Research seems to indicate that early substance use is predictive of more severe abuse later on. Though most research studies have only looked at the youth group between 8th and 12th grades, regarding first use, continued use, etc., anecdotal information from treatment professionals indicates that many children first use alcohol, tobacco, or drugs during preadolescence. Some report being exposed even earlier.

A 1999 Brevard County Florida report indicated that lifetime prevalence of alcohol use in middle school was 44.7 percent. Usage in the previous 30-day period was 28.3 percent (1999, p.4). A later report indicated that 7.9 percent of the County’s middle school students had reported marijuana usage in the previous 30 days (2002, p.3). “Abuse of inhalants by middle school children has increased by as much as 44 percent over a two-year period” (Partnership for a Drug Free America, 2004, p.1). SAMHSA (2003) reported that for “[F]irst alcohol use and first cigarette use, initiation before age 12 is common.” A survey to identify early deviance and related risk factors in children of narcotic addicts showed that, of the the children surveyed, the “mean age at first alcohol use was 12.26 years” (American Journal of Drug and Alcohol Abuse, 1999).

Generally, most addiction treatment professionals believe that teenage drinking begins early, often during the preteen years. Psychosocial development is a lifelong process, but the addiction field has long recognized that, at the age of onset of substance abuse, psychosocial as well as cognitive development, becomes significantly delayed or retarded. This presents to treatment, clients whose psychosocial and cognitive function is well below that expected of their chronological age. Proper assessment of these issues strongly impacts treatment planning and client/counselor interaction, as well as client function in the treatment milieu. The theoretical perspectives of Erikson, Piaget, and others help to identify specific areas of struggle.

If, in fact, the age of onset is between ages 8 and 11, then the early onset substance abuser would be stuck in middle school years, which range from 6 to 12 years of age. That age group — now presenting as someone 16 or 35, who functions psychosocially as a 10-year old — and the developmental issues associated with it, is the focus of this article. This article also addresses the client described, some of the problems that may present in treatment, and thoughts about adapting treatment planning to accommodate cognitive and psychosocial deficits.

This discussion assumes that addiction is a biopsychosocial disease, which then leads to the belief that when the addict begins substance use, psychosocial growth becomes significantly retarded.

What is normal development?

Typical is probably a better word than normal. There is a range in development, dependent upon many factors. We do know that development is, in many ways, culturally determined. We develop according to the age-graded expectations of our culture. An obvious example is the adolescent development typical in the United States regarding acting out behavior and peer pressure, as compared to countries where the expectation is that children grow into older children, then young adults, then adults. In those cultures, the luxury of adolescent acting up generally is not part of typical development.

Psychosocial development is, as are most developmental theories, sequential or cumulative in nature. Each stage has a theme, also called a psychosocial crisis. One level has to be mastered effectively before the next can be laid down. If the critical issue is mastered, the child dev-elops adaptive ego qualities (Ford, as cited in Newman & Newman, 2003), which help him or her to progress and cope throughout life. If it is not resolved, core pathologies develop, hampering growth.

Psychosocial development is divided into stages, each of which has its own set of tasks or a job description for that life stage. Most texts on psychosocial development reference ideas of Erikson and Paiget extensively. One such text, Development Through Life: A Psychosocial Approach (B.M Newman & P.R. Newman, 2003), references some of the tasks specific to middle school years, including: skill building, self evaluation, friendship, team play, and concrete operations.

Skill building

The central process or critical theme of middle school years is education, but it is much more than book learnin’. Consider all that is learned in those years — fixing a bicycle chain, running the washing machine, making the bed, cooking, counting change at the market, building a fort, etc. Now, imagine this early onset child whose focus is on where to get the substance, with whom to use it, and how to hide it, while still being able to brag to peers about it. All the while this child is not feeling typical at all.

These skills will be inadequately developed and the loss will be evident in the client who says she doesn’t like to read, when assigned a reading in a recovery text, or thinks journaling is stupid. In fact, she is a poor writer or speller and, in either case, doesn’t want to be discovered. One of the critical alterations in treatment planning for this individual would be allowing her to save face, by allowing her to modify the reading assignment to something that will result in success. For example, ask if this assignment works for her and then be willing to say, “How much are you willing to read — a page? Okay, let’s agree on a page, and tomorrow we can talk about what you thought about it.”

