans, conclusive neurotoxicity
in humans has not been established.
However, a variety of studies have shown
that some chronic, heavy users of MDMA
have cognitive deficits.
Typically, ecstasy is taken in tablet or
capsule form, and its effects last 3 to 6
hours. The average reported dose is 1 to
2 tablets. It is not uncommon for users to
take a second dose as the effects of the
first dose begin to fade. Ecstasy is
sometimes mixed with other substances,
such as alcohol or marijuana, to get an
extra euphoric effect.
This may produce immediate undesirable
effects, including anxiety, agitation, and
recklessness. Ecstasy use can prompt
vigorous physical activity for extended
periods, which can result in dehydration,
hypertension, and even heart failure.
Ecstasy can be addictive.
RED FLAGS
for Ecstasy
Increased tactile sensitivity
involuntary teeth clenching
Muscle tension,
Nausea
movements
Blurred vision, rapid eye
Hallucinations
Hot and flushed feeling
Excessive energy
Presence of light sticks for
visual stimulation,
pacifiers for oral
stimulation, and Vicks
VapoRub for sensory
stimulation
Psychological difficulties
include confusion, depression,
sleep problems, drug craving,
severe anxiety, and paranoia
during use and can sometimes
persist for months or years
after use has ceased. Ecstasy is
considered a “date rape” drug
because it impairs memory
and cognitive function.

21
RESOURCES
Family health-care provider
School guidance counselor, student
assistance professional, nurse,
or social worker
Northwestern Counseling
& Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
www.howardcenter.org
802 488-6265
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
Nar-Anon
802 363-6046
www.naranonvt.com
Narcotics Anonymous
24 Hour Champlain Valley Helpline
802 862-4516 www.cvana.org
Stop Meth Addiction
www.stopmethaddiction.com
800 405-8409
National Institute on Drug Abuse
www.teen.drugabuse.org
Parents. The Anti-Drug.
www.theantidrug.com
National Clearinghouse for Drug and
Alcohol Information
www.health.org
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance Abuse
Knowledge Base
www.adolescent-substance-abuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com
Responses
For teens
Educate yourself about the risks of using ecstasy and
methamphetamines.
Be smart at parties: Never leave your drink
unattended. Go in groups and watch out for one another.
If you or someone you care about is using club drugs, talk
with a trusted adult and ask for help.
If you or a friend is experiencing adverse effects from use
of these drugs, get medical help immediately. Call 911.
For adults
Educate yourself and your children about ecstasy and
methamphetamines.
Help your teen learn safe party behavior and rehearse ways to
decline party drugs.
Talk with your teen if you think he is using ecstasy or
methamphetamines; establish clear, firm limits about social
activities. Do not hesitate to seek guidance.
If you believe a teen is experiencing adverse effects such as
those mentioned under Red Flags, dial 911 or take the teen to an
emergency department.

22
CLUB DRUGS:
Methamphetamine (Meth)
ethamphetamine is a highly lethal, addictive,
M and unpredictable stimulant. The effects of this
drug are damaging to the central nervous system. It is
a white, odorless, bitter tasting, easily dissolvable
powder. Slang names are speed, meth, chalk, Christina
or Tina, ice, crystal, glass, crank, and quartz.
Lead poisoning from production errors is another potential
risk as lead acetate is used as a reagent. Ingredients such
as anhydrous ammonia (farm fertilizer), lithium (from batteries),
drain cleaner, camp fuel, and engine starter are very
acidic causing very aggressive erosion of tooth enamel.
Users who inject any drug are at high risk for HIV/AIDS.
Recent discoveries of methamphetamine labs in
Franklin County in the spring of 2010 have raised the
profile of meth in our region. While use is not widespread,
methamphetamine is a toxic, highly addictive
substance. Its manufacture and use can be very disruptive
to communities even when produced or used
by a small number of people. The by-product created
during the manufacturing process is very volatile and
extreme caution must be taken.
Methamphetamine can be smoked, snorted, swallowed,
or injected. It is inexpensive and increasingly
popular. Methamphetamine’s effects last 6 to 8 hours.
An initial “rush” is followed by high agitation. After the
stimulant effects wear off, the user may experience a
severe crash (depression, slowed thinking) or agitation.
At high doses hallucinations and delusions have
been reported. Over time methamphetamine appears
to reduce levels of dopamine which can result in
symptoms like those of Parkinson’s disease, a severe
movement disorder.
Environmental Hazards
The mixing of the chemicals used in Methamphetamine
production produce toxic and potentially explosive fumes.
Breathing these fumes may cause irreparable harm to nasal
passages, lungs, and the brain.
Six pounds of toxic waste are produced for each pound of
Methamphetamine manufactured.
Dumping of waste occurs wherever possible; contaminated
garbage and toxic chemicals dumped indiscriminately can pollute
water supplies, farm land, neighborhoods, etc.
There is a risk of fire and explosion from the byproducts of
the manufacturing process.
Clandestine labs have many known & unknown liquids/
substances in marked & unmarked containers deemed
hazardous waste

23
RED FLAGS of a
Methamphetamine Lab
Unusual, strong odors
Unusual number of chemical containers
Lots of jars, bottles, jugs
Windows that are covered or blacked out
People smoking outside
Paranoid or odd behavior
Lots of traffic, especially at night
Secretive and protective of area
Exhaust fans
Additional Responses
For Teens and Adults
Meth labs are toxic and could be explosive!
If you suspect Methamphetamine related
activity always put your own safety first.
Leave the scene immediately and contact your local
police or the Vermont State Police for assistance.
ADDITIONAL RESOURCES
The Vermont Department of Health
Signs, symptoms, toxicity, and clean-up.
www.healthvermont.gov/adap/meth/meth.aspx
RED FLAGS for Methamphetamine
with sleeping for extended periods of time
Excited speech
Dry mouth
Dilated pupils
Increased energy or hyperactivity
Clouded mental functioning
Euphoria and rush
Hot flashes, sweating and flushed skin
A tendency to compulsively clean and groom and
repetitively sort and disassemble objects
Shortness of breath
Nausea, vomiting, and diarrhea
Episodes of sudden and violent behavior
Presence of inhaling paraphernalia such as straws,
mirrors, and razor blades
Presence of injecting paraphernalia such as syringes,
blackened spoons, or surgical tubing
Decreased appetite and weight loss with chronic use
Not sleeping for extended periods of time combined
Dramatic mood swings
Increased heart rate, blood pressure, and respiration
Auditory or visual hallucinations
Paranoia or excessive panic
Nervous activity
Irritable, aggressive, even violent
behavior
Open sores caused by picking at the skin
Unpleasant body odor that might smell like glue or
mayonnaise

nabolic steroids (also called Arnold, gym candy, pumper, stacker, weight trainer, and juice) are synthetically derived from the
A male sex hormone, testosterone, and are misused for performance enhancement (muscle growth, increased strength) and to
alter appearance. Anabolic steroids are available legally only by prescriptionfor the treatment of specific medical conditions.
Steroids are taken orally or injected typically in cycles of weeks or months (referred to as “cycling”), rather than continuously. Cycling
involves taking multiple doses of steroids over a specific period of time, stopping for a period, and starting again. In addition
users often combine several different types of steroids to maximize their effectiveness while minimizing negative effects (referred to
as “stacking”).
Abuse of anabolic steroids can lead to serious health problems, some irreversible. Major side effects can include liver tumors and
cancer, jaundice, fluid retention, and high blood pressure. Other side effects include kidney tumors, severe acne, and trembling.
Abuse of steroids is growing among teens. In fact, the most rapidly growing group of abusers is adolescent girls.
Female users may experience decreased breast size, increased growth of body and facial hair, male pattern baldness, and
enlarged genitalia. Their voices may deepen and their menstrual periods may stop. In males, abuse of steroids can cause baldness,
breast enlargement, reduction in size and function of the testicles, reduced sperm count, infertility, impotence, and increased risk for
prostate cancer. Males may also experience difficulty or pain when urinating.
Adolescents can have their growth halted prematurely through premature skeletal maturation and accelerated puberty changes.
This means that teens risk remaining short for the remainder of their lives if they take anabolic steroids before the typical adolescent
growth spurt.
Over-the-counter “supplements” such as creatine and androstenedione are not steroids, but they can be converted into testosterone
in the body. Medical authorities say that if these are taken in sufficient quantities, they could cause some of the same harmful effects
that anabolic steroids do. The U.S. Food and Drug Administration does not regulate these substances, which are sold in many
stores.
Corticosteroids, which are used to treat asthma and inflammation, are not anabolic steroids and do not produce these effects.
24
Steroids

