Diagnosis of Alcohol Abuse and Dependence in Adolescents

by National Institute of Health

(Page 2 of 6)

A valid diagnostic system is essential to advancing treatment and research of adolescent AUDs. Diagnoses should facilitate communication among clinicians and researchers, identify cases for different levels of clinical intervention, provide phenotypes for genetics research, and convey information about prognosis. DSM-IV includes two AUDs, alcohol abuse and alcohol dependence, which are defined by nonoverlapping criterion sets. DSM-IV abuse focuses on negative psychosocial consequences resulting from drinking, as well as hazardous use, and requires the presence of at least one of four criteria. DSM-IV dependence is diagnosed when at least three of seven criteria related to physical dependence, salience of alcohol use, and impaired control over drinking behavior are met within the same 12-month period. Both DSM-IV AUDs require evidence of clinically significant impairment or subjective distress resulting from alcohol use for diagnosis.

Diagnostic criteria for AUDs were derived largely from clinical and research experience with adults, and only recently has their validity been assessed among adolescents. Numerous developmental differences between adolescents and adults may affect the applicability of AUD criteria to youth. For example, adolescents tend to drink less often than adults but typically consume a greater quantity per occasion. Developmental differences in alcohol use patterns indicate the need to adapt criteria to make them relevant to and properly scaled for an adolescent's stage of maturation. Because a construct may manifest itself differently in adolescents and adults, a perspective that takes developmental factors and contextual influences into account is essential for valid assessment of AUD symptoms.

DSM-IV AUDs have shown some validity when used with adolescents in that teens classified as having alcohol dependence, abuse, and no diagnosis differ on external measures of alcohol involvement. Several important limitations have been identified, however, both at the criterion level of how symptoms are defined and measured and at the level of the diagnostic algorithms for alcohol abuse and dependence. At the criterion level, certain symptoms tend to occur only after years of heavy drinking and have low prevalence and limited utility when applied to teens. Other DSM-IV AUD symptoms appear to be more relevant to specific adolescent subgroups. For example, hazardous use and legal problems have been associated with male gender, increased age, ethnic background, and presence of conduct disorder symptoms in teens. Ethnicity and gender have been found to influence whether and when certain DSM-IV AUD symptoms tend to occur in teen drinkers.

Some symptoms, such as tolerance, appear to have a high prevalence among young drinkers in part because they are poorly defined or scaled for the developmental period of adolescence. DSM-IV's definition of tolerance as a "marked increase to obtain the same effect" is only modestly associated with adolescent alcohol dependence. Many adolescent drinkers report marked increases to produce the same effect but are relatively light drinkers, often not having any other symptoms. Some level of tolerance may occur as a normative developmental phenomenon in youth who drink. Other adolescents are heavy drinkers who are not assigned the tolerance symptom; they report high quantities of drinking during early drinking experiences without a subsequent marked increase to produce the same effect. Better guidelines need to be developed regarding the identification of clinically significant levels of tolerance in teens, or alternatives such as a heavy drinking criterion must be considered.

Some AUD criteria may be interpreted differently or have different meanings when used with adolescents compared with adults, such as "drinking more or longer than intended." This symptom often is assigned as a result of an adolescent's poor judgment, inexperience with alcohol's effects, or social pressures to drink, rather than as a compulsive pattern of alcohol use. Research has examined the development of more specific interview probes that query contextual factors, such as adolescents' motivations for drinking and reasons for limiting alcohol use, as a way to increase the validity of this symptom among youth. Differences in how tolerance and drinking more or longer than intended are assessed affect diagnostic validity and have a large effect on the estimated prevalence of AUDs in adolescent community samples.

There are other limitations of the DSM-IV at the level of diagnostic algorithms, that is, abuse as one out of four criteria and dependence as three out of seven criteria. Some adolescents who engage in relatively low levels of alcohol use meet criteria for an abuse diagnosis only because of arguments with their parents about alcohol use and may be considered to be "diagnostic impostors". However, "diagnostic orphans," who have one to two dependence symptoms and no abuse symptoms, and thus no DSM-IV AUD, are similar to teens with DSM-IV alcohol abuse on drinking levels and clinical outcomes. Diagnostic impostors and orphans limit the ability of the DSM-IV diagnostic system to provide appropriate categories for research studies and to guide the allocation of scarce health care resources.

The DSM-IV's separate criterion sets for abuse and dependence are not well distinguished conceptually or empirically. Data do not support a distinction between the two categories in severity, age of symptom onset, age of onset of the two diagnoses, or symptom profiles identified by latent class analysis and factor analysis. Some community surveys report higher prevalence of the more severe dependence diagnosis relative to the milder abuse diagnosis, a situation that does not conform to most disorders in psychiatry or medicine. In contrast to the DSM-IV dichotomy of abuse and dependence, evidence suggests that the latent structure of adolescent alcohol problems represents a continuum of severity distinguished more by the number than the type of symptoms.

Longitudinal studies indicate that alcohol problems which occur in adolescence and young adulthood are only modestly associated. The alcohol abuse diagnosis appears to be particularly transient, with a high rate of transitions into and out of this category. Many adolescents with AUDs mature out of problem drinking, whereas others show a more chronic course through adulthood. Multiple developmental trajectories of adolescent-onset AUDs exist and have been characterized as developmentally limited or persistent, with diagnoses that may be relatively continuous or intermittent. Ongoing longitudinal research will help investigators understand more about the clinical course and prognosis of adolescent-onset abuse and dependence and will help them test the predictive validity of diagnostic criteria, course specifiers, and algorithms in the DSM-IV and beyond.

About the Author

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