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Prevention and early detection of substance abuse is key Drug and alcohol abuse can have a serious and lasting impact on the health and wellbeing of young people. Stephanie Thornton explains what to do if you or a member of school staff suspect drug or alcohol abuse in a student.

A student who has always seemed fairly motivated, fairly balanced starts to have problems concentrating; he or she seems lethargic, perhaps depressed, irritable, aggressive— moody. Schoolwork falls off; perhaps there is absenteeism. Does this reflect mental health problems? Physical illness? Are there problems at home? Or, is this a sign of substance abuse?

Cause or effect? In fact, it is likely to be a mixture of things, one thing exacerbating another. We know, for example, that teenagers often begin drinking or trying drugs after problems in the family—a parental breakup, for instance (Roustit et al, 2007). Problems in school, struggling with work, bullying or social rejection are miseries in themselves, and put the young at risk of substance abuse. Mental health problems are strongly associated with substance abuse of all kinds—though it is not always clear whether these problems are caused by drugs and alcohol or are the reason for using those substances, in an effort to self-medicate.

There is good evidence that regular use of cannabis is associated with aggression in the young (Copeland et al, 2013), and can cause or exacerbate depression, anxiety (Patton et al, 2002) and other psychiatric illness including major mental illness such as psychosis (Johns, 2001). But the evidence that alcohol abuse causes depression and anxiety is more equivocal. Heavy drinking is certainly associated with problems such as depression (Sher, 2004), but it is unclear

Dr Stephanie Thornton,�chartered� psychologist�and�former�lecturer�in� psychology�and�child�development

functioning and substance abuse, it is always worth considering whether a troubled youngster is using drugs or drinking. The point is underlined by statistics on substance abuse in British teenagers: such abuse is far from rare. And, in fact we appear to have a greater problem in this area than most of our European neighbours.

As the media has noted, teenage drug abuse has actually declined in the UK in the past 20 years (Hibell et al, 2012). Nevertheless, the most recent data report that 25% of our 15–16-year-olds have tried

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Both drugs and alcohol abuse affect the ability to learn. For example, cannabis can cause a decline in memory function and concentration, and alcohol can disrupt the development of the teenage brain.

whether drinking causes depression or depression causes drinking (Haynes et al, 2005). However, the evidence suggests that both drugs and alcohol abuse affect the ability to learn. Cannabis, for example, can cause a decline in memory function and concentration (Pope et al, 1994). Alcohol can disrupt the development of the teenage brain (Squeglia et al, 2009), potentially causing lasting cognitive damage.

Incidence Given these complex associations between life problems, cognitive and emotional

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cannabis and 9% have tried other drugs, usually amphetamines or ecstacy—both figures significantly above the European averages. 10% have abused inhalants— about average (Hibell et al, 2012). Some of these will have tried these drugs once or twice and stopped. It is hard to say how many are consistent users.

More shocking still is the incidence of alcohol abuse, where British teenagers come very near the top of the European league (Hibell et al, 2012). Over half of our 15–16-year-olds report that they engage in regular episodes of heavy drinking (52% in the UK, whereas the European average is 39%). And, they drink more per binge than their average European counterpart. Unlike other nations (with the sole exception of Finland), British girls report more such drunkenness than boys. Levels of alcohol abuse in UK teenagers have not changed over the past 20 years (Hibell et al, 2012).

Why are British teenagers particularly prone to substance abuse? We don’t know. Factors that correlate with such abuse are not more prevalent here than elsewhere. Is access to drink or drugs easier here than

elsewhere in Europe? It seems unlikely. Is such abuse more socially acceptable in the UK? Or is there something protective in other cultures that we are lacking?

Prevention and early detection Whatever the cause, the sheer scale of substance abuse among our teenagers, and the immediate and potential long- term consequences of this pose a serious challenge in our schools. Most schools have active programmes to counter substance abuse. In an ideal world, these would steer the young away from such experiments, and identify and support all those who do go down that path. But this is not

an ideal world. Anti-abuse messages are evidently not working. And it is still down to the individual teacher or school nurse to identify, and often to manage, cases of substance abuse.