25
Responses RESOURCES
For teens
Educate yourself about the risks of
misusing or abusing steroids.
If you or someone you care about is
misusing them, talk with a trusted adult
and ask for help.
Remember that most athletes achieve
without relying on steroids.
For adults
Examine family values about
athletic excellence or body
appearance.
Consult your healthcare provider
for help.
Family health-care providers
School guidance counselor, student assistance
professional, nurse, or social worker
Northwestern Counseling & Support Services (NCSS)
(adolescents)
802 524-6554
www.ncssinc.org
Howard Center (adults)
802 488-6265
www.howardcenter.org
RED FLAGS
Mood swings or “roid rage,” severe aggressive behavior
Hallucinations, paranoia, anxiety, depression
Worries about not “measuring up” to an idealized body image
Over-focus on body strengthening and toning
Changes in body appearance
Severe acne on face and back
Yellowing of the skin (jaundice)
Aching joints, muscle cramps, ligament and tendon injuries
Bad breath
With all such drugs, financial problems and change of friends may
also be warning signs.
Friends of Recovery
800 769-2798
www.friendsofrecoveryvt.org
Nar-Anon
802 363-6046
www.naranonvt.com
National Clearing House for Alcohol and Drug Information
800 729-6686
Partnership for a Drug-Free America
www.drugfreeamerica.org
Teens Health
www.kidshealth.org
ASK — Adolescent Substance Abuse Knowledge Base
www.adolescent-substance-abuse.com
Troubled Teens, Help for Parents
www.4troubledteens.com
Parents. The Anti-Drug
www.theantidrug.com
National Institute on Drug Abuse
www.teens.drugabuse.gov

26

27
E M O T I O N A L H E A L T H
A dolescents are learning who they
want to be as adults. As they grow more
independent, more is expected of them,
and they expect more of themselves.
And, of course, they are coping with
changes to their bodies and the onset of
hormones. In short, adolescents are
vulnerable.
During this transition, parents need to
listen more, stay involved, and keep the
lines of communication open. Teens seek
support and love from peers, and it’s
important that all members of your
family appreciate and respect this.
The most powerful resources for teens
are caring adults. By being attuned to a
teen’s “normal” self, parents can detect
changes that may indicate that a teen is
struggling. Be vigilant and trust your
instincts. If you think your teen has a
problem, he or she probably does. Seek
help.
Stress and Anxiety
page 26
Depression and Suicide
page 28
Eating Disorders
page 30
Obesity
page 32

28
Stress and Anxiety
RED FLAGS
For excessive stress
S tress is a normal part of life. It can be positive—nervousness
about performance can give you the extra boost you need to do
well. But stress can quickly get out of hand, especially for teens
trying to manage many feelings and pressures all at once.
How well a teen copes with stress depends on his/her coping skills
and positive internal and external assets. Healthy self-esteem,
feelings of competence, close friends, good social skills, and close
and trusting relationships with parents or other caring adults are
positive assets.
The effects of too much stress differ from person to person and can
progress to include anxiety and depression, substance use and
abuse, acting out and other behavioral problems, school problems,
relationship difficulties, and physical illnesses.
As you can see in the Red Flags, it can be hard to discern whether
someone is feeling stressed or whether they are experiencing
anxiety. It may be difficult for teens themselves to tell the difference.
Most kids talk about feeling “stressed out.” So it’s important that
adults observe their teens’ behavior and initiate more
communication.
Anxiety includes feelings of unease, apprehension, uncertainty,
and fear. Anxiety is an essential instinct to help us cope with
danger. Anxiety can be harmful when it is prolonged or pervasive
and/or when it is so acute and intense that it disrupts normally safe
activity and causes severe physical effects.
previously enjoyed activities
Social withdrawal, loss of interest in
Aggression, acting out, irritability
Headaches, back aches, stomach aches
Changes in eating and sleeping habits
Difficulty concentrating
enough air, feeling faint or dizzy
palpitations; sweaty, cold, or shaking hands
Breathing too fast, feeling there is not
Burning sensation in the chest and heart
Unexplained rashes or hives
Changes in menstrual cycle
Unexplained hair loss
For anxiety, in addition to the
symptoms of excessive stress:
Nausea and/or diarrhea
Excessive sweating
Numbness and tingling
Inability to stop worrying
Avoidance, social withdrawal, excessive
shyness
Intrusive thoughts and repetitive behaviors
Hyper-vigilance

RESOURCES 29
Family health-care providers, mental-health
professionals
School guidance counselor, student assistance
professional, nurse, or social worker
Northwestern Counseling
& Support Services
www.ncss.org
(802) 524-6554
American Academy of Child and Adolescent
Psychiatry
www.aacap.org
National Alliance for the Mentally Ill
www.nami.org/youth
Your local recreation department or
community center, for information about
exercise and stress management classes
Pathways: A resource guide connecting families
supports for adolescents who experience
serious emotional disturbances
(802) 241-2650
Responses
For teens
Try to understand what stresses you. Reduce or eliminate some activities if you
are feeling overwhelmed. Learn to delegate responsibilities or ask others for help.
Get enough rest. Maintain a good diet.
Identify and practice ways to de-stress. Learn relaxation techniques like deep
breathing, calming self-talk, and taking time to exercise.
Do not use alcohol, marijuana, over-the-counter medications, or unprescribed
medicine to cope.
Tell your doctor, school nurse, or guidance counselor about new physical
symptoms.
Don’t bear anxiety alone; talk it out.
If you or someone you care about shows signs of being overstressed or
persistently anxious, get help from an adult.
For adults
Know the signs and symptoms of too much stress for your
teen.
Together with your child, try to identify stressors and
eliminate unnecessary ones. Help your child verbalize the
nature of his worries.
Offer opportunities to learn coping strategies for stress
management, such as relaxation techniques, yoga, and
other exercise.
Model effective ways to manage stress.
Be patient and supportive.
Consult a professional for guidance. Mental health
professionals know how to treat stress and anxiety.

30
RED FLAGS
Depression
Eating or sleeping too much or too little
Difficulties at school
Frequent crying
Diminished interest in or pleasure from usual activities
Persistent feelings of worthlessness or inappropriate guilt
Restlessness or lethargy
Inability to concentrate, indecisiveness
Depressed or irritable mood
Withdrawal and isolation from friends and family
Alcohol and substance abuse
Unusual neglect of personal appearance
Suicidal thoughts, plans, or attempts
Suicide
Depression and Suicide
O
ne of the hallmarks of
adolescence is the roller
coaster ride of changing moods.
For this reason, the early signs
and symptoms of depression
may be difficult to distinguish
from age-appropriate
emotionality. The features of clinical depression are a
prolonged depressed, sad, or irritable mood for at least 2
weeks and a loss of interest or pleasure in nearly all
activities. These symptoms may persist most of the day,
nearly every day, and may interfere with academics,
athletics, sexual feelings, and family functioning.
Many teens who are suicidal are suffering from clinical depression,
which in many cases is caused by a chemical
imbalance in the brain. Each year in the United States,
thousands of teenagers commit suicide.
Complaints of being a bad person
Verbal hints such as, “I won’t be a problem for you much
longer.”
Putting affairs in order (e.g., giving away favorite possessions,
making a will)
Sudden, unusual cheerfulness after a period of depression
Heightened interest in people who have committed suicide
Previous suicide attempt, or acquiring means for committing
suicide (medications, rope, weapons)
Risk taking or self-destructive behaviors
Themes of death expressed in writing or artwork
Self-injury refers to hurting oneself to relieve emotional pain.
Teens who engage in cutting, burning, or picking may be trying
to numb or relax themselves. These teens may cut themselves
deeply enough to damage the tissue and bleed, but not
enough to cut veins or arteries. Some teens burn the skin,
usually by using cigarette butts, creating small round scars.
Repetitive picking of the skin can cause scarring.
Self-injury is a way for some to cope with difficult feelings. Selfinjury
is very different from suicidal behavior. The intent of selfinjury
is to relieve pain, not to die.
If you or someone you care about is hurting themselves seek
medical help.

