Risk Assessment, Prevention, & Intervention Strategies
Substance abuse is a complicated social issue that begins in most people’s adolescent years. Substance abuse often transforms into addiction or what is known as substance abuse disorder. There are a variety of factors including genetic, social, and psychological elements which create risk factors for substance abuse. By analyzing these factors, risk assessment, prevention, and intervention strategies can be formed in order to reduce the likelihood of this social problem.
Understanding Substance Abuse as a Disorder
Substance abuse disorder is a generalized “maladaptive pattern of substance use” in which individuals become impaired or experience distress (DSM-IV, 1994 pp. 181–183). Substance abuse disorder is currently classified in the DSM IV in two areas; substance abuse and substance dependence (DSM-IV, 1994 pp. 181–183). There is currently a large controversy over the separation of substance abuse and substance dependence but for the purpose of clarity this research will focus on substance abuse with a focus on at-risk youth.
Substance abuse is distinguished be a continual patter of use of a medication, drug, or substance which results in adverse consequences for the user. The DSM-IV substance abuse criteria are referenced as:
Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following, occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (such as repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; or neglect of children or household).
2. Recurrent substance use in situations in which it is physically hazardous (such as driving an automobile or operating a machine when impaired by substance use)
3. Recurrent substance-related legal problems (such as arrests for substance related disorderly conduct)
4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (for example, arguments with spouse about consequences of intoxication and physical fights) (DSM-IV, 1994 pp. 181–183).
Understanding substance abuse disorder is difficult because it is nuanced with varying degrees of severity and what is considered abuse or a disorder for one person may not apply to another person by virtue of usage alone. There are also numerous legal and ethical issues surrounding the topic as well controversies surrounding prevention, interventions, and treatment.
Characteristics of at Risk Youth
There are a variety of risk factors for substance abuse disorder and these factors are extremely varied and broad in nature. Age, peer groups, socioeconomic status, and numerous other factors have been associated with the risk of substance abuse. While there are many different factors and controversies surrounding substance abuse, what is known for certain is that that upbringing and adverse conditions in the home have the most significant impact on substance abuse. Specifically, children raised in adverse conditions have the highest chances of becoming substance abusers.
Childhood abuse is a significant risk factor for later alcohol and substance abuse (Schuck and Widom 2001). Women who were physically abused are 1.5- 2 times more likely to abuse alcohol than non-abused adults. Children from crowded, noisy, and disorderly homes without rules or religion are more likely to abuse alcohol as teens (University of Florida, 2017).
The most compelling and large body of research shows parents to be the most important factor in an adolescent’s decision to drink. A recent survey found that parents and siblings influence whether or not teens drink, smoke or use other drugs (CASA, 2002) (University of Florida, 2017).
Children and adolescents who have the highest risk of substance use and addiction are also characterized by age, parental monitoring, peer groups, and poor academic achievement. The earlier a person begins drinking or using drugs the higher the chance of him or her becoming an addict or alcoholic. Many of these overlap such as age and parental monitoring. Children who are supervised are less likely to fraternize with peer groups that drink and use drugs. As well, children who are supervised are also less likely to perform poorly in school and this reduces the risk of substance abuse.
One of the more controversial risk factors with substance abuse is genetics. There is evidence that that there could be a correlation between genetics and substance abuse disorder. Statistically speaking, individuals that have substance abuse in their family history are three to five times more likely to form substance abuse behavior. However, these results are inconclusive and many children of substance abusers do not have substance abuse problems. According to the National Institute of Health (2007), “More than half of the alcoholics in the United States have no multigenerational family history of the disease, suggesting that their form of alcoholism was unlikely to have genetic causes.” There is a lack of empirical evidence to support genetic risk factors. No specific gene or biological abnormality has been identified as being causal to substance abuse. While the corollary evidence is strong, there is no direct genetic link between substance abuse and biology.
Besides social risks, the strongest risk factors for substance abuse reside in psychological factors. Individuals who are at the highest risk tend to exhibit many factors such as being susceptible to stress, having aggressive temperaments, moodiness, negative mindsets, and are often ostracized by peer groups. Along with these risk factors, individuals who suffer from co-occurring disorders have the highest rates and most severe forms of substance abuse. This means that youth at the highest risk will often suffer from depression or other syndromes such as bipolar disorder.
