Amy Yule, MD

The following is a case of an adolescent girl who has been more argumentative recently, despite ongoing therapy for ADHD and anxiety. You, the clinician, wonder if her mother’s recent job loss and history of substance abuse may be contributing factors to her daughter’s behavior, and you decide to meet with your patient’s mother alone.

Questions to consider after reading the case


• You normally meet with your patient alone or with the patient and her mother together. How would you present to your patient and her mother the change in appointment structure to meet with the mother alone?
• What questions would you ask the mother to assist her in disclosing alcohol use or substance use if she is using substances?


Katie, age 13 years, entered treatment 2 years ago for ADHD and general anxiety disorder. She presents for a routine psychopharmacologic appointment. Katie’s mother, Laura, reports that things have been particularly stressful at home recently. She states that she recently lost her job and her daughter has been more confrontational than usual and spends too much time on the computer late at night. The mother has a psychiatric history significant for marijuana dependence and you wonder what else might be going on at home.

Normally you meet with Katie alone and then with Laura and Katie together. Today you wish to speak with the mother privately to discuss her substance abuse and to further assess home stressors.

You discover that Laura is worried about the family’s finances since she lost her job. Katie’s father found extra part-time employment and has been at home less frequently to help with parenting Katie and her younger brother. Laura says she has been considering using cannabis again to “help her relax.” Instead, she tries to unwind by drinking 2 to 3 glasses of wine over the course of the evening.

You continue to screen for problematic alcohol use by asking Laura if she ever has more than 4 drinks at a time. You also ask about other risky behaviors, including driving under the influence, which she denies. Her answers give you reason to believe that Laura has been drinking heavily and that she would benefit from further evaluation.

Katie’s behavior patterns in the evenings raise your concern that stressors at home may be exacerbating her ADHD and anxiety symptoms. Because ADHD is a risk factor for adolescent substance use disorder, close monitoring of ADHD symptoms and monitoring for signs and symptoms of substance use is suggested.

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Open-ended questions can help you elicit Laura’s own concerns about her drinking. By letting her know that her drinking increases her daughter’s risk of a substance use disorder, you may help motivate Laura to change her behavior and seek treatment.

In addition to helping minimize Katie’s exposure to her parent’s substance use, you also educate Laura on the principles of social control theory to help potentially decrease Katie’s risk of developing a substance use disorder. Social control theory suggests that it is essential for parents to be aware of what their child is doing and with whom they are spending time. You also encourage Laura to let Katie know that her parents disapprove of adolescent substance use.  


Laura contacts her primary care physician for a referral to treatment and establishes care with a local substance abuse program. With individual and group therapy, Laura is able to successfully stop drinking and develops alternative coping skills to help her manage increased stress. Laura reports that Katie has been less argumentative. Although Katie continues to want to spend more time on the computer, Laura has been more effective in setting limits around technology use and there has been less conflict at home.

Familial Influences on Adolescent Substance Use

, by Amy Yule, MD and Timothy Wilens, MD.]


1. Wilens TE, Martelon M, Joshi G, et al. Does ADHD  predict substance-use disorders? A 10-year follow-up study of young adults with  ADHD. 

Articles

A parent's heavy drinking can increase a child's risk of substance use disorder.

Decreasing the Risk for Adolescent Substance Use by Intervening With Parents

Substance use disorders (SUDs) are associated with significant morbidity and mortality that affects individuals and their families. Problems with substance use most often emerge during adolescence and young adulthood. Adolescent-onset SUDs are becoming the most significant public health problem affecting adolescents.

 Recent work by Merikangas and colleagues

 showed that 11.4% of adolescents have an SUD, yet only 15.4% of those youths receive treatment. Preventing the onset of an SUD in adolescence remains a critical area of clinical and public health significance.

Familial influence-biological and behavioral

Clinicians and researchers have long observed that SUDs frequently affect multiple members within families over different generations. Researchers have found that approximately 50% of the risk of substance abuse or dependence in adolescence is genetically influenced.