Responses RESOURCES 31
(Statistics according to the 2007 Vermont Youth Risk Behavior Survey)
For adults
If a teen seems depressed
Try to talk through what is troubling the teen.
Sometimes teens don’t know or can’t
articulate why they are feeling down. Be
patient.
Seek a professional evaluation. Ask your
health-care provider for help deciding
whether medication or therapy is needed.
If a teen seems suicidal
If you are worried that your child is thinking of
suicide, ask her about it. Talking about it will
not cause suicide.
Take seriously all comments about suicide.
Don’t assume the situation will take care of
itself. Don’t act shocked or surprised by what
the person says.
Don’t challenge or dare. Don’t argue or debate
moral issues.
Get help immediately. Suicidal feelings are
very powerful, and immediate treatment is
needed.
Do not leave the teen alone if you believe he
is suicidal.
Call the help numbers at right.
Take your child to the local emergency
department.
For teens
For depression
Talking can help when you are feeling down or
desperate.
If a friend seems depressed, be willing to listen.
Encourage them to seek help. Tell an adult, parent or
school counselor of your concerns.
If you believe you are depressed, ask an adult to help
you get a professional evaluation. A doctor or mentalhealth
professional can help you get the treatment you
need.
For suicidal behavior
Suicidal thoughts should never be a secret. If you or
someone you know is having thoughts of suicide, tell a
trusted adult. No matter what you “promised” to keep
secret, a friend’s life is more important than a promise.
If you believe a friend is suicidal, get help and stay with
the friend until help arrives. Do not leave your friend
alone.
You are allowed and expected to make mistakes as
you become an adult. Be easy on yourself. The
intensity of your feelings of embarrassment, rejection,
shame, or guilt will diminish.
Seek help from a trusted adult. Call 911 or one of the
help numbers at right.
Northwestern Counseling
& Support Services (NCSS)
www.nssinc.org
802 524-6554
Crisis Line
(800) 834-7793 toll free
Crisis and Suicide Prevention Lifelines
800 784-2433 800 273-TALK (8255)
Call 911 or take the teen to a hospital
emergency department.
Emergency professional assessment is
always available through the Emergency
Department at Northwestern Medical Center.
Family health-care providers and mentalhealth
professionals
School guidance counselor, student assistance
professional, nurse, or social worker
American Foundation for Suicide Prevention
www.afsp.org/education/teen
Troubled Teens, Help for Parents
www.4troubledteens.com
For a Depression Screening go to:
www.depression-screening.org
Suicide is the third leading cause of death among U.S. 15 to 24-year-olds.
In Vermont, 20 percent of students (grade 8 -12), felt so sad or hopeless almost every day for
at least two weeks that they stopped doing some usual activities. 9 percent of these
students made a plan about how to attempt suicide. 5 percent of these students actually
attempted suicide.

32
Teens are under a lot of pressure to succeed and fit in. Many spend a lot of time
worrying about what others think and they desperately try to conform to society’s
unattainable “ideal” body image. Many popular television shows lead the teen to believe
that they must be thin. They watch these shows and many will do anything to try and look
like the actor/actresses on these shows. Teens will paste pictures of actor/actresses all
over their rooms, and some will resort to dangerous methods of weight control to try and
look like their idols.
Disordered eating is a complex illness requiring psychological and medical care. It often
begins with the desire to lose weight and to feel better about oneself. The most prevalent
eating disorders are anorexia nervosa, binge eating disorder, and bulimia. All can cause
severe long-term effects, including organ damage, weakening of the bones, and impaired
cognitive functioning.
Eating Disorders
Responses
For teens
If you find yourself preoccupied
with food intake or weight
control, it is important to get help
now, before these issues control
you.
If someone you care about
shows signs of disordered
eating, encourage them to seek
help.
Tell an adult of your concern.
You cannot manage disordered
eating by yourself. A trusted
adult will help you get the special
care you deserve.
For adults
Provide love, concern, and help.
Do not become the food police.
Never threaten or force food.
Model realistic beliefs and behavior
about body image and nutritious
eating. Avoid preoccupation with
thinness (yours or theirs)
or physical attractiveness.
Focus on health, not weight or size.
Understand that this is not normal
adolescent behavior. Children do
not get better by themselves.
An individual suffering from anorexia nervosa is intensely afraid of
gaining weight. People with this disorder often say they “feel fat” or
that part of their body “is fat” despite obvious signs to the contrary.
Binge eating disorder entails compulsive overeating and a
feeling of being out of control over food intake and body image.
Bingers eat large quantities of food, usually when alone, regardless
of appetite. Binge eating disorder does not include purging.
Bulimia nervosa is characterized by cycles of binge eating and
purging, either by vomiting or abusing laxatives or diuretics, such as
water pills. Bulimics may also exercise excessively to lose weight.
Bulimics may be of any weight.
Although disordered eating is seen primarily in females, males also
can be afflicted.

33
RED FLAGS
Behavioral and emotional signs for disordered
eating
Disordered eating calls for professional intervention.
Preoccupation with eating and/or exercise
Use of laxatives, diuretics, or diet pills
Use of muscle building supplements and/or
steroid products
Under-eating or over-eating
Secretive behavior around food; not eating
in public
Excuses for not coming to meals
Frequent weighing
Oral gratification with sugar-free gum or beverages
Flaunting weight loss, or hiding it by wearing
oversized clothes
Depression, irritability, mood swings, social isolation
Perfectionist attitude, inflexibility
Increasing self-criticism and negative self-talk
Physical signs of anorexia nervosa and
binge eating disorder
Observable weight loss or gain; frequent
changes in weight
Headaches, fatigue, and intolerance of cold
Swollen glands under the jaw
Tooth decay, bone injuries, such as shin
splints, stress fractures
Persistent constipation and abdominal pain
Development of a fine, downy body hair
Lethargy or excess energy
Lack of menstrual periods
Physical signs of bulimia nervosa
In addition to extreme concern about weight
and appearance and other emotional signs
discussed under anorexia nervosa:
Making frequent trips to the bathroom
immediately after meals
Dental cavities and permanent dental
enamel erosion, which cause teeth to look
ragged and “moth eaten”
Scars and calluses on fingers used to induce
vomiting
RESOURCES
Family health-care providers
School guidance counselor, student assistance
professional, nurse, or social worker
Northwestern Counseling & Support Services
NCSS
802 524-6554
www.ncssinc.org
National Eating Disorders Association (NEDA)
www.nationaleatingdisorders.org
800 931-2237
National Women’s Health Information Center
www.4woman.gov
Girl Power
www.health.org/gpower
The Body Positive
www.bodypositive.com
Eating Disorders
Mirror Mirror
www.mirror-mirror.org

Exercise. Find an activity you enjoy. Take a walk daily.
A trainer at a gym can help you set reasonable goals.
Limit your soda and fast food intake and follow guidelines for
healthy eating.
34
Responses
Obesity
For teens
If you are overweight, talk to your doctor. A doctor should
supervise any weight management program.
O besity has become an epidemic among children,
teens, and adults. Type 2 diabetes, previously considered
an adult disease only, is rapidly becoming a disease of
children and adolescents. Obesity affects boys and girls
and is found in all age, race, and ethnic groups. In
addition to Type 2 diabetes, studies show high blood
pressure, menstrual abnormalities, impaired balance,
orthopedic problems, and reduced life expectancy can
result from obesity.
Obesity also puts emotional well-being at risk. Overweight
students may be the targets of social ostracism or
bullying.
Regardless of the causes, obesity requires a change of
behavior. It is a medical problem, and doctors and other
health care professionals can help.
Limit time spent at the computer or television. When you need
to reward yourself or give yourself a lift, choose a non-food
reward.
For adults
Be understanding and encouraging, not critical or demeaning.
Focus on health rather than size or appearance.
Offer resources for help with weight issues, such
as a pediatrician, counselor, nutritionist, gym
membership, personal trainer, and weight loss or
exercise groups.
Take walks with your child.
Limit TV viewing and computer time.
Encourage participation in physical activity and sports.
Provide nutritional, well-balanced, low-calorie, low-fat meals.
Be a role model.
Limit availability of high-fat, high-sugar snacks.
Don’t use food as a reward for accomplishments. Don’t
withhold food as a punishment.

RED FLAGS
RESOURCES 35
Poor eating habits
Interest in eating constantly
Weight gain
Decrease in physical activity,
no physical activity
Wearing loose clothes
Lethargy
Family health-care providers
School guidance counselor, student assistance
professional, nurse, or social worker
Northwestern Counseling & Support Services
(NCSS)
802 524-6554
www.ncssinc.org
Dietary Guidelines for Americans (U.S. Department
of Health and Human Services and the U.S.
Department of Agriculture)
www.health.gov/dietaryguidelines
Troubled Teens, Help for Parents
www.4troubledteens.com
Teens Health
www.kidshealth.org

ADDITIONAL RESOURCES
The Vermont Bicycle & Pedestrian Coalition
www.vtbikeped.org
National Highway Traffic Safety Administration
http://www.nhtsa.gov/
D
ata from the YRBS indicates that some simple safety measures are not commonly used among youth in our region.
Fifty-nine percent of teens in Grand Isle County never wear a helmet while riding a bicycle. These numbers rise to
69% in Franklin County and some towns are as high as 81%. Head injury is the leading cause of death in bicycle crashes.
Helmets have been proven 85-88% effective at reducing the impact of head and brain injury and saving lives. Teens also
continue to be injured, some fatally, while riding ATV’s without helmets. Another area of concern is the lack of seat belt
use with only 53-56% of teens reporting they always wear their seat belt. Our region has a way to go to reach the
Healthy Vermonters 2010 statewide goal of increasing consistent seat belt use to 92%.
36
Image: Ian Kahn / FreeDigitalPhotos.net

