Substance use disorders (SUD) are defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as recurrent use of alcohol and/or drugs causing significant clinical and functional impairment (SAMHSA, 2015). In 2017, the National Survey on Drug Use and Health found that 1 in 12 American adults (18.7 million) had a substance use disorder (McCance-Katz, 2017). The NSDUH reported that an estimated 16.6% adolescents in the U.S. ages 12-17 drank alcohol or experimented with illicit drugs for the first time and indicated that approximately 7% (1.7 million) of adolescents met the criteria for an alcohol or illicit drug disorder (McCance-Katz, 2017). According to the University of Michigan’s Institute for Social Research Monitoring the Future Study, 5.8% of 8th graders, 9.4% 10th graders and 13.3% 12th graders reported use of illicit drugs over the past-year (Monitoring the Future Study, 2017). While these statistics are on the decline, teenage SUD remains a serious public health problem that must continue to be addressed through well-designed and strategically executed interventions.
The signs and symptoms of SUD can take on many forms depending on which type of substance is abused. After alcohol and tobacco, adolescents are most likely to abuse marijuana, amphetamines and prescription pain killers (Monitoring the Future Study, 2017). One of the earliest signs to predict teenage drug use is changes in behaviors and mannerisms. Adolescents may have a sudden change in their friend group or begin to withdrawal from usual family bonding (Ali, 2011). While under the influence the adolescent may have limited communication, may skip school, or exhibit lack of self-control or aggressive behaviors (Mericle, 2015). SUD frequently co-occur with mental disorders with nearly 8.5 million people having both an SUD and a mental illness as reported in the 2017 SAMHSA survey (McCance-Katz, 2017). High levels of substance use among teenagers have been associated with motor vehicle accidents, homicides, suicidality, risky sexual behavior, high rates of school dropout and the development of major depressive disorders, anxiety disorders, conduct disorders and ADHD (Mericle, 2015).
Addiction is a developmental disorder where the age of introduction plays a vital role in the development of addictive behavior. Jay Giedd was a leading scientist in the discovery that the brain continues to develop throughout adolescence and that the brain grows an excessive number of connections during this time (Winters, 2011). At age 12, the brain begins pruning these connections to improve efficiency in information processing (Winters, 2011). It has been found that 7.2% of individuals who began drinking around the age of 11-13, were found to have an alcohol disorder within two years, compared to only 3.7% of individuals who waited until 21 years old to get drunk for the first time (Winters, 2011). The fact that these statistics coincide with the changes in the brain, provides evidence that early onset rather than duration is a strong predictor of SUD and the vulnerability of the brain during this period plays an important role (Winters, 2011). The development of the pre-frontal cortex during adolescence suggests that the influences children experience in their early years through family, friends and educational systems, have profound effects on inhibitory control, cognitive flexibility and mental health.
There are many contextual and compositional factors that play significant roles in mediating and moderating the risks of developing SUD among teenagers. Two important compositional moderating factors that must be considered when addressing interventions for SUD among teenagers are gender and race while geography, as a contextual moderating factor, should also be addressed. Understanding the differences in drug misuse among gender, racial, and geographic groups, is vital to determining who is at risk, how to make early treatment by clinicians accessible and where to target educational intervention programs. For example, boys and girls tend to misuse some types of prescription drugs for different reasons, with boys being more likely to misuse prescription stimulants to get high, while girls tend to misuse them to stay alert or to lose weight (Prescription Drug Overdose in Teens and Young Adults). Boys also tend to initiate drug use before girls and use slightly greater quantities. Given the gender divide among types of drugs used, reasons for use and age of introduction, interventions to prevent and protect against drug use should be targeted differently towards boys and girls. Illicit drug use among adolescents also varies among different races and ethnicities with 9.5% of use among African Americans, 8.2% of use among Caucasians and 6.6% of use among Hispanics (Ulbrich, 2010). While the explanation to this racial differentiation remains unclear, studies have suggested that family factors, religion and school may contribute to these trends (Shih, 2010). Acknowledging these factors, can aid in creating public health interventions specifically targeting these influences, in an effort to reduce SUD among young minorities (Ulbrich, 2010). In terms of geographic location, 34% of rural adolescents reported lifetime nonmedical use of prescription medications which is much higher than the national rate and is likely a results of the built environment (Ulbrick, 2010). Neighborhoods in rural areas tend to be more isolating with lower levels of social connectiveness, than mixed-use neighborhoods, further supporting the evidence that geographic location can play a moderating role in the risk of early onset exposure to substances and in turn an increased risk of developing SUD (Szapocznik, 2006). Gender, race and geography can all act as interacting factors between adolescents and SUD.
