Substance Use Disorders Among Adolescents

Case Vignette

William “Billy” Case is a 16-year-old Caucasian male who presents to you with his father to address problems related to high school. Billy is somewhat tall and thin. He is wearing tattered jeans and a T-shirt. His hair is poorly shorn, with streaks of purple. He has multiple earrings and a nose ring. Billy’s father reports that Billy has significant truancy, poor grades, and episodes of oppositional-defiant behavior both at home and at school. The father also reports that Billy is almost pervasively irritable and appears in a constant state of fatigue, complaining about his life and future being pitiful and hopeless.

Initially, Billy says little and does not see what the problem is—he just does not like school. His father relates a long history of behavior problems, including impulsivity and oppositional and aggressive behavior starting in preschool. At one point, sometime in early elementary school, Billy’s pediatrician prescribed methylphenidate (Ritalin). However, soon after, Billy’s parents divorced due to his father’s drinking. Billy lived with his mother in a distant state until recently, when his mother sent Billy to live with his father. The father believes that the mother met with a family therapist several years ago due to problems similar to those presenting today. According to the father, Billy has been “very difficult” since he moved to live with him. The father admits difficulty managing Billy and providing any limits, stating “I cannot keep track of where he is or who he is with.” Attempts to provide structure have been met with hostility and arguing, with Billy ignoring his father or stating that he “forgot” to do what he had promised him.

During your interview with Billy alone, he reluctantly describes that is he frequently irritable with intense but limited periods of depressed mood (less than a day) and frequent angry outbursts, which may include threats of harming himself (or others) or punching holes in household walls. He admits to intermittent periods of hopelessness and suicidal ideation. He states that he could get a gun if he really wanted to. Billy denies sleep disturbance. He states that he has never done well in school, never does homework, and believes he used to be “hyper” in elementary school. He has been fired from several part-time jobs as a result of being chronically late or making “silly” mistakes. He initially admits to “some” marijuana use, having tried a variety of other drugs but rejecting alcohol unless he is really high. Billy is fidgety in his chair and seemingly distractible. His affect is quite labile. Billy’s mood is likewise reported as rapidly changing from angry to irritable to depressed with periods of euthymia as well. His thought processes are linear and goal directed. Cognitive functions are intact and within normal limits. Additional history includes Billy’s eventual admission that he will usually go to school high, skip classes to use drugs, or miss entire school days. On a search of his school locker, a pipe was discovered, resulting in a suspension. The case is being referred to a local magistrate, with a hearing date pending. When Billy is not using drugs, he admits to thinking about getting high “a lot.”

Consideration Point A

At this point in the assessment of the patient’s history, your differential diagnosis includes the following:

Vignette Continues

Billy acknowledges that his friends are also often in trouble with drugs and with the law. You screen him for drug and alcohol use, and Billy reluctantly reports daily use of cannabis. He started using marijuana at age 11 with other middle school friends who were likewise doing poorly in school and were often in trouble. He does not care how he is doing in school, and he plans to drop out next year and get his GED. Most of his time outside of school involves using cannabis or obtaining marijuana. He has lost two jobs because he was late to work as a result of using marijuana. Even at times when he planned to stay sober or to smoke “just a bit” for some occasion, he admits to using much more than he had planned—often through an entire evening and into the early morning hours. One of his former girlfriends thought he used “way too much” and wanted him to quit. He has tried to cut down, unsuccessfully, and even quit several times, but eventually lost his relationship with his girlfriend and felt even more hopeless and worthless. Several times during the interview, Billy emphatically declares that he is not interested in stopping his marijuana use, although the idea of possibly “cutting down” intrigues him.

Consideration Point B

At this point, the following therapeutic strategy is recommended for the patient:

Vignette Continues

Given Billy’s ambivalence, you begin to utilize motivational interviewing in hopes of moving Billy toward a more active interest in initiating treatment and curtailing his marijuana use. When asked if there were any problems that bothered him, Billy again acknowledges periods of dysphoria, hopelessness, and low self-esteem. Although he continues to express little desire to stop marijuana use, he seems to soften when he begins to connect much of the dysphoric mood to his cannabis use and resulting consequences. Using this motivation for entering active treatment, you and Billy develop a change plan that includes the use of cognitive-behavioral therapy for drug abuse. Together, you identify triggers for use. For Billy, these triggers included his dysphoric mood states, association with friends, and general frustration when his daily plans go awry. Billy is thus able to develop strategies for dealing with or even avoiding the triggers. In addition, Billy is able to formulate a list of prosocial activities and peers to replace those that he needed to avoid or give up in order to avoid drug-related triggers that might provoke his return to marijuana use. Although not explicitly part of his change plan, Billy begins to avoid similar triggers for marijuana use, and his use of this substance begins to decline. Billy’s mood shows overall improvement, with the cessation of severe dysphoric episodes. Although he is not entirely abstinent concerning substance use, he begins to attend school. However, his academic progress remains poor because he finds studying or completing homework to be difficult. In addition, he intermittently makes foolish, impulsive decisions. Many of these decisions place him in problem situations such as being suspended in school or rejected by peers.

Consideration Point C

Given all of the details of the case, your next therapeutic step or steps are as follows:

Vignette Concludes

In cooperation with Billy’s father, you prescribe Billy a sustained-release psychostimulant. Billy’s father gives him a daily dose in the morning and keeps track of the prescription. You continue to monitor Billy’s drug use, both soliciting self-reports from him but also using random urine drug screens. With his father, you arrange a program of contingency management, providing set rewards for negative screen results. Billy’s school performance improves, and he finds that he is no longer getting into trouble because of impulsive comments and poor decisions. Billy finds a more prosocial peer group in which there is little drug or alcohol use. He is better able to avoid triggers for marijuana use and demonstrates several months of abstinence. He feels he is better able to proceed with and master other elements of his change plan.

Answers: Scoring, Relative Weights, and Comments

Consideration Point A

Consideration Point B

Consideration Point C

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