R E L A T I O N S H I P S A N D P E R S O N A L S A F E T Y
37
I t’s an adolescent’s job to become more
independent of parents and family. Teens
naturally reach out to peers and other adults
for perspectives and help. They will encounter
many influences and experience new kinds of
relationships, with friends, with strangers, and
with boyfriends and girlfriends.
Not every action or decision will be perfect.
Teens learn from mistakes. In the pages that
follow, we describe the ways in which some
relationships can become destructive and put
an adolescent’s safety at risk.
Although it is important for teens to separate
from their parents, they still need to have
strong relationships with family. Disagreements
are natural. It’s important that both teen and
parent understand that. Yet, there can be times
when communication seems impossible. At
such times, it is a relief both to parent and teen
to know the teen can turn to other trusted
adults. It is good to include such people in the
life of your family before a crisis occurs.
Bullying, page 38
Harassment, page 40
Abusive Relationships, page 42
Internet Safety, page 44
Sexual Behavior, page 46

38
RED FLAGS
The target, male or female, may:
Be quiet and shy, not part of a
group; may excel in school,
prompting jealousy
Have poor relationships with
peers, siblings, or difficulty
making friends
Have academic problems and
look for excuses to stay home
from school
Express feelings of loneliness,
may withdraw from enjoyable
activities
Be anxious or depressed
Complain of insomnia, bad
dreams, unexplained
stomachaches, and headaches
Avoid specific students or social
activities
May become too thin or
overweight
Some girls who are targeted may
stop seeing certain friends. Girl
targets may appear sad and cry
frequently.
Boys who are targeted may return
from school without money, clothing,
electronics, or other possessions.
Watch for unexplained scratches,
cuts, bruises, or torn clothing.
The bystander may experience some
of the same signs that targets do.
They may also become insensitive to
slights and injuries made to others. A
bystander may also become a bully
to avoid becoming a target.
Bullying
Bullying is a form of violence in which one repeatedly targets another who is weaker, smaller, or more vulnerable. It is
repeated behavior intended to harm or disturb the target. An imbalance of power exists in all bullying situations.
Bullying can be physical, verbal, and/or psychological. Verbal bullying includes taunting, name-calling, making threats,
and belittling the target. Physical bullying can include hitting, kicking, spitting, pushing, biting, and taking personal
belongings. Psychological bullying consists of spreading rumors, social exclusion, intimidation, extortion, and sexual
harassment.
Cyber-bullying is the harmful application of technology by students or others wishing to extend the reach and impact
of their bullying behavior during and beyond school hours. It is the use of information and communication technologies
(such as e-mail, cell phone and pager text messages, instant messaging, defamatory personal websites, defamatory
online personal polling websites, and digital photography) to support repeated acts by an individual or group, that are
intended to embarrass, humiliate or intimidate their victim.
Both boys and girls can be bullies, but some general differences seem to exist. Research indicates that boys tend to
bully others through physical aggression. Generally, girl bullies are more likely to use relationships and words to hurt
others. The tight structure of girls’ peer relationships makes it easier for them to manipulate and harm others in lessdirect
ways, such as excluding former friends and ostracizing others. This generalization does not mean that girls don’t
get into fights or that boys don’t use words to exploit and manipulate. Both boys and girls need to understand bullying
behaviors and how to deal with them.
The effects of bullying can last a lifetime for all involved—target, bully, and bystander.
Targets may be quiet, shy, a sibling, or socially awkward and less mature than their peers. Some targets are very
bright and are picked on because of it. Being an ally to a target may result in becoming a target as well. Targets have
a greater risk of developing anxiety, depression, and other mental health problems.
Most bullies act out of anger, frustration, or a desire to win respect. Bullies can develop into violent adults. Some
bullies have previously been targets. Bullies are concerned with their own power and enjoy humiliating their targets in
front of others.
The bystander may not seem to be affected, but having witnessed bullying behavior, this child may fear that they will
also be bullied. The bystander often feels powerless, guilty, and that they lack the courage to stop the bullying.
Bystanders exposed to repeated acts of bullying can become desensitized to the suffering of others.
RESOURCES
Family health-care providers
School guidance counselor, SAP, School
Resource Officer, nurse, or social worker
Bullies and School Violence
The MindOH! Foundation
www.mindOH.org
In Memory of Ryan Patrick Halligan
www.ryanpatrickhalligan.org
TeensHealth (The Nemours
Foundation)
www.kidshealth.org/teen
Kids Health
www.kidshealth.org/kid/feeling/
emotion/bullies/html
Vermont—State Anti Bullying Law
www.bullypolice.org/vt_law.html
Comeback Lines for Targets
www.bullystoppers.com/101 great comebacklines.html
Safe Schools Program
Vermont Dept. of Education
www.education.vermont.gov/new/html/
pgm_safeschools.html
Voices Against Violence
www.cvoeo.org/htm/DomesticViolence/Contact_Us.html

The male bully:
Relishes having control and uses physical stature to his
advantage
Is aggressive, impulsive, or hot-tempered
May be defiant towards adults
Shows little empathy for others
May be fascinated with violent TV and video games
May come home with money, clothing, food, and electronics
that are not his
May live in a home that uses physical discipline, threats,
and/or verbal abuse
The female bully may:
Make telephone calls to discuss other girls
Send vicious e-mail or instant messages (IMs) about a
targeted girl
Post rumors or nasty messages about target on social network
sites such as MySpace or FaceBook
Pretend to be someone else on-line or on the telephone to
trick another person; leave rude messages
Exclude former friends, spread hurtful rumors
Change language or clothing to establish control over
others
For teens
If you or someone you know is being physically bullied and you
don’t feel you can have a reasonable conversation with the bully,
ask an adult to help.
If you or a friend is being hurt physically, get help immediately.
If you or someone you know is being targeted by a gossiper or
someone saying hurtful things, don’t answer back or seek
revenge. It may work in the movies, but it doesn’t often work in
real life. If you can ignore the situation, do. But if you cannot, or if
the behavior persists, get adult help.
If you are often frustrated and angry and you find yourself acting
out against others, physically or verbally, ask an adult for help.
Teachers, counselors, and other trusted adults can help you
resolve conflicts.
Responses 39
For adults
If your child is the target
Ask if they are being bullied. If they need help starting the conversation, describe some of the ways that
teens bully each other. Make sure they knows that you do not blame them or feel disappointed in them.
Encourage your child to participate in activities he/she enjoys as a way to build self-esteem and
develop a peer group with similar interests.
Take seriously any report of bullying and report any incident to school administrators.
Advise your teen not to tease, punch back, or seek revenge.
Work with school personnel to ensure that your child feels safe.
If your child is the bystander
Encourage them to lend support to targets and to report incidents to a trusted adult.
Assure them that telling an adult is not tattling—it’s helping to keep people safe. Taking a friend along
may make this easier.
Work with school personnel to develop solutions to ensure that your child feels safe.
If your child is the bully
Talk through why the teen has behaved this way. Do not accept excuses or justifications. Make it clear
you will not tolerate bullying.
Discuss how it feels to be a target. You might ask, “How would you feel if it happened to you?”
Discuss the situation with school personnel to develop problem-solving techniques.
Set firm, consistent limits.
Use non-physical consequences, such as loss of privileges.
Be a positive role model. Make sure your teen is not witnessing physical or verbal aggression or
psychological manipulation at home.
Limit exposure to violent media.
Supervise your teen’s activities, including Internet use if the bullying entails e-mail or IMing.
Cyber-bullying is different from face-to-face bullying because the bully is removed
from the immediate and tangible feedback of the victim. They don't "see" the harm they
have caused or the consequences of their actions, which minimizes any feelings of remorse
or empathy. This creates a situation where kids do and say things on the Internet
that they would be much less likely to do in person. – The MindOH! Foundation

40
Harassment
arassment is any behavior that creates a hostile, intimidating,
H or offensive environment. It can include words, gestures, or
written materials that are demeaning. Slurs, insults, and visual
taunts, such as graffiti or negative symbols, all can be considered
harassment.
Sexual harassment consists of unwanted written, verbal, or physical sexual advances
or requests for sexual favors. This includes sexual jokes, reference to sexual conduct,
gossip regarding one’s sex life, comments about an individual’s body or sexual activity,
or displays of suggestive or pornographic materials.
Racial harassment includes racist insults or jokes; comments about someone’s skin
color, language, or national origin; ridicule of cultural differences; or display of offensive
racist material.
Homophobic harassment includes degrading comments about gay, lesbian, bisexual,
or transgendered individuals, derogatory name-calling, and physical threats and abuse.
Religious harassment consists of attacks on someone’s religious beliefs, customs,
practices, or affiliations.
Teens who are harassed may develop emotional difficulties. They are at risk for
depression. Teens who harass others may become abusive in later relationships. Some
harassing behaviors are illegal.
RED FLAGS
Social withdrawal or avoidance
Sadness
Anxiety and depression
Unexplained aggressiveness
or acting out
Repeating offensive jokes or
comments (Some teens will
imitate those who have
harassed them.)

