A Transgenerational Perspective on Prevention and Treatment of Adolescent Substance Use Disorders

As professionals trained in the treatment of children with mental health challenges, our mindset is naturally one of prevention and early intervention. In regard to substance use disorders (SUDs), this powerful preventative way of thinking can be strengthened and shared with our colleagues treating individuals of any age. For maximal benefit, our efforts at early intervention and prevention of SUDs can expand from a focus on one individual's life cycle to a broader, multigenerational vision of an entire family's life cycle.

During my training I frequently found myself wondering, “What's the perfect age for prevention?” At what age might guidance and education have the greatest impact? Age 15? Age 13? Age 10 or even 8? Eventually, as we follow that emphasis toward earlier and earlier opportunities, we end up back at the prior generation's adults. There is no wrong age or stage in the individual or family life cycle to think about prevention. Certainly there do appear to be known “hot spots” in the life cycle that may be particularly impactful regarding a risk of SUDs, including in utero and the perinatal period, early adolescence, transitional/college age, and old age. However, because we know of perpetuation of SUDs across generations, we and our adult-focused colleagues can think about prevention, no matter who we're meeting with. With a family-conscious transgenerational mindset, treatment in adult clinics can be as preventative as treatment in child and adolescent clinics.

Through the impact of genes, epigenetics, and shared environment, perpetuation of SUDs within families is ubiquitous. Heritability of SUDs is ∼50%, mirroring the heritability of other common illnesses such as type II diabetes or asthma (Bevilaqua and Goldman 2009). Animal models have shown epigenetic changes conveying heightened risks of substance use in offspring even when substance exposure occurred preconception (Vassoler et al. 2014). Numerous studies have demonstrated the detrimental impacts of in utero exposure, including but not limited to a heightened risk of development of a use disorder for the same substance to which the fetus was exposed (Alati et al. 2006). Regarding an individual's own use, abundant neuroscientific evidence confirms that both the age of first intake of substances and the age of first regular use of substances are inversely correlated with the risk of development of a use disorder. Furthermore, this inverse correlation is nonlinear with an exceptionally higher risk for very early exposure. Regarding environmental factors, in the landmark study of adverse childhood events (ACEs), the two most common ACEs were physical abuse and exposure to substance use in the household. Childhood exposure to these events portends an increased risk of later-life SUD, which then increases the risk of ACEs for the third generation, creating a recurring, too often catastrophic cycle (Dube et al. 2003).

The terms family and parent used herein refer broadly to those individuals who contribute genes, hold primary caregiving roles, share environment, and/or have the child's best interest most deeply in their hearts. It is the input and own lived experience of these individuals that will best inform us as we care for their loved ones.

We habitually gather a family history to understand how family members confer risk, but less commonly seek to understand how those family members and their experiences might impact effective treatment and prevention. Embarrassment and secrecy have long contributed to our treating individuals with SUDs in isolation. The pattern of removing an individual from the community and family unit and sending them to some remote, even if beautiful, residential treatment program to fix the problem without further attention to and guidance from family members is at best a missed opportunity and at worst a reinforcement of stigma and shame associated with SUDs.

In light of this family life cycle consideration and our primary role in treating children, appreciating and understanding the role of parents in both prevention and treatment of adolescent SUDs will improve clinical efficacy.

Society jokes colloquially that as adolescents increasingly rely on their peers they cease to care about their parents' opinion. This black-and-white thinking is harmful. Unfortunately, in some surveys, up to a quarter of parents don't think they will have any impact on whether their teen uses substances. Subsequently, many parents never speak up in disapproval of substance use and experimentation. Well-validated, positive parenting strategies, including effective communication, encouragement of prosocial behaviors, conflict resolution, limit setting, and appropriate supervision, have been disseminated by the National Institute on Drug Abuse. These may seem intuitive but require practice and modeling (Dishion et al. 2003). Parents can be encouraged to know that effective, authoritative parenting will protect not only their own child from high-risk behaviors but, their child's peers as well by spreading thorugh the social network (Shakya et al. 2012). Parents discouraged by or accepting of the idea that “all teens try drugs” can be shown that illicit substance use occurs in a small minority of adolescents and that nationwide trends show two decades of steadily declining alcohol and tobacco use among 8th-, 10th-, and 12th-graders. Parents can be taught that harm reduction is used in the setting of an already developed severe use disorder and isn't a strategy for permitting “safe” experimentation.

