Adolescent substance abuse: Diagnostic and treatment issues

We are left to return to the discussion Alice had with Humpty Dumpty. 'When I use a word,' Humpty Dumpty said in a rather scornful tone, 'it means just what I choose it to mean - neither more nor less.' 'The question is,' said Alice, 'whether you can make words mean so many different things.' 'The question is,' said Humpty Dumpty, 'which is to be master - that's all.' When exploring the world of adolescent chemical abuse, we are left with a sense that words mean exactly what those who make the diagnosis and effect the therapies want them to mean. There are as many definitions for substance abuse as there are treatment programs. There are as many ways of evaluating the treatment success as there are programs in need of assessment. We are left with but a dim sense of the parameters that discriminate use from abuse, those in need for therapy and those not, and those most likely to benefit from therapy in the short run from those less likely to benefit. Through it all, however, we do have some insights that should prove useful to the clinician. The model for assessment developed by Halikas et al. represents a significant step forward, and it appears that a standardized and normed adolescent assessment tool is on the horizon. There is increasing awareness that drug abuse in adolescence stems not from a unitary etiology of one's inability to 'handle' liquor or drugs but rather from multifactorial etiologies. Additionally, there is a growing awareness that there are many types of drug users, and, as a consequence, drug treatment programs ideally should be tailored to individual problems rather than to defining one's problems from within the philosopy of the drug treatment program. Finally, there is an emerging awareness that for youths with drug-related problems although short-term therapy may be beneficial, long-term impact is far more uncertain. For the primary care clinician, however, as always, in the face of uncertainty we still must act. We must still make diagnosis using imperfect instruments and refer to treatment programs of which we know little. The hope is that perhaps we can improve our diagnostic questioning and investigation of the treatment programs to which we may refer patients.