41
Responses
For teens
Know that you have the right not to be harassed. Don’t blame
yourself.
If you have been harassed, try to speak to the harasser to make
clear that his behavior is offensive. Sometimes this is enough to
stop the harassment. Ignoring harassment rarely works and can
encourage the behavior.
If talking doesn’t help, seek support from an adult at home or at
school. All Vermont schools have harassment policies and staff
trained to help.
If you know someone who is being harassed, encourage them to
get help from an adult, and let them know that you support them.
For adults
If a teen tells you he/she is being harassed, take it seriously.
Encourage them to tell the harasser their behavior is offensive.
If the harassment continues, encourage the child to tell a teacher or
counselor. Speak to authorities yourself if your teen is reluctant.
Tell your teen it is not his/her fault.
If your teen witnesses someone being harassed, encourage them to
be an ally to the target. Suggest using non-threatening comments,
such as, “Knock it off. That’s not funny.” Other teens can help get
appropriate school personnel involved.
RESOURCES
School counselor, administrator, school
diversity coordinator, nurse, or social worker
TeensHealth – Answers & Advice
www.kidshealth.org/teen/school_jobs
The Safe Schools Coalition
www.safeschoolscoalition.org
An Abuse, Rape, and Domestic Violence Aid
& Resource Collection
www.aardvarc.org/dv/states/vtdv.shtml
Voices Against Violence
www.cvoeo.org/htm/DomesticViolence/
Contact_Us.html
Fight Hate and Promote Tolerance
www.tolerance.org
Parents and Friends of Lesbians and
Gays
866 427-3524
Gay Lesbian and Straight Education
Network
www.glsen.org
212 727-0135
Outright VT
www.outrightvt.org
Youth Support Line:
800-GLB-CHAT

42 Abusive Relationships
Responses
For teens
A
rguments and disagreements are normal in relationships.
Relationships grow stronger when partners approach
differences with mutual respect and an expectation of equality.
If one partner, male or female, coerces the other, physically,
emotionally, or sexually, this is abuse—and it is wrong. The
controlling partner tries to maintain power through one or more of
the following means.
Emotional—Hurtful teasing, humiliation, name calling, stalking,
threats, intimidation, put downs, excessive criticisms, or refusing
to speak; twisting the truth to keep the victim in a subservient
role, blaming the victim for abuse; restricting the victims social
connections.
Physical—Grabbing, pushing, slapping, hitting, spitting, kicking,
and destroying personal possessions and being harmful to pets.
Sexual—Sexual humiliation, non-consensual relations, unwanted
sexual contact. Abuse occurs across all social, economic, religious,
and racial lines, in both heterosexual and homosexual
relationships. Males and females can be victims and abusers.
Victims in abusive relationships are at risk, not only for physical
injury, but also for emotional problems, such as anxiety,
depression, and suicide.
Don’t blame yourself.
To end an abusive relationship, you will probably need
professional advice.
If you have been sexually assaulted, have your parents or a
trusted adult take you to a hospital emergency department.
Even if you are not physically injured, you need to have a
doctor check for sexually transmitted diseases or pregnancy.
Specially trained nurses can help with collection of evidence.
This evidence can be important when you report the assault
to police. Avoid bathing, showering, or brushing your teeth
before being examined.
For parents and friends
If you are worried about the relationship of your teen or
someone you care about, let them know you are concerned
about their safety and well-being. Assure them that they are
not to blame.
If you are concerned that a teen is abusing or controlling
another, stress the importance of respect for others.
Emphasize that loving relationships never involve abuse or
manipulation.
Help the teen, whether the victim or the controlling partner,
recognize the effect that the relationship is having on them.
Ask how they have changed during the course of the
relationship.
Provide the teen with the encouragement needed to be able
to leave the relationship. Offer professional help.
Call a school counselor, health care provider, or social
worker for advice. If you are the friend of a teen who is being
abused, offer to accompany them to someone who can help.
Call the police immediately if the teen shows signs of
physical abuse.

RESOURCES 43
Call 911 for immediate assistance.
Health-care provider
School guidance counselor, student assistance
professional, nurse, or social worker
Voices Against Violence
www.cvoeo.org/htm/DomesticViolence/
Contact_Us.html
Vermont Network Against Domestic & Sexual Violation
www.vtnetwork.org
1-800-489-7273
Information for Teens on Dating Violence
www.womenslaw.org/teens.htm
Vermont Healthcare & Intimate Partner Violence
www.vtmd.Org/Domestic%20Violence/Victims and survivors.html
RED FLAGS
For victims
Fearfulness
Frequent crying
Exhaustion
Social isolation
Feelings of shame and mistrust of self and
others
Unexplained bruises, sprains, broken bones,
or marks
Symptoms of depression, such as loss of
appetite, or anxiety, such as difficulty
sleeping, and restlessness
Reports of being left in dangerous situations
Receiving expressions of love following
violence
Having to account to partner for
whereabouts
Poor school attendance, academic
difficulty
For abusers or controlling partners
Controls aspects of partner’s life, such as
clothing, spending
Showers partner with gifts
Tracks partner’s whereabouts
Is jealous and angry when partner spends
time with others
Insults partner publicly
Threatens harm to self or partner if partner
leaves relationship
Vermont Domestic Violence Crisis
and Support Resources
www.aardvarc.org/dv/states/vtdv.shtml
Rape Crisis Services
www.rcsgl.org
800-542-5212
National Domestic Violence/Abuse Hotline
800-799-SAFE
National Youth Violence Prevention
Resource Center
www.safeyouth.org
Teen Dating Violence – Just for Teen
www.wcstx.com
TeensHealth – Answers & Advice
www.kidshealth.org/teen/your_mind

44
Internet Safety Responses
T
he Internet is like being in public. There are people and sites you
should avoid. People online may not be who they say they are.
Chat rooms ar e sometimes used by people who want to exploit
others. Teenagers, especially girls, are at high risk for sexual assault
and other serious dangers if they agree to meet in person people they
meet on the Internet. Beware of online scam artists who send text,
email or pop-up messages to ‘phish’ for personal information
M
any pre-teens and teens share intimate information online and
then have no control over how this information is used by their
Internet “friends.” Teens should also be aware that social networking
sites are often used as a reference check by admissions offices of educational
institutions and employers. Care should be taken when deciding
what to post to FaceBook and other social networking pages. Once
information is online it can’t be taken back even if posts have been
deleted. There is no control over older versions that may exist and
circulate on other computers.
P
re-teens (many of whom are big users of instant messaging) can
be especially vulnerable. Knowing what your child is doing online
is important. Helping them understand how to avoid trouble is critical.
RED FLAGS
Excessive use of online services or bulletin boards, especially late at
night
Personal computer tucked away, where parents can’t see
Secretive online behavior
Unwillingness to talk about online activities
Unusual credit card activity
Unknown names appearing on home caller ID
Unsolicited pornographic e-mail and/or postal mail
Withdrawal from family and friends
For teens
Never go alone to a face-to-face meeting with someone you know
only from the Internet. Any meeting should be in a public place with a
trusted adult present.
If you are made uncomfortable in any area online, leave it. Don’t put
up with rudeness, bullying, or provocative chat.
Do not answer obscene or threatening e-mails or statements in chat
rooms.
Harassment is a federal crime. If someone sends you messages or
images that abuse, threaten, or harass you, report it to your Internet
service provider and the police.
Don’t tell anyone anything online you would not want others to know.
Never enter any information about yourself without first checking with
your parents. Never include your home address, telephone number,
photograph, or your passwords.
Never download anything or click on any link in e-mail unless it is from
a trustworthy source.
For adults
Supervise use of the Internet. Place the computer in a common area
of the house where adults are able to monitor use.
Set reasonable family expectations for online behavior; tell teens
never to respond to threatening or obscene messages.
Consider installing filtering software to block unwanted mail and
access to objectionable sites.
Ask your child about his/her online interests and friends, and ask to
see the sites they visit. Explore the Internet together.
If your child receives inappropriate online mail and/or pornography,
do not punish your child. Instead, immediately contact the police or
FBI. Computer crime specialists will work with you to identify the
person targeting your child.