Family Problems Related to At-risk Youth
Family problems are at the center of at-risk youth. There are a variety of family problems such as physical and psychological abuse which can increase risk for youth becoming involved with drugs and alcohol. Most of these problems can be categorized under the heading of functional or dysfunctional family dynamics. Family dynamics is a category of behaviors that psychologists refer to as functional or dysfunctional. When family dynamics are dysfunctional there is a significant increase in risk of youth becoming involved in adolescent substance and alcohol use.
The problems that categorize a family as dysfunctional may include behaviors and practices such as constant conflict, misbehavior, neglect, abuse (physical or sexual), or manipulation by adults (Neuharth, 1999). Some factors such as sexual and physical abuse typically have greater risk value with regard to substance and alcohol abuse. The statistics are staggering in this area:
More than a third of adolescents with a report of abuse or neglect will have a substance use disorder before their 18th birthday, three times as likely as those without a report of abuse or neglect (ChildHelp, 2014).
Children who are raised in abusive environments often become apathetic and resentful in adolescence. In an effort to find acceptance, adolescents will often turn to negative peer pressured activities such as drug and alcohol (Neuharth, 1999). Family functionality is tremendous force in creating problems and risk factors. In evidence of this, one can see that functional families do not exhibit the same issues as dysfunctional families. Children who are exposed to positive parenting, supportive environments, and encouragement are far less likely to become involved in substance and alcohol abuse (Neuharth, 1999). For these reasons, family problems are the most significant factor in measuring risk of youth with substance and alcohol abuse.
School Issues Impacting At-risk Youth
School is an important factor that impacts at-risk youth. School provides the foundation for peer interaction and children learn to associate with other children through the development of friendships. The negative aspect of school is that it also provides a means for at-risk youth to be exposed to negative peer pressures and damaging relations. Peer relationships are a large risk factor for alcohol and substance abuse. According to Berger (2008) and Erdley (2004), there are tremendous risk factors associated with peer relations:
We know that children who are rejected by their peer group are at risk for a variety of negative outcomes that have implications for their psychological adjustment as adults. More recent studies are beginning to uncover similar risks for children who fail to develop close friendships. For instance, children without friends appear to be at increased risk for depression, anxiety, and low self-esteem. However, many questions about just how friendship impacts adjustment remain (Erdley, 2004).
School problems such as bullying and other forms of rejection from peers can be extremely damaging since adolescents are intensely self-aware and conscious of how their peer perceive them (Berger, 2008). School problems not only place children at higher risk but also increase other risk factors associated with substance and alcohol abuse. These peer relations are also intrinsically linked with family dynamics. Children who come from functional families are far less at risk of falling prey to problems at school such as peer rejection and bullying.
The problem of preventing substance abuse in at risk youth is difficult due to the many factors surrounding the issue. The first step in prevention is risk assessment. Risk mitigation techniques require the use of an assessment model that measures the risk factors of the youth with regard to environment, culture, individual etc (Bronfenbrenner, 1994). An assessment model would need to measure the interactions between the child and their environment (McWhirter, McWhirter, McWhirter, & McWhirter, 2013). The following metrics would need to be considered:
· Individual activities: social roles, and interpersonal relationships such as school, work, family, etc… (McWhirter, et al., 2013).
· The connections between home and school.
· External factors such as economic conditions or community (Bronfenbrenner, 1994).
· Cultural factors such as how the person’s culture impacts their view of substance use (Bronfenbrenner, 1994).
This can be used to create an “at-risk tree”. This tree organizes all of the risk associated with substance abuse:
…using the metaphor of a tree as an organizational device. The tree with all its parts — the soil (environment), the roots (family, peer, and school issues), the trunk (high-risk versus low-risk attitudes and behaviors), the branches (specific at-risk categories), and the foliage, fruit, and flowers (individual young people) — together with the gardener (human service professionals) who provides pruning (intervention) and nurturing (prevention) are a conceptual metaphor for understanding the complex interrelationships of risk and protective factors related to the problems that youth face (McWhirter, McWhirter, McWhirter, & McWhirter, 2013).
