We take greater pains to persuade others that we are happy than in trying to think so ourselves.” -Confucius

Recently, during clinical rounds, our treatment team engaged in a lively conversation about the clinical challenges we face when identifying substance use disorders in certain teenagers.  Among them is a misperception by many parents and clinicians that their teenagers must be drug-free because they (mistakenly) assume that high-functioning in school, participation on sports teams, and involvement in extra-curricular activities eliminate the risk of drug problems in their kids.

Unfortunately, as clinicians, we all too often see teenagers who appear to be high-functioning, but in reality suffer from substance use disorders and perhaps other psychiatric issues as well.  Often, these kids look like they are doing well: they look happy, they are getting good grades, they are popular with teachers and peers and may be involved in various activities both inside and outside of school. As such, their problems aren’t obvious to parents, teachers, coaches, pediatricians, etc… Child psychiatrists are well-aware that many teenagers can masquerade happiness and stability very well while what is happening on the inside may be quite a different story.  The same problem seems to exist with regards to teenage substance use problems – certain teens are able to mask the issues until the problem has progressed significantly.

Why is it that these kids are able to mask the signs of substance abuse so well while others can’t?  What is the appropriate message to send to parents, teachers, coaches and pediatricians regarding this issue?

As it turns out, these parents aren’t totally off base in making the assumption that their kids are not suffering from drug problems, but they may be oversimplifying the issue.  Data support the idea that there are “protective” factors that seem to be associated with a reduced risk that an adolescent will develop a substance use disorder.   According to studies, some of the most robust protective factors are: getting good grades, involvement in sports teams, involvement in community-based activities, not getting into trouble in school, and good family communication with clear boundaries and rules.  Sadly, the fact remains that these factors are only protective and hence reduce, but do not eliminate, the risk of an otherwise healthy child developing a substance use disorder.

I believe that the point in all of this is two-fold.

First, it is important to have a clear understanding of myth vs. reality not only in order to properly educate parents, teachers, coaches, etc…but also to make sure that as clinicians we send a clear and consistent message to those we treat, as well as to each other about the risk of substance abuse in teenagers.  In essence, parents and clinicians need to be aware that “high-functioning” kids are less likely to develop problems with drugs and alcohol, but the risk is hardly zero and there may always be cause for some degree of concern.  Likewise, it is important that families, educators and clinicians are aware of which factors provide a measure of protection against substance abuse in teenagers.

Second, it may be that kids who maintain a high level of functioning both academically and outside of school – who also suffer from a substance use disorder – and fall beneath the radar, may in fact represent a special class of adolescent substance abuser.  That is, these kids may be more difficult to identify early, they may respond differently to treatment, and the patterns of substance abuse in high-functioning kids could look differently from most teenagers who exhibit functional decline in the face of a substance use disorder.  Research to elucidate these issues could shed light on this challenging clinical problem, and may improve our ability to protect, identify and treat adolescent substance abusers.