Your local police department, 911
Your Internet service provider, for filtering software and to
register complaints about inappropriate material sent to
your teen
Safe Kids
www.safekids.com www.safeteens.com
The law
A number of federal laws prohibit misuse of computers
at home and in public places, such as libraries and
schools. Children may not be aware that they may be
breaking the law by spreading rumors over the web or
misrepresenting themselves on the Internet. Bullying,
harassment, or a prank, regardless of intent, can result
in criminal prosecution.
RESOURCES
School Resource Officer
45
Wired Safety
www.wiredsafety.org
Netsmartz
www.netsmartz411.org
Web Wise Kids
www.webwisekids.org
Cyber Bullying
Cyber-bullying is the harmful application of technology by students or others wishing
to extend the reach and impact of their bullying behavior during and beyond school
hours. It is the use of information and communication technologies (such as social
networking sites, e-mail, cell phone and pager text messages, instant messaging,
defamatory personal websites, defamatory online personal polling websites, and
digital photography) to support repeated acts by an individual or group, that are
intended to embarrass, humiliate or intimidate their victim.
Please refer to page 36 for more information and resources regarding Bullying.
National Institute on Media and the Family
www.mediafamily.org/facts
Top 50 Internet Acronyms Parents Need to Know
www.netlingo.com/top50teens.cfm
National Center for Missing and Exploited Children’s
Cyber Tip Line
www.cybertipline.org
800 THE-LOST
Forward phishing emails to spam@uce.gov or
reportphishing@antiphishing.org

46
Sexual Behavior
T
he desire for intimacy and sexual feelings is normal and
healthy. Still, many of us, both kids and adults, have a hard
time talking about sexual behavior. As adolescents seek more
independence and privacy, the parent-child conversation may
become more difficult. Yet surveys consistently show that teens
want to be able to talk to their parents.
So how do we talk about something so private?
First, adults need to be aware of their own values about
sexual behavior.
By reflecting on the messages we received as youth, we can be
clearer about what we want to teach our own children. If we do not
communicate our values about sexual behavior, children may
adopt the values they see elsewhere.
Know the facts.
You don’t have to be an expert to teach the facts, but you do need
to know where to find the facts. Bookstores, the library, and this
book contain excellent sources of information.
If young children are taught the correct words for body parts (such
as vulva, vagina, penis, and rectum), they learn there is nothing
mysterious about these parts. Adolescents become better
advocates for themselves, both in relationships and with healthcare
professionals, when they can talk about their bodies clearly.
Adolescents have their own culture and vernacular. Learn what
words they are using to describe sexual activity, including petting,
oral sex, intercourse, “hooking up,” and “friends with benefits.”
Adults may think they know what certain terms mean, but many of
the terms used to describe sexual activity have changed.
Educate yourself about the signs and symptoms of sexually
transmitted infection and pregnancy, and make sure your teens
learn about these.
As you answer questions, try not to share your feelings about the
questions until you have shared the facts. Discuss responsibility.
Teens need to know that every decision has a consequence.
Foster positive feelings.
Talking with children in a way that fosters positive feelings will
enhance self-esteem and build pride. If children feel good about
their bodies, they will make good decisions about how they use
their bodies.
Don’t wait for children to ask.
Talking about sex doesn’t make it happen. Look for teachable
moments to bring up the topic of sexual feelings and behavior. It
doesn’t have to be “one talk.” Education takes place over many
years as a child’s ability to understand sexuality develops. If your
child approaches you with questions before you approach them,
tell them the facts. If children ask, they are old enough to know the
answers.
It’s okay to respond to questions by letting a child know that they
have asked a good question, but you want to talk about it after you
have had a chance to think about it. Always follow up with the child
without waiting to be asked again. Encourage your child to come to
you if he/she hears about sexual activity with which he or she is
unfamiliar. Be honest.
If you haven’t started talking, don’t worry that it’s too late.
Start now.
Similarly, don’t worry if you haven’t said something just the way
you wish you had. Talking about sex should be a continuing dialog;
you can always correct yourself or offer a better explanation
another time.
If you are too embarrassed to talk about sexual behavior, it is
important to find another adult with whom you feel comfortable
having your child talk. By doing so, you ensure that your child is
hearing the facts and values that you support.

Facts About Sexually Transmitted Infections (STI)
47
STIs can be present with no symptoms.
STIs can be found in the throat, vagina, penis, or rectum.
Anyone who engages in vaginal, oral, or anal sex is at risk for an STI.
For girls: burning upon urination, vaginal discharge, lower abdominal pain,
bleeding between periods, flu-like symptoms, lesions around infected area
For boys: penile discharge, burning upon urination, pain/swelling of the testicles,
flu-like symptoms, lesions around affected area
Beware: Misinformation abounds! If you have questions about sex, ask a parent
or trusted adult friend. Find a time when you won’t be interrupted or distracted.
It is normal for you or your parent to feel awkward as you begin the discussion.
This is a learning experience.
If your parent begins to lecture, respectfully remind him that you are just seeking
information.
SIGNS AND SYMPTOMS
SOME ADVICE FOR TEENS
RESOURCES
Communication
A recent phenomenon with cell phone use among teens is
known as “sexting”, the sending or forwarding of sexually explicit
photos, videos, or messages from a mobile phone. In
addition to risking one’s reputation and friendships, one could
be breaking the law by creating, forwarding, or even saving
this kind of message.
Family health-care providers
School guidance counselor, nurse, or
social worker
American Social Health Association
www.iwannaknow.org
Not Me, Not Now
www.notmenotnow.org
Planned Parenthood of Northern New England
www.plannedparenthood.org/ppnne/get-the-facts.htm
1-800-230-PLAN
National Campaign to Prevent Teen
Pregnancy
www.teenpregnancy.org
Advocates for Youth
www.advocatesforyouth.org
Sexuality Information and Education
Council of the U.S.
www.siecus.org
Teens Health
www.kidshealth.org/teen/sexual health/

48
F O R M O R E I N FORMAT I O N
About substance use and abuse
Adolescent Drug and Alcohol Abuse. How to Spot it,
Stop it, and Get Help for Your Family. Babbit, N. 2000.
Drug Abuse and Teens: A Hot Issue. Masline, S.R. 2000.
“Marijuana Abuse,” National Institute on Drug Abuse
Research Report Series. www.nida.org
Information about Marijuana, www.Marijuana-Info.org
“Wake Up to the Risks of Marijuana – A Guide for
Parents, ” National Clearinghouse for Alcohol and
Drug Information (NCADI). www.theantidrug.com
www.streetdrugs.com
About emotional health
Anorexia Nervosa: Survival Guide for Families,
Friends & Sufferers. Treasure, J. 1997.
Body Wars. Maine, M. 2000.
Bulimia: A Guide for Family & Friends. Sherman, T.,
& Thompson, R.A. 1997.
Helping Your Depressed Teenager: A Guide For
Parents and Caregivers. Oster, G.D. 1994.
How to Get Your Kids to Eat . . . But Not Too Much.
Satter, E. 1987.
A Parent’s Guide for Suicidal and Depressed Teens.
Williams, K. 1995. Hazelden Center City, MN 55012.
Preventing Childhood Eating Problems: A Practical,
Positive Approach to Raising Children Free of Food
and Weight Conflicts. Hirschmann, J.R., and
Zaphiropoulos, L. 1993.
Raising Depression-Free Children: A Parent’s Guide to
Prevention and Early Intervention. Hockey, K.P. 2003
Hazelden Center City, MN 55012.
Secret Scar: Uncovering and Understanding the
Addiction of Self-Injury. Turner, V.J. 2002. Hazelden
Center City, MN 55012.
Stress Relief: The Ultimate Teen Guide. Powell, M. &
Adams, K. 2003.
Surgeon General’s report, “Children and Mental Health,
www.surgeongeneral.gov/library/mentalhealth/
toc.html#chapter3
Understanding Teenage Depression: A Guide to
Diagnosis, Treatment, and Management. Empfield, M.,
and Bakalar, N. 2001.
The Worried Child: Recognizing Anxiety in Children
and Helping Them Heal. Foxman, P. 2004.
Your Dieting Daughter: Is She Dying for Attention?
Costin, C. 1997.
About relationships and safety
Beyond the Big Talk: Every Parent’s Guide to Raising
Sexually Health Teens from Middle School to High
School and Beyond. Haffner, D. 2001.
The Bully, the Bullied, and the Bystander. Coloroso, B.
2004.
But I Love Him: Protecting Your Teen Daughter from
Controlling, Abusive Dating Relationships. Murray, J.
2001.
Changing Bodies, Changing Lives: Expanded Third
Edition: A Book for Teens on Sex and Relationships.
Bell, R. 1998.
Everything You Never Wanted Your Kids to Know
About Sex But Were Afraid They’d Ask: The Secrets to
Surviving Your Child’s Sexual Development from Birth
to Teens. Richardson, J., M.D., and Shuster, M.A.,
M.D. 2003.
Flight of the Stork: What Children Think (and When
about Sex and Family Building), Bernstein, A.C. 1994.
From Diapers to Dating. Haffner, D., et al. 2004.
Go Ask Alice Book of Answers: A Guide to Good
Physical, Sexual and Emotional Health, Columbia
University Health Education Program. 1998.
How to Talk So Kids Will Listen and Listen So Kids
Will Talk. Faber, A., and Mazlish, E. 1999.
In Love and in Danger: A Teen’s Guide to Breaking
Free of Abusive Relationships. Levy, B. 1998.
Odd Girl Out: The Hidden Culture of Aggression in
Girls. Simmons, R. 2003.
Odd Girl Speaks Out: Girls Write about Bullies,
Cliques, Popularity, and Jealousy. Simmons, R. 2004.
Raising Cain: Protecting the Emotional Life of Boys.
Thompson, M., Ph.D., and Kindlon, D.J., Ph.D. 2000.
Real Boys: Rescuing Our Sons from the Myths of
Boyhood. Pollack, W. 1999.
Real Boys’ Voices. Pollack, W. 2001.
School Girls – Young Women, Self-Esteem and the
Confidence Gap. Orenstein, P. 1995.
Speaking of Boys: Answers to the Most-Asked
Questions about Raising Sons. Thompson, M., Ph.D.,
and Barker, T. 2000.