Using a risk assessment model such as this can clearly identify risk better than simply looking for or watching risk signs. This assessment provides the means to identifying an issue and a degree of severity such that action can be taken in the form of an intervention.
There is a great deal of difficulty when implementing interventions in at risk youth situations. The problem is that there are many factors that are outside the purview of control. For instance, because youth are must vulnerable due to family dynamics, there is little that can be done as a direct intervention unless legal means arise such as court ordered counseling. Typically, when these situations occur it is after long periods of abuse. This problem means that most ways of intervening are limited to programs designed to target at risk youth. Often these programs are provided through community centers or are placed in schools. Such programs include programs such as DARE which involves government and law enforcement.
D.A.R.E. is a police officer-led series of classroom lessons that teaches children from kindergarten through 12th grade how to resist peer pressure and live productive drug and violence-free lives (DARE, 2014).
Programs such as DARE have a strong impact on at-risk youth. As a result of its tremendous impact on at-risk youth, DARE has been implemented in 75% of the US school districts and is now international sponsored in 43 countries (DARE, 2014).
It is best to intervene when issues begin first appearing with drugs and alcohol in teens. The best interventions seem to come from programs such as DARE which use authority figures and from parental guidance. When these interventions fail treatment is the only alternative.
There are three major forms of treatment for substance abuse: psychodynamic, sociocultural, and cognitive/behavioral. These forms of substance abuse treatment may or may not be coupled with pharmaceutical intervention. Often these forms of treatment are combined.
Within the psychodynamic treatment underlying causes of a person’s addictive behavior will be analyzed. This approach has certain logic as there are many people who have used drugs or alcohol and have not become addicted. One could infer that there are individual factors that are causal in this behavior. Some of these factors could involve unfulfilled childhood needs, lack of nurturing in childhood, and child abuse (Comer, 2001).
Cognitive/behavioral therapy works at changing the person’s behavior through developing new coping skills and adopting normal behaviors that do not indulge addictive behavior. For instance, stressful situations that once made a person drink might instead be dealt with through exercise or relaxation techniques (Comer, 2001). This form of therapy requires some effort and willingness on the part of the patient since he or she must track and sometimes record their behaviors. The primary issue with this form of treatment is that children are not always mature enough to take advantage of this therapy (Comer, 2001).
All forms of treatment all have limited success and are often combined with drug therapies. The rates of recovery in treatment are not glowing. For this reason, prevention and intervention strategies should be formulated early for at-risk youth.
Substance abuse disorder is a complicated social issue. The many different risk factor necessitate the use of an assessment model to form accurate identification of the problem early on. Mere research into substance abuse will hopefully yield more definitive concepts but what is known is that treating the issue early or preventing has the best long term outcomes.
American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington D.C.: American Psychiatric Association. (pp. 181–183)
CASA. The National Center on Addiction and Substance Abuse. 2002 National Survey of American Attitudes on Substance Abuse VII: Teens, Parents and Siblings. Retrieved from http://www.casacolumbia.org/publications1456/publications_show.htm?doc_id=119563
Comer, R. (2001). Fundamentals of abnormal psychology. New York, NY: Worth Publishers.
Childhelp (2014) National Child Abuse Statistics Retrieved from http://www.childhelp.org/pages/statistics
DARE (2014) What Parents Can Do Retrieved from http://www.dare.org/keeping-kids-drug-free/
Erdley, C. (2004). Finding a friend: children’s friendships are training ground for adult relationships. Retrieved from http://scienceblog.com/community/older/2000/E/200004605.html
Neuharth, D. (1999). If You Had Controlling Parents: How to Make Peace with Your Past and Take Your Place in the World. DIANE Publishing Company.
SAMSHSA. (2014) Common Risk and Protective Factors for Alcohol and Drug Use Retrieved from http://captus.samhsa.gov/access-resources/common-risk-and-protective-factors-alcohol-and-drug-use
University of Florida. (2017). Risk and protective factors for alcohol abuse and dependence. Retrieved from http://www.psychiatry.ufl.edu/aec/courses/501/risk and protective factors.pdf