 The transition between stages of use, from regular use to abuse and dependence is also genetically influenced, although the relative genetic contribution compared with environmental influences varies by substance.

 found that a common genetic influence accounts for comorbid substance use during adolescence, specifically problem use of tobacco, alcohol, and cannabis.

Behavioral modeling of substance use through exposure to parental substance use early in life also accounts for part of the familial association in SUDs. The association between exposure to parental SUDs and the development of an SUD in offspring is consistent with social learning theory. A review by Petraitis and colleagues

 further described social learning theory as the hypothesis that children model their behavior on people who are important to them and those they frequently interact with, such as their parents. The researchers also reviewed social control theory, which hypothesizes that children who are closely attached to their parents are less likely to break rules because they want to connect with their parents. Children who are closely monitored by their parents and have clear rules are also more likely to conform to their parent’s rules and are less likely to act out by abusing substances.

There is evidence that supports the principles of social learning theory and social control theory. Researchers have examined components of both theories by assessing the relationship between adolescent substance use and parental attitudes toward substances, parental substance use, the quality of the relationship between parent and child, and parental monitoring. Bahr and colleagues

 found that the family factors that were most strongly associated with an increased prevalence of binge drinking, cigarette use, cannabis use, and illicit drug use were tolerant parental attitudes and sibling substance use. In addition, adolescents who had parents who were tolerant of substance use interacted with higher-risk peers and were more likely to have friends who were substance users.

Exposure to parental substance use increases children’s risk

To understand familial patterns of SUD, family-based research has focused on differentiating between risk mediated primarily by genetics from risk mediated primarily by behavioral modeling through exposure to parental SUD and delineating the risk posed by the combination of both. In a larger longitudinal study of predominantly males with and without ADHD, Biederman and colleagues

 found an association between exposure to parental SUD and SUD in offspring after controlling for both family history and ADHD.

We recently evaluated a predominantly female sample with and without ADHD.

 In this study of 552 individuals of whom 71% were female, a specific association was found between exposure to maternal drug use disorders (primarily cannabis) and drug use disorders in female offspring after controlling for family history and ADHD. In other words, mothers who abused drugs increased the likelihood that their daughters would also abuse drugs. Interestingly, research findings have not shown consistent sex patterns when the risk associated with exposure to parental substance abuse was examined.

 Our finding of a specific risk between mothers and daughters may reflect the greater impact that interpersonal relationships have on an adolescent girl’s risk of using substances relative to the risk in adolescent boys.

It is also important to consider whether the developmental timing of exposure to parental substance use may influence the chances that the child will develop an SUD. For instance, Biederman and colleagues

 assessed offspring risk of developing an SUD connected with exposure to parental SUD during different developmental stages. Predominantly, boys were at significantly greater risk for developing an SUD when they were exposed to parental SUDs during adolescence than when they were exposed during preschool and latency years.

In our predominantly female sample, we also found that exposure to parental SUD during adolescence was specifically associated with an increased risk of developing an SUD.

 It is unclear why adolescents are particularly vulnerable to exposure to parental substance use; it may be that behavioral modeling of use at a time when adolescents have greater ease of access to substances partially accounts for their increased risk.

What is already known about familial influences and adolescent substance use disorders (SUDs)? 
? The development of adolescent-onset SUDs is influenced by both genetic and environmental risk factors. Familial environmental risk factors include behavioral modeling of substance use, parental attitudes toward substance use, and parental monitoring.

What new information does this article provide? 
? Adolescent girls exposed to maternal drug use disorders are at increased risk for developing a drug use disorder. Exposure to parental SUDs specifically during adolescence increases a child’s risk of developing an SUD.

What are the implications for psychiatric practice? 
? Practitioners may be able to prevent adolescent-onset SUDs by screening for parental SUDs and educating families about the risks associated with exposure to parental SUDs.

While genetic risk for SUD is a nonmodifiable risk factor that influences the development of adolescent-onset SUD, exposure to parental SUD is something that can, theoretically, be changed. Psychiatrists may help decrease the risk of adolescent SUD by educating parents about the power of behavioral modeling. Many parents of adolescents, for instance, still smoke marijuana regularly without considering the consequences of such use on their children.