For updates, corrections and comments or to receive additional copies of Red Flags & Resources; Northwestern Vermont Second Edition , please
contact: Franklin County Caring Communities at (802) 527-5049 or Grand Isle County Clean Team at (802) 309-2515
49
E D I TO R I A L A N D F I N A N C I A L C O N T R I B U TO R S
Franklin County Caring Communities
67 Fairfield Street
St. Albans, VT 05478
www.fcccp.org
Phone: (802) 527-5049
e-mail: info@fcccp.org
Executive Director: Beth Crane
Grand Isle County Clean Team
PO Box 64, 3537 US Route 2
North Hero, VT 05474
www.gicct.org
Phone (802) 309-2515
e-mail: info@gicct.org
Executive Director: Mary Fletcher
Rural Partnerships
2860 Route 105
Berkshire, VT
www.ruralpartnershipsvt.org
phone: (802) 393-5383
e-mail: ruralpartnerships@gmail.com
Director: Ethan Dezotell
Vermont Department of Health
Division of Alcohol and Drug Abuse Programs
20 Houghton Street, Room 273
St. Albans, Vermont 05478
Phone: (802)524-7918
e-mail: mary.pickener@ahs.state.vt.us
Mary Pickener, MPA
Substance Abuse Prevention Consultant
Thanks go to the following organizations and
individuals in Massachusetts for their original work in
creating the first local Red Flags and Resources guide
published in 2005 for their communities:
Acton-Boxborough: Community Alliance for Youth
Concord-Carlisle: Alliance for Teen Safety
Groton Dunstable: Alliance for Youth
Westford Against Substance Abuse
Original Authors
Christina Granahan, LICSW Pat MacAlpine, LCSW
Tina Grosowsky Linda Minkoff
Barbara Howland Judy Robinson, Ph.D.
Sally Lewis Sally Wood
Franklin and Grand Isle County
Community Contributors and Reviewers
Angela Baker, MPA
Todd Bauman, MA
Amy Brewer, MPH, CHES
Laura Bellstrom, MD
Beth Crane, MSW
John Halligan
Frederick Holmes, MD
Deb Kalstein-Lamb, MSW/LICSW, CSAP
Kris Lukens-Rose
Carol Stata
Ann Simpson, LSW
Chief Gary Taylor, St Albans Police Dept.
Winfield Thomas, MA, LADC
Nathan Williams
Olivia Weed Laporte, LSW
The following organizations provided funding for
Red Flags and Resources; Northwest Vermont Edition:
A. N. Deringer
BFA Boosters
Boss Excavating
Champlain Islands Parent Child Center
Elks Lodge # 1566
Franklin-Grand Isle United Way
Franklin County Caring Communities
Franklin County Sheriff’s Office
Grand Isle County Clean Team
Grand Isle Supervisory Union
Isle La Motte PTO
King’s Daughters Home
Missisquoi Valley Union Boosters
Mullen Insurance
N.O.T.C.H.
Northwestern Counseling & Support Services
Northwestern Medical Center
Northwest Access TV
Peoples Trust Company
Special thanks to the members of the 2008 Franklin-
Grand Isle L.E.A.D. Program project team for the
project management of this publication:
Sally Bortz Laura Lussier
Dee Boudreau Samantha Stygles
Lori Jordan Jeff Young
Elizabeth Lee-Newman
L.E.A.D. is a unique program designed to give
potential community leaders the training and
confidence to become leaders in northwest Vermont.
Franklin-Grand Isle L.E.A.D. Program
Phone: (802) 524-2444

© 2010

Page 74 of 96

Page 76 of 96

Advocacy Foundation Publishers
Page 77 of 96

Advocacy Foundation Publishers
The e-Advocate Quarterly
Page 78 of 96

Issue Title Quarterly
Vol. I 2015 The Fundamentals
I
The ComeUnity ReEngineering
Project Initiative
Q-1 2015
II The Adolescent Law Group Q-2 2015
III
Landmark Cases in US
Juvenile Justice (PA)
Q-3 2015
IV The First Amendment Project Q-4 2015
Vol. II 2016 Strategic Development
V The Fourth Amendment Project Q-1 2016
VI
Landmark Cases in US
Juvenile Justice (NJ)
Q-2 2016
VII Youth Court Q-3 2016
VIII
The Economic Consequences of Legal
Decision-Making
Q-4 2016
Vol. III 2017 Sustainability
IX The Sixth Amendment Project Q-1 2017
X
The Theological Foundations of
US Law & Government
Q-2 2017
XI The Eighth Amendment Project Q-3 2017
XII
The EB-5 Investor
Immigration Project*
Q-4 2017
Vol. IV 2018 Collaboration
XIII Strategic Planning Q-1 2018
XIV
The Juvenile Justice
Legislative Reform Initiative
Q-2 2018
XV The Advocacy Foundation Coalition Q-3 2018
Page 79 of 96

XVI
for Drug-Free Communities
Landmark Cases in US
Juvenile Justice (GA)
Q-4 2018
Page 80 of 96

Issue Title Quarterly
Vol. V 2019 Organizational Development
XVII The Board of Directors Q-1 2019
XVIII The Inner Circle Q-2 2019
XIX Staff & Management Q-3 2019
XX Succession Planning Q-4 2019
XXI The Budget* Bonus #1
XXII Data-Driven Resource Allocation* Bonus #2
Vol. VI 2020 Missions
XXIII Critical Thinking Q-1 2020
XXIV
The Advocacy Foundation
Endowments Initiative Project
Q-2 2020
XXV International Labor Relations Q-3 2020
XXVI Immigration Q-4 2020
Vol. VII 2021 Community Engagement
XXVII
The 21 st Century Charter Schools
Initiative
Q-1 2021
XXVIII The All-Sports Ministry @ ... Q-2 2021
XXIX Lobbying for Nonprofits Q-3 2021
XXX
XXXI
Advocacy Foundation Missions -
Domestic
Advocacy Foundation Missions -
International
Q-4 2021
Bonus
Page 81 of 96

Vol. VIII
2022 ComeUnity ReEngineering
XXXII
The Creative & Fine Arts Ministry
@ The Foundation
Q-1 2022
XXXIII The Advisory Council & Committees Q-2 2022
XXXIV
The Theological Origins
of Contemporary Judicial Process
Q-3 2022
XXXV The Second Chance Ministry @ ... Q-4 2022
Vol. IX 2023 Legal Reformation
XXXVI The Fifth Amendment Project Q-1 2023
XXXVII The Judicial Re-Engineering Initiative Q-2 2023
XXXVIII
The Inner-Cities Strategic
Revitalization Initiative
Q-3 2023
XXXVIX Habeas Corpus Q-4 2023
Vol. X 2024 ComeUnity Development
XXXVX
The Inner-City Strategic
Revitalization Plan
Q-1 2024
XXXVXI The Mentoring Initiative Q-2 2024
XXXVXII The Violence Prevention Framework Q-3 2024
XXXVXIII The Fatherhood Initiative Q-4 2024
Vol. XI 2025 Public Interest
XXXVXIV Public Interest Law Q-1 2025
L (50) Spiritual Resource Development Q-2 2025
Page 82 of 96

LI
Nonprofit Confidentiality
In The Age of Big Data
Q-3 2025
LII Interpreting The Facts Q-4 2025
Vol. XII 2026 Poverty In America
LIII
American Poverty
In The New Millennium
Q-1 2026
LIV Outcome-Based Thinking Q-2 2026
LV Transformational Social Leadership Q-3 2026
LVI The Cycle of Poverty Q-4 2026
Vol. XIII 2027 Raising Awareness
LVII ReEngineering Juvenile Justice Q-1 2027
LVIII Corporations Q-2 2027
LVIX The Prison Industrial Complex Q-3 2027
LX Restoration of Rights Q-4 2027
Vol. XIV 2028 Culturally Relevant Programming
LXI Community Culture Q-1 2028
LXII Corporate Culture Q-2 2028
LXIII Strategic Cultural Planning Q-3 2028
LXIV
The Cross-Sector/ Coordinated
Service Approach to Delinquency
Prevention
Q-4 2028
Page 83 of 96