Two important mediating factors that must be considered when developing effective interventions for adolescents are socioeconomic status (SES) and social support or educational connectiveness. There are many reasons why teenagers living in lower SES families may be at increased risk for SUD including early life exposure, living in unsafe neighborhood environments, decreased parental supervision, poor education systems, and early life trauma. It has been shown that children who use drugs are more likely to skip school and through a social causation model, this disconnect between the education system could lead to more drug use and eventually the development of a SUD (Ali, 2011). In families with lower incomes, often both parents must work multiple jobs, resulting in a lack of child supervision after school. This offers teens more freedom to experiment with drugs and alcohol. The natural experiment written about by Costello, further explains the mediating response that increased parental supervision can have on decreasing behavioral symptoms for children (Costello, 2005). Further, the impact of family structure (i.e., intact versus broken families), have shown that adolescent drug use is more common among children growing up in disrupted families (Swadi, 1999). Peer influence and social support is another mediating factor that cannot be overlooked when creating interventions to protect against substance use among adolescents (Swadi, 1999). Social support, can act as a positive and negative mediator. It has been shown that peer drug use has been universally identified as the single, most likely factor to predict current drug use (Swadi, 1999). Social setting can also increase the risk of initiation and continued use of illicit drugs. On the other hand, increasing social support through team sports and extracurricular activities has been shown as a protective effect against the use of illicit drugs. One study found that students who spent no time in school-sponsored activities were 49% more likely than those who did participate in activities to have used drugs, 35% more likely to have smoked cigarettes and 27% more likely to have been arrested (Barnes, 2007). Socioeconomic status and social support through peer influence and educational systems all play important roles in preventing adolescent substance abuse and can act as clarifying mechanisms in the link between adolescents and SUD.
The Squash and Education Alliance (SEA) is one of many programs created with the intention to intervene on some of the mediating and moderating factors of substance use and abuse among teens. This program was founded in 2005 and has become the governing body of all urban squash programs throughout the United States (Squash and Education Alliance). SEA leads inter-city youth programs that combine squash, academics, mentoring, travel, college support and career readiness. The program offers an intensive, year-round youth development model in which students attend practices and tutoring sessions 3-4 times a week, after school, during the school year and most of the summer (Squash and Education Alliance). The participants also volunteer in communities, travel to colleges and visit various cities. In 1995 the first urban squash program emerged in Boston and similar organizations have been popping up across other U.S. cities. There are now 23 cities and more than 2,5000 children enrolled in these programs (Squash and Education Alliance). The academic tutoring provides additional support for kids who may be struggling with school in the traditional academic setting. The additional layer of supervision for children who may not have anyone around at home offers a level of structure and mentorship that is protective against the use of substances. The academic portion of this program helps kids maintain a strong connection with their school through increases in academic success. This sense of accomplishment keeps teens invested in their education long-term and reduces their likelihood of skipping school and participating in risky behaviors. The program also helps children receive scholarships to private schools where they may have even further increased supervision throughout the day and less access to drugs and alcohol. Another benefit of this program is the college support the students receive through tutoring for standardized tests, attending college tours and supporting students financially. It has been shown that having a sense of future goals can improve mental health outcomes for adolescents. The kids also have an opportunity release stress and anxiety through sports. They learn to play a team sport which provides a safe and secure social support system that they may not have had in their traditional after school activities. Playing on a team provides a level of perceived support that many of these teens have never experienced. The urban squash programs offers many different pathways including educational assistance, athletics and access to social workers that work together to discourage the use of substances and decrease SUD among adolescents.
The urban squash program model is relatively new and thus the scientific statistical evidence supporting the programs benefits on improving the mental health status and reducing substance abuse among inter-city adolescence is lacking. While the programs have been successful in getting children scholarships to colleges and removing them from otherwise unsafe after school environments, an official qualitative study should be conducted to establish the effectiveness of these program on improving mental health outcomes. Delivering a survey to be deployed throughout the students involvement in the program or creating focus groups with the participants would provide useful qualitative evidence to show that these programs are successful in preventing substance use and subsequent SUD among adolescents. Another evaluation approach would be to track data over time on drug abuse among students in school, school suspensions, drug abuse arrests, and drug-related emergency room admissions and use data from community drug abuse assessments to serve as a baseline for measuring the effectiveness of this program. Because drug abuse problems change with time, periodic assessments would ensure that the program is meeting current needs of the students.
Despite substance use among teens being on the decline, it is essential to encourage policy makers and other organizations to continue to support the expansion of programs like SEA. Successful interventions targeting the mediating and moderating factors of SUD among teens can make a huge impact on the quality of life and future mental health outcomes of this vulnerable population.