If treatment professionals continue to demand that clients don’t dictate their own treatment, and insist that all clients follow the same mold, failure is a given. It has been said that the best way to win any conflict is to give the other person room to save face. This can be a hard thing to do when it seems so important to make a point, but the end result will be worth it. There will be many times, with early onset clients, when the counselor will have to modify a treatment plan to allow even a small success. After all, what’s the point of treatment at all, if the client is set up to fail from the start?

If treatment is inpatient and requires chores to be done, refusal may be seen as treatment resistance, when in fact there is an issue with Industry vs. Inferiority (Erikson, as cited in Newman & Newman), and she won’t try because she has not acquired the can do attitude that comes with successful industry. She won’t try because she is afraid she can’t do it. The main issue here is that the client can’t, [not won’t] do what is asked. If that developmental task hasn’t been mastered, then the client has built on sand rather than a solid surface, and is unable to move past a developmental stage not yet mastered.

Self evaluation

In this age group, self-efficacy is measured by comparing oneself to others, by receiving feedback from others, and by measuring criticism as well as approval. This is a tough age at a good time, but now the young substance user has drug-using peers as the measuring stick. Now parents and other adults, such as teachers, are showing distress and disappointment in the behavior and function of the child. This is registered as, “You are bad” — not the activity [or lack thereof] is bad. Self-efficacy is influenced by how a child determines the probability of success. If peers do poorly as well, the perceived odds of the child succeeding are lessened. Success begets success; failure begets failure. Repeated experiences influence what happens next time.

Self-evaluation also takes place in regard to one’s body and growth. Comparing oneself to others in regard to development, sexuality and so forth, begins during this time. Although there was time in the not-too-distant past when sexual activity was not even a consideration during this period, it is currently in vogue to be aware, if not active. Being sexually attractive is not relegated to the teens anymore. In any event, for a boy, being short is still a major problem, and for a girl, having breasts or not, in either case, is a disaster. Their bodies have not fully matured, yet there is an expectation that they should not only be sexually active, but sexually creative. Young women of this age may even let it be known in what sexual activities they will participate by wearing colored jewelry or some other sign. When children of this age begin using substances, and that fledgling judgment area of the brain is altered, the experiences and behaviors in which they may engage will influence their sense of worth for a lifetime. They see their value as being measured in areas other than those typical of their age appropriate peers.

Friendship

Remember your best friend at age 11? Remember the loyalty, respect for secrets and absolute trust? This is the beginning of learning about faithful relationships. In this period of Loyalty Stage I, the loyalty and fidelity are to the best friend. Establishing the parameters of that steadfast relationship then sets the stage for Loyalty Stage II, or the fidelity to the beloved, which typically comes in adolescence or early adulthood. The relationship with the best friend is a vital part of this stage.

With girls, secrets and jokes are shared, other relationships discussed, and phone conversations may go on for hours. Many will remember the notes sent in school saying, “Ask him/her if she likes me,” and asking of a friend “Will you be my best friend?” All goes well until the third friend enters the picture and fidelity is challenged. This is an age where the learning to share friends or associates with others and to play a role in someone’s life, rather than be only, is learned. This is a hard lesson that requires multiple resources like other friends, parents, family, and a healthy functioning brain with which to process the conflict and then store the new information.

Boys share sports, or computer games and learn to compete. They may learn who is biggest, who is strongest and who can spit [or worse] the farthest. But they also learn the loyalty that is central to this developmental task. Altered brain function is not conducive to competition that requires coordination or quick response. The value of the other boy becomes who can cop the substance, who can find the place to use, or who knows the man. The question is not “Does she like me?” but “Can she get me some?” Some see their value as a friend in being the man, but it’s a shallow talent and one that does not translate well into a sober lifestyle.
When these young people come into treatment, their resources for a sober support system are limited. We say, “Stay away from people, places and things.” Yet, the other clients with whom they are expected to bond, share intimate details, and confess limitations, may have the same loyalty deficits. It is a problem in treatment whether the client is 15 or 40. Early onset halted the progress; they are in the same boat and, therefore, cannot model for one another.

