Anticipatory Guidance

Substance Abuse Prevention and Management




Alcohol, tobacco, and marijuana are the most commonly abused substances by adolescents according to the Youth Risk Behavior Surveillance System (YRBSS) from the CDC and the Monitoring the Future Survery (MTF) from the University of Michigan

  • 25% of high school and college students reported lifetime cigarette use (at least one cigarette per day for 30 days) (YRBSS)
  • 80% of students have consumed alcohol by the end of high school, 52% by the end of 8th grade (MTF)
  • 47% of students reported using marijuana in their lifetime, 11.3% before age 13 (YRBSS)

Risk factors for substance abuse:

  • Behavioral disorders
  • Psychiatric illness
  • Genetic predisposition
  • Chaotic family or community environment
  • Substance use by family members


  • The American Academy of Pediatrics has strongly advocated the need for health care professionals to participate in the promotion substance abuse prevention among children and adolescents.
  • Start early
    • At early school age visits, pediatricians should discuss with parents the importance of parental modeling and the role of exposure to substances in the media, and encourage parents to initiate conversations about substances early
  • Promote open communication about substances between child, parents, and physician
    • Help parents promote factors associated with decreased drug use such as open communication with parents, involvement with extracurricular activities, family involvement in religious/social groups, academic success, and self-esteem
    • Starting in late childhood/early adolescent visits, pediatricians should have direct and confidential conversations with children about substances, and the negative effects and consequences of their use 
    • AAP: A Parent's Guide to Teen Parties - Click here
  • Referral to community prevention programs
    • DARE
    • Life Skills Training
    • Project ALERT
    • Project STARR

Screening for Substance Use

  • Past medical and psychiatric history, family history of substance use
  • HEADSSS(Home, Education, Activities, Drugs, Safety, Sexuality, Suicide)
  • Guidelines for Adolescent Preventative Services (GAPS) questionnaire

Evaluation of Substance Use

  • Identify substances, frequency of use, and duration of use
  • Identify substance related dysfunction: poor school performance, personality/mood changes, depression, isolation from family and friends, changes in sleep or eating habits, engagement in other risky behaviors
  • Drug screening outside of emergent situations has limited use due to issues of consent and confidentiality

Management of Substance Abuse

Stages of Adolescent Substance Abuse*

Stage 1: Potential for abuse

  • No personal experimentation with substances but high risk for future risk due to availability of substances, and behavioral characteristics such as decreased impulse control

Stage 2: Experimentation: learning the euphoria

  • Use of inhalants, alcohol, tobacco, or marijuana with few consequences and little to no behavior changes

Stage 3: Regular use: seeking the euphoria

  • Increased frequency of use, solitary use, behavioral changes, and some consequences from substances use.  Use of other substances such as stimulants, LSD, sedatives

Stage 4: Regular use: preoccupation with the “high”

  • Daily use of substances with loss of control, multiple consequences and risk-taking behaviors, isolation from family and sober friends

Stage 5: Burnout: use of drugs to feel normal

  • Use of multiple substances with physical and mental deterioration, guilt, depression, self-destructive behavior,

*Adapted from Comerci

  • Early stages of substance abuse (stage 1 and 2) can be managed in the outpatient setting through parent and patient education and counseling
  • When adverse consequences are associated with substance use (injury, decline in school performance, legal problems), physician counseling should be augmented with by interventions such as self-help groups, patient and family therapy
  • If an adolescent meets criteria for Stage 3-5 substance abuse or the DSM IV criteria for substance abuse or substance dependence, adolescents should be referred to a treatment program (intensive outpatient or inpatient treatment)


Comerci, GD. Recognizing the 5 stages of substance abuse. Contemp Pediatr. 1985;2:57-68

Barangan CJ, Alderman EM. Management of Substance Abuse. Pediatrics in Review. 2002;23(2):123-131