A revered mentor taught me that one of the greatest things we can offer to a family in distress is to help make difficult things “talk-about-able” (Rauch and Muriel 2006). Family members from older generations who have struggled with substance use may feel ashamed or embarrassed as they consider sharing their own experiences with younger generations. For parental substance use, actions do speak louder than words (Ebersole et al. 2014), but words speak louder than no words (Mrug and McKay 2013). While honoring autonomy and privacy, as child psychiatrists we can guide parents toward age-appropriate language and conversation strategies. Families may take hope in understanding that knowledge of family history, including awareness of illness and hardship, is correlated with higher youth self-esteem and internal locus of control (Duke et al. 2008). In fact, a family narrative inclusive of trial, struggle, and overcoming is often more meaningful and impactful in this regard than an illusionary narrative of only success and accomplishment (Feiler 2013).

Parents are integral to not only the prevention but also the treatment of adolescent SUDs. As research about pharmacologic treatments for adolescent SUDs grows, psychosocial treatments remain the mainstay. Parents can be powerfully involved in these treatments. In fact, family-based treatments make up the bulk of the most strongly empirically based psychosocial treatments for adolescent SUDs (Waldron and Turner 2008). Parents may take courage to know that even if an adamant teen never sets foot in a treatment setting, there are unilateral parent- and family-focused treatments, such as Community Reinforcement and Family Training, that can decrease the severity of adolescent SUDs (Kirby et al. 2015) and alleviate the emotional toll these often take on the family system (Bisetto Pons et al. 2016).

In light of this emphasis on expanding toward a multigenerational focus on family members joining in prevention and treatment, a couple of empirical points: First, in the case of any form of physical, sexual, or emotional abuse, a child or adolescent should not be expected or encouraged to participate in treatment with the perpetrator of abuse. Involving family members in treatment should be preceded by assuring an environment of safety in which trauma is not perpetuated or exacerbated. Second, as substance use can be emotionally, socially, and even politically charged, we will experience implicit bias and counter-transference related to our own experiences and life circumstances. We may tend to align with parents in their exasperation or exhaustion caused by an “oppositional, reckless or defiant” teen. We may find ourselves aligning with an adolescent in their anger toward “excessively strict” parents, or experience rescue fantasies of being surrogate parents where none are to be found. Mindful awareness of our biases will help us remain grounded in sound therapeutic principles and remain evidence-based, not ideology-based. Consultation with treatment teams will decrease the likelihood of our own biases becoming detrimental. Lastly, without losing confidence in our own capacity for good as providers, we must humbly recognize that our brief sojourn with these individuals, sometimes only an hour per month, pales in comparison to those who have been primary nurturers and who live with them day and night. In our enthusiasm, we may sometimes rush forward with teens, wanting to change their thoughts and motivation, while discounting those who changed their diapers.

Despite dark periods in the history of SUD treatment, including instilling fear rather than self-efficacy, we move toward a happier time. Thanks to advocacy from individuals and families affected by SUDs and providers who treat them, political and social will, legislation, funding, insurance coverage, policy, and public awareness all appear to be moving toward improving care for individuals and families affected by SUDs. With this movement we must stand ready to expand far beyond harm reduction and offer multidisciplinary, multigenerational, family-focused treatment toward both recovery and remission for those suffering from SUDs, and prevention of perpetuation to younger generations. Those trained in the treatment of mental health challenges of both children and adults are strongly positioned to lead this effort.