Team play

When learning to play on a team, or in a group, the child learns about roles, rules, and rights. They learn how to maintain the system, which in adult life translates well into business, home or social skills. This is not to say that one has to play at sports. Computer games have replaced the sandlot, in many cases, due to geographical restrictions. Schoolmates may not live nearby; a neighborhood may not support old style, outside group games. Agreed, face-to-face interaction is far preferable to the anonymity of a computer connection, but in a pinch, the same skills are learned that are accomplished in baseball, such as taking a turn, learning the rules, respecting opponents, and negotiating and maintaining the system.

Any group activity that fosters these skills will serve the same purpose. There are rules supporting drug acquisition, of course, and even negotiation. However, in a group that is using substances, one’s rights — as in one for all and all for one — become very self involved, the idea being, “As long as I have mine.”

When this person comes into treatment, there is bitter resistance at taking on chores, “Why do I have to do this?” and following rules, “That is so stupid!” — the only rights of concern are those of oneself and the idea of protecting oneself. This person has not learned to live successfully in a milieu or to take responsibility for a part of the job when working with a group toward a common goal.

Concrete operations

Cognition is a cumulative, layered process that builds consistently and fairly predictably. There seem to be clear changes seen between stages. Jean Paiget (as cited in Newman & Newman, 2003) developed a theoretical base for development that included cognition, or how we understand things. For example, one of the early stages of how a child understands his world is Sensorimotor. The lips, sensitive for purposes of survival (like nursing), determine size, shape, textures and form. Everything goes into the mouth, including Mom’s glasses, the dog’s ear, or stray tacks on the floor. The curiosity and interest is boundless. His job description is to touch, taste and move. Unfortunately, parents sometimes drive themselves crazy by insisting they will not put anything away, but that the child will adapt to their home. Parents say, “Don’t touch,” but that’s his job.

Thinking and cognitive development is complex and multilayered, but for the purposes of making the point about early onset addicts, the concept is discussed here in its simplest form and in regard to the most fundamental problems.

Later, comes concrete thinking. At this stage, from ages 6 or 7 until around 11 or 12, a child understands those things that he can see feel, smell, touch, and hear. They are here and now oriented, which prevents them from hypothesis testing. Abstract thinking and using hypotheses comes with the stage of formal operations, which begins in early teens. These early onset individuals, therefore, have great difficulty determining cause and effect involving concepts. If you ask an 8-year old, “Why did you do that?” the typical answer is, “I don’t know.” To ask, then, “What will you do differently next time?” the answer would likely be “not that,” whatever that was. In other words, developing an alternative behavior, using hypothesis testing, such as, “If I did this last time and it didn’t work, doing x, y, z, this time is more likely to make it work,” is unlikely to happen. Looking at just this simple component of concrete thinking, imagine the dilemma created when a client is asked to identify triggers or antecedent behaviors to drug use. This is self-defeating for the counselor and frustrating for the client.
Treatment plans must be concrete, measurable, time-limited, and above all do-able. Asking this client to understand the disease process, or to internalize new behaviors, is not measurable, nor do-able, for that matter. It is more reasonable to ask the client to discuss the disease concept, to list two good things and two bad things about his drug use, and to give three examples of places he liked to go to use. To an experienced counselor it may not seem like a thorough exploration, but it may seem profound to this client.

Conclusion

It can be seen from this superficial look at some developmental issues, that treatment for these clients must be tailored to their age of onset, not their chronological age. Though relapse is not a requirement, it is nonetheless, common. One protection against relapse is success in recovery efforts. Though tailored treatment plans might not accomplish the growth desired in treatment, small, but definite successes will accumulate. It is rewarding to sit with a client, review a treatment plan and be able to say, “Look, you accomplished this and this and this. You read more than you thought you would, delivered an effective oral journal to the group, and identified four areas of danger to staying clean. We’re proud of your accomplishments.” This may be the first time in recent memory that this client has heard such positive words.

Beginning the repair of lost developmental tasks, with an accumulation of small accomplishments, builds a resilient ego, a competent sense of self. These adaptive abilities now replace the core pathology of inertia (Erikson, 1982) that had been established. If you recall physics terminology, inertia means, “A body in motion tends to stay in motion, a body at rest tends to stay at rest.” This client’s growth has been at rest. You can be the force that starts the movement and encourages it to stay in motion.