Vol. XV 2029 Inner-Cities Revitalization
LXIV
LXV
LXVI
Part I – Strategic Housing
Revitalization
(The Twenty Percent Profit Margin)
Part II – Jobs Training, Educational
Redevelopment
and Economic Empowerment
Part III - Financial Literacy
and Sustainability
Q-1 2029
Q-2 2029
Q-3 2029
LXVII Part IV – Solutions for Homelessness Q-4 2029
LXVIII
The Strategic Home Mortgage
Initiative
Bonus
Vol. XVI 2030 Sustainability
LXVIII Social Program Sustainability Q-1 2030
LXIX
The Advocacy Foundation
Endowments Initiative
Q-2 2030
LXX Capital Gains Q-3 2030
LXXI Sustainability Investments Q-4 2030
Vol. XVII 2031 The Justice Series
LXXII Distributive Justice Q-1 2031
LXXIII Retributive Justice Q-2 2031
LXXIV Procedural Justice Q-3 2031
LXXV (75) Restorative Justice Q-4 2031
LXXVI Unjust Legal Reasoning Bonus
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Vol. XVIII 2032 Public Policy
LXXVII Public Interest Law Q-1 2032
LXXVIII Reforming Public Policy Q-2 2032
LXXVIX ... Q-3 2032
LXXVX ... Q-4 2032
Page 85 of 96

The e-Advocate Journal
of Theological Jurisprudence
Vol. I - 2017
The Theological Origins of Contemporary Judicial Process
Scriptural Application to The Model Criminal Code
Scriptural Application for Tort Reform
Scriptural Application to Juvenile Justice Reformation
Vol. II - 2018
Scriptural Application for The Canons of Ethics
Scriptural Application to Contracts Reform
& The Uniform Commercial Code
Scriptural Application to The Law of Property
Scriptural Application to The Law of Evidence
Page 86 of 96

Legal Missions International
Page 87 of 96

Issue Title Quarterly
Vol. I 2015
I
II
God’s Will and The 21 st Century
Democratic Process
The Community
Engagement Strategy
Q-1 2015
Q-2 2015
III Foreign Policy Q-3 2015
IV
Public Interest Law
in The New Millennium
Q-4 2015
Vol. II 2016
V Ethiopia Q-1 2016
VI Zimbabwe Q-2 2016
VII Jamaica Q-3 2016
VIII Brazil Q-4 2016
Vol. III 2017
IX India Q-1 2017
X Suriname Q-2 2017
XI The Caribbean Q-3 2017
XII United States/ Estados Unidos Q-4 2017
Vol. IV 2018
XIII Cuba Q-1 2018
XIV Guinea Q-2 2018
XV Indonesia Q-3 2018
XVI Sri Lanka Q-4 2018
Vol. V 2019
Page 88 of 96

XVII Russia Q-1 2019
XVIII Australia Q-2 2019
XIV South Korea Q-3 2019
XV Puerto Rico Q-4 2019
Issue Title Quarterly
Vol. VI 2020
XVI Trinidad & Tobago Q-1 2020
XVII Egypt Q-2 2020
XVIII Sierra Leone Q-3 2020
XIX South Africa Q-4 2020
XX Israel Bonus
Vol. VII 2021
XXI Haiti Q-1 2021
XXII Peru Q-2 2021
XXIII Costa Rica Q-3 2021
XXIV China Q-4 2021
XXV Japan Bonus
Vol VIII 2022
XXVI Chile Q-1 2022
Page 89 of 96

The e-Advocate Juvenile Justice Report
______
Vol. I – Juvenile Delinquency in The US
Vol. II. – The Prison Industrial Complex
Vol. III – Restorative/ Transformative Justice
Vol. IV – The Sixth Amendment Right to The Effective Assistance of Counsel
Vol. V – The Theological Foundations of Juvenile Justice
Vol. VI – Collaborating to Eradicate Juvenile Delinquency
Page 90 of 96

The e-Advocate Newsletter
Genesis of The Problem
Family Structure
Societal Influences
Evidence-Based Programming
Strengthening Assets v. Eliminating Deficits
2012 - Juvenile Delinquency in The US
Introduction/Ideology/Key Values
Philosophy/Application & Practice
Expungement & Pardons
Pardons & Clemency
Examples/Best Practices
2013 - Restorative Justice in The US
2014 - The Prison Industrial Complex
25% of the World's Inmates Are In the US
The Economics of Prison Enterprise
The Federal Bureau of Prisons
The After-Effects of Incarceration/Individual/Societal
The Fourth Amendment Project
The Sixth Amendment Project
The Eighth Amendment Project
The Adolescent Law Group
2015 - US Constitutional Issues In The New Millennium
Page 91 of 96

2018 - The Theological Law Firm Academy
The Theological Foundations of US Law & Government
The Economic Consequences of Legal Decision-Making
The Juvenile Justice Legislative Reform Initiative
The EB-5 International Investors Initiative
2017 - Organizational Development
The Board of Directors
The Inner Circle
Staff & Management
Succession Planning
Bonus #1 The Budget
Bonus #2 Data-Driven Resource Allocation
2018 - Sustainability
The Data-Driven Resource Allocation Process
The Quality Assurance Initiative
The Advocacy Foundation Endowments Initiative
The Community Engagement Strategy
2019 - Collaboration
Critical Thinking for Transformative Justice
International Labor Relations
Immigration
God's Will & The 21st Century Democratic Process
The Community Engagement Strategy
The 21st Century Charter Schools Initiative
2020 - Community Engagement
Page 92 of 96

Extras
The Nonprofit Advisors Group Newsletters
The 501(c)(3) Acquisition Process
The Board of Directors
The Gladiator Mentality
Strategic Planning
Fundraising
501(c)(3) Reinstatements
The Collaborative US/ International Newsletters
How You Think Is Everything
The Reciprocal Nature of Business Relationships
Accelerate Your Professional Development
The Competitive Nature of Grant Writing
Assessing The Risks
Page 93 of 96

About The Author
John C (Jack) Johnson III
Founder & CEO
Jack was educated at Temple University, in Philadelphia, Pennsylvania and Rutgers
Law School, in Camden, New Jersey. In 1999, he moved to Atlanta, Georgia to pursue
greater opportunities to provide Advocacy and Preventive Programmatic services for atrisk/
at-promise young persons, their families, and Justice Professionals embedded in the
Juvenile Justice process in order to help facilitate its transcendence into the 21 st Century.
There, along with a small group of community and faith-based professionals, “The Advocacy Foundation, Inc." was conceived
and developed over roughly a thirteen year period, originally chartered as a Juvenile Delinquency Prevention and Educational
Support Services organization consisting of Mentoring, Tutoring, Counseling, Character Development, Community Change
Management, Practitioner Re-Education & Training, and a host of related components.
The Foundation’s Overarching Mission is “To help Individuals, Organizations, & Communities Achieve Their Full Potential”, by
implementing a wide array of evidence-based proactive multi-disciplinary "Restorative & Transformative Justice" programs &
projects currently throughout the northeast, southeast, and western international-waters regions, providing prevention and support
services to at-risk/ at-promise youth, to young adults, to their families, and to Social Service, Justice and Mental
Health professionals” everywhere. The Foundation has since relocated its headquarters to Philadelphia, Pennsylvania, and been
expanded to include a three-tier mission.
In addition to his work with the Foundation, Jack also served as an Adjunct Professor of Law & Business at Nat ional-Louis
University of Atlanta (where he taught Political Science, Business & Legal Ethics, Labor & Employment Relations, and Critical
Thinking courses to undergraduate and graduate level students). Jack has also served as Board President for a host of wellestablished
and up & coming nonprofit organizations throughout the region, including “Visions Unlimited Community
Development Systems, Inc.”, a multi-million dollar, award-winning, Violence Prevention and Gang Intervention Social Service
organization in Atlanta, as well as Vice-Chair of the Georgia/ Metropolitan Atlanta Violence Prevention Partnership, a state-wide
300 organizational member, violence prevention group led by the Morehouse School of Medicine, Emory University and The
Original, Atlanta-Based, Martin Luther King Center.
Attorney Johnson’s prior accomplishments include a wide-array of Professional Legal practice areas, including Private Firm,
Corporate and Government postings, just about all of which yielded significant professional awards & accolades, the history and
chronology of which are available for review online. Throughout his career, Jack has served a wide variety of for-profit
corporations, law firms, and nonprofit organizations as Board Chairman, Secretary, Associate, and General Counsel since 1990.
www.TheAdvocacyFoundation.org
Clayton County Youth Services Partnership, Inc. – Chair; Georgia Violence Prevention Partnership, Inc – Vice Chair; Fayette
County NAACP - Legal Redress Committee Chairman; Clayton County Fatherhood Initiative Partnership – Principal
Investigator; Morehouse School of Medicine School of Community Health Feasibility Study - Steering Committee; Atlanta
Violence Prevention Capacity Building Project – Project Partner; Clayton County Minister’s Conference, President 2006-2007;
Liberty In Life Ministries, Inc. – Board Secretary; Young Adults Talk, Inc. – Board of Directors; ROYAL, Inc - Board of
Directors; Temple University Alumni Association; Rutgers Law School Alumni Association; Sertoma International; Our
Common Welfare Board of Directors – President)2003-2005; River’s Edge Elementary School PTA (Co-President); Summerhill
Community Ministries; Outstanding Young Men of America; Employee of the Year; Academic All-American - Basketball;
Church Trustee.
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www.TheAdvocacyFoundation.org
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