Clinicians should assess parents for substance use in a nonjudgmental manner.

 Brief interventions such as the Substance Abuse and Mental Health Services Administration’s recent screening, brief intervention, and referral to treatment (SBIRT) initiative have been shown to be effective in decreasing both alcohol and drug use.

 Parental screening and subsequent modifications in patterns of substance use may thus decrease the risk of development of SUDs in children.

Kate, a 13-year-old girl with ADHD and general anxiety who you have been treating for 2 years, presents for a routine psychopharmacological appointment with her mother. Kate’s mother reports that things have been more stressful at home. You remember that the patient’s mother has a psychiatric history significant for previous marijuana dependence.

Because Kate’s mother has a history of marijuana dependence, it is important to privately check with her to ask about recent marijuana use as well as other substance use. Discuss with the mother how her marijuana use may increase her daughter’s risk for drug abuse.

George, a 40-year-old father with depression who has a 10-year-old son and a 13-year-old daughter, presents with increasing alcohol use. Lately he has been passing out after drinking in the evening. George does not think that his drinking is a problem.

In this case, it may be useful to carefully query George about his perception of how his drinking is affecting his family. It would also be helpful to educate him about his adolescent daughter’s increased risk of substance use problems given her exposure to his choices and behavior patterns.

In addition to modifying an adolescent’s risk of developing an SUD by minimizing his or her exposure to a parent’s modeling substance use, clinicians can educate parents about the principles of social control theory. The risk of SUD onset is decreased in children whose parents know what their children are doing. Parental control also decreases the risk that the child will have friends who use alcohol or drugs.

SUDs in adolescents interfere with emotional and cognitive development and can be associated with long-term medical and legal consequences. There is a substantial genetic influence on the development of SUDs. The aggregate data also show that other familial factors that can be modified, such as exposure to parental SUDs particularly during adolescence, are significant as well. Conscious efforts to screen for parental SUDs and educate families about exposure risk may help prevent the onset of substance abuse during adolescence.

 The National Center on Addiction and Substance Abuse at Columbia University. Adolescent Substance Use: America’s #1 Public Health Problem. June 2011.

 http://www.casacolumbia.org/templates/NewsRoom.aspx?articleid=631&zoneid=5

 Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). 

 Merikangas KR, He JP, Burstein M, et al. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). 

 Lynskey MT, Agrawal A, Heath AC. Genetically informative research on adolescent substance use: methods, findings, and challenges. 

 Young SE, Rhee SH, Stallings MC, et al. Genetic and environmental vulnerabilities underlying adolescent substance use and problem use: general or specific? 

Petraitis J, Flay BR, Miller TQ. Reviewing theories of adolescent substance use: organizing pieces in the puzzle. 

 Bahr SJ, Hoffmann JP, Yang X. Parental and peer influences on the risk of adolescent drug use. 

 Biederman J, Faraone SV, Monuteaux MC, Feighner JA. Patterns of alcohol and drug use in adolescents can be predicted by parental substance use disorders. 

 Yule AM, Wilens TE, Martelon MK, et al. Impact of exposure to parental substance use disorders (SUD) on SUD risk in girls and their siblings. Poster presented at: 57th Annual American Academy of Child and Adolescent Psychiatry Meeting; October 27, 2010; New York.


 Chassin L, Curran PJ, Hussong AM, Colder CR. The relation of parent alcoholism to adolescent substance use: a longitudinal follow-up study. 

 Yeh MY, Chiang IC, Huang SY. Gender differences in predictors of drinking behavior in adolescents. 

 Eisenberg ME, Neumark-Sztainer D, Fulkerson JA, Story M. Family meals and substance use: is there a long-term protective association? 

 Simmons LA, Havens JR, Whiting JB, et al. Illicit drug use among women with children in the United States: 2002-2003. 

Substance use disorders are associated with significant morbidity and mortality that affects individuals and their families. Preventing the onset of an SUD in adolescence remains a critical area of clinical and public health significance.