Prevention is better than cure. If possible, stepping in to offer support when a teenager is first exposed to the stresses or peer pressures that lead to exploring alcohol or drugs may head off problems that will be much harder to manage later, when unhealthy habits have become established. But, it can be hard to detect the early stages of substance abuse, and hard, too, to know how best to handle your suspicions. Various websites and helplines offer advice on both these matters. YoungMinds has a useful website and a helpline that can offer general advice and point you to more specialised resources in light of the specifics of a problem. Useful sources of information and advice for issues with drugs include Talk to Frank and Addaction, and for alcohol problems: Drinksense and Alcoholics Anonymous (see Further information). General advice from such sources suggests 4 key points: „„Be constantly vigilant for the signs of substance abuse—A student who comes to school high or hungover may seem physically ill, may be slurred, have bloodshot eyes, or eye pupils that are too large or too small for the ambient light (check another nearby individual). But in the early stages of abuse, teenagers may keep their experiments away from school, so that the signs of abuse are more ambiguous. Clumsiness or poor concentration may be the first sign of a problem. Substance abuse can also progressively affect energy levels, either producing increased lethargy and apathy or the opposite: hyperactivity and agitation. There may also be mood swings, extreme moods, loss of control of various kinds (angry outbursts, irrational anxiety, even paranoia). „„Take your suspicions seriously from the

‘If possible, stepping in to offer support when a teenager is first exposed to the stresses or peer pressures that lead to exploring alcohol or drugs may head off problems that will be much harder to manage later ...’

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‘... 25% of our 15–16-year-olds have tried cannabis and 9% have tried other drugs, usually amphetamines or ecstacy—both figures significantly above the European averages.’

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start—A teenager who is palpably ill may need urgent medical attention. But any real suspicion of substance abuse should be referred to your school abuse team without delay. It is far better to err on the side of caution, suspecting substance abuse where there is none (which can be quickly cleared up) than to let such abuse slip through and grow—especially as the signs of substance abuse may also point to other forms of mental health or a personal issue. „„Explore what is driving this individual’s experiments with drugs or drink—An individual who uses these substances to manage stress or medicate misery is in a very different situation from one who is abusing to keep up with a peer group, for example—and needs a very different kind of intervention. Talking the reasons for using alcohol or drugs through with the teenager, as non-judgmentally as possible, may provide vital insights for supporting that individual in finding healthier strategies. „„Discuss the realities of substance abuse, which may be less salient for the young than one might suppose—A key finding of the recent European School Survey Project on Alcohol and Other Drugs (ESPAD) research (Hibell et al 2012) is that British teenagers are more likely than peers in many other European nations to discount the negative

‘... British teenagers are more likely than peers in many other European nations to discount the negative consequences of drinking, focusing only on the personal and social benefits ...’

consequences of drinking, focusing only on the personal and social benefits— and this, despite the fact that they also report having experienced more negative consequences of alcohol than most of their European peers. The same may well be true for their attitude to illegal drugs. Such perceptual biases may play a role in fuelling the high rates of substance abuse in the UK. BJSN

Copeland J, Rooke S, Swift W (2013) Changes in cannabis use among young people: Impact on mental health. Curr Opin Psychiatry 26(4): 325–9

Haynes J, Farrell M, Singleton N, Meltzer H, Araya R, Lewis G, Wiles N (2005) Alcohol consumption as a risk factor for anxiety and depression. Br J Psychiatry 187: 544–51

Hibell B, Guttormsson U, Ahlstrom S, Balakireva O, Bjarnason T, Kokkevi A, Kraus L (2012) The ESPAD report 2011: Substance abuse in students in 36 European countries. The Swedish Council for Information on Alcohol and other Drugs (CAN), The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Council of Europe, Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group)

Johns A (2001) Psychiatric effects of cannabis. Br J Psychiatry 178 116-122

Patton G, Coffey C, Carlin J, Lynskey M, Hall W (2002) Cannabis use and mental health in young people: A cohort study. BMJ 325(7374): 1195–8

Pope H, Gruber A, Yurgelun-Todd D (1995) The residual neuropsychological effects of cannabis: The current status of research. Drug Alcohol

Alcoholics�Anonymous Mutual�aid�fellowship�for�people�who� have�a�drinking�problem. www.alcoholics-anonymous.org.uk/

Addaction Addaction�is�a�UK-based�drug�and� alcohol�treatment�charity. http://addaction.org.uk

Drinksense Local�alcohol�and�drugs�charity�for� young�people. www.drinksense.org

Talk�to�Frank Talk�to�Frank�is�a�long�running�anti- drugs�campaign.�The�website�offers� advice�to�young�people. www.talktofrank.com/

YoungMinds YoungMinds�specialises�in�supporting� children�and�teenagers�with�mental� health�problems,�their�family�and� professionals�working�with�them� (helpline�0808�8025544). www.youngminds.org.uk

Further information

Depend 38(1): 25–34 Roustit C, Chaix B, Chauvin P (2007) Family

breakup and adolesent’s psychosocial maladjustment: Public health implications of family disruptions. Pediatrics 120(4): 984–91

Sher L (2004) Depression and alcoholism. Quarterly Journal of Medicine 97: 237–40

Squeglia L, Jacobus B, Tapert S (2009) The influence of substance abuse on adolescent brain development. Clin EEG Neurosci 40(1): 31–8

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