Although the primary focus of this article is the middle school years, a significant number of adolescents have a later age of onset, in early adolescence. In the areas of cognition and skill development, they have some small advantage, though their cognition is not formalized enough to be consistent in reasoning or problem solving abilities. The transition into hypothesis testing is not complete and these new skills are unpracticed. Under stress, they will, as do many adults, resort to concrete, more predictable ways of looking at things.
Of the one percent of the U. S. population meeting criteria for past year substance abuse, 2.6 percent of that group are of the 12 to 17 age group. One research report (Dennis, M., Babor, T.F., Roebuck, M.C., & Donaldson, J., 2002) showed a significantly high connection of this age of first use of cannabis and DSM-IV criteria, such as increased tolerance, preoccupation, loss of use over amount consumed and health, educational, employment and psychological problems. “Complicating matters further, more than 90 percent of adolescents and many of the adults using cannabis also engage in binge drinking — a combination that produces a synergistic increase in potency” (Siemens, 1980).

The “job description” of the early adolescent (ages 12 to18) is group identity vs. alienation. Also, the need for acceptance into a “cool” group has more power than parental distress. Unfortunately, the peer group of a youth who is beginning substance use has few other interests. Groups usually are distinctly divided into “straight edge” (no smoking, drugs or drinking) and “stoners,” or may be divided by music preferences (punk, etc.). Once a person is established in such a group, and has adopted its music, clothing and affectations, moving to another group in the same school is rarely possible. The boundaries and expectations of these groups are clear.

Not yet ready for complete autonomy from parents, the teen’s relationship with them is “push-pull,” vacillating between needs for parental emotional sustenance and peer acceptance. The adolescent is further confused and alienated from family by the need to protect the substance use and behaviors. Under the best of circumstances, this transition is awkward, choppy and emotionally labile. When manifesting in a young adult who had onset at this early adolescent age, it is called “treatment resistance.”

It would be beneficial for clinicians to remember this when a person with this developmental age enters treatment. The need for belonging is strong. Yet, anything which identifies a youth with a particular group is stripped away — t-shirts, colors, headbands, etc., have to go. The idea is to “break down to rebuild,” but this stripped young person has no identity anchor and may abort treatment to reclaim it.

Treatment offers an new opportunity to bond, whether by having the group members make a collage, using magazine pictures as icons identifying each member, and/or by allowing mottos, passwords or colors that can ground this person with this group. The 12-step groups are of great value, as well. Clinicians and counselors have been overshooting and treating at chronological, rather than developmental ages. We must adjust our sites in order to hit the mark.

Susan T. Edgar, PhD, RN, CAC, is a registered nurse and is certified in addictions. She has been a trainer for the Penn. Department of Health, Bureau of Drug and Alcohol Programs since 1988, and trains members of other state agencies.

References
Brevard County Report Highlights (1999, p.4). Retrieved July 1, 2004, from http://countygovt.brevard.fl.us/tip/pdf/availability-of-drugs.pdf
Brevard County Report Highlights (2000-2002, 3). What Every Parent Should See. Retrieved July 1, 2004 from http://studentservices.brevard.k12.fl.us/Reportpercent20Highlights.htm
Dennis, M., Babor, T.F., Roebuck, M.C., & Donaldson, J. (2002). Changing the focus: the case
for recognizing and treating cannabis use disorders. Addiction, 97, (Suppl. 1), 4-15.
National Survey on Drug Use & Health (2003). Results. Retrieved October 24, 2004, from
http://oas.samhsa.gov/NHSDA/2k3NSDUH/2k3results.htm#ch5
Newman, B.M. & Newman, P.R. (2003). Development Through Life: A Psychosocial Approach.
(8th ed.). Wadsworth/Thomson: Belmont, CA
Nurco, D.M., Blatchley, R.J., Hanlon, T.E. & O'Grady, K.E. (1999, Feb 1). American Journal of Drug and Alcohol Abuse. Early Deviance and Related Risk Factors in the Children of Narcotic Addicts. Retrieved June 30, 2004, from http://www.findarticles.com/p/articles/mi_m0978/is_1_25/ai_54097334
Partnership for Drug Free America. (2004, June 1) More Pre-Teens Abusing Inhalants.
Retrieved July 1,2004 from http://www.drugfreeamerica.org/Templates/Article.asp?ws=PDFA&vol=1&grp=NewsCenter&cat=News+Releases&top=2004&tit=More+Prepercent2DTeens+Abusing+Inhalants

This article is published in Counselor,The Magazine for Addiction Professionals, June 2005, v.6, n.3, pp.59-65.

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