Michael Jellinek, MD

When a parent comes to you and reports their child is stealing, first determine if it was a single act or part of a pattern. Is the child old enough to understand their action? Have the parents had this concern before? Was the child motivated by peer pressure, like a "dare" to take something? Is the stealing associated with other unacceptable behaviors such as lying or hurting others? Does the child feel remorse or empathy for the victim of the theft?

These are important questions to ask as you figure out the frequency and context of the behavior. On one hand, you do not want to overreact and label the child a future felon. On the other hand, you do not want to miss the early signs pointing to a serious, persistent pattern of stealing.

Children steal for a lot of different reasons. It’s helpful to look at the behavior from a developmental perspective.

Sometimes at very young ages – less than 5 years – children take things because concretely they want them. A 3-year-old does not have much of a concept of theft or violating the property rights of others. If they want a candy bar when they are standing in front of a counter at the grocery store, they may just reach out for it.

At that point, parents will say: "Don’t take that. It’s not yours" or "‘We have to pay for it." This is one of the places where kids learn to control just grabbing and taking. I would not really call this stealing because they are not aware of what they are doing in that context.

In contrast, even in first grade, there are children who consistently take things from other kids.

Stealing as an Isolated Act

As children get older, they may be very attracted to some things. Someone he knows gets a spectacular new pen or cell phone or something else he really wants, and he takes it. There may be an isolated act of stealing when she is 3 or 4 years old, and another when she is 11 or 12 years old. It’s near normal and in the range of what might be expected from children, with the 11-year-old feeling uneasy and guilty about the secret she is trying to contain.

Isolated stealing in childhood does not necessarily mean a child is on track to delinquency. And being a juvenile delinquent certainly does not mean a child will become an adult offender. This information can be very reassuring to parents. As parents find out that their child stole a fancy pen from another child and lied about it to the teacher, they may come to you quite automatically thinking their kid is going to lead a life of crime. As I’ve said in a previous column, one lie does not make a child into a criminal either ("Don\'t Ever Lie to Me!" February 2012, p. 20).

Understanding that there are circumstances at different developmental stages helps parents not consider their child’s action as catastrophic.

Let’s say a young teenager is with a group of friends and they dare him or her to take the teacher’s calculator. Or they dare each other to go into a neighbor’s house and take something they saw and really liked. That is stealing in a social context motivated by peer pressure.

There may also be a group of kids who want potato chips and they don’t have the needed money. They go into a grocery store, cause a distraction, and shoplift. Again, ideally you don’t want them to do that, but groups of kids sometimes act on a dare because they are egged on by friends, or act on an impulse. This does not point to a life of crime or reach the level of robbing a bank.

For some children and teenagers, stealing is a solution to a problem. One of your jobs as a pediatrician is to figure out what problem the kid is trying to solve.

Stealing, for example, could point to internal family conflict. A teenager might really want something, but their parents say no. In response, he takes an item out of the parent’s car or desk. This is theft motivated by anger in an attempt to "get even" or to assert his autonomy from parental control. Further examples include taking the car keys when a parent says he is not allowed to drive, or secretly taking jewelry or clothing from a parent after being told she is not allowed to wear them.

These are hostile acts and it’s technically stealing, but again understanding the context of the behavior would not connect it to robbing a bank.

Those are examples at different ages of one-off stealing. These children deserve a talking to and maybe even punishment within a family. They should apologize to the victim, acknowledge the harm done, offer to make up for any damage, and promise not to steal again.

When Stealing Persists

Persistent stealing is of much greater concern. When a child steals frequently, he is probably lying all the time as well. He will lie, for example, when asked: "Where did you get that? How did that happen? Did you take it?" or "Have you seen it?"

Be careful not to leap and consider childhood stealing in the context of adult behavior. Instead, look at the family dynamics, evaluate the child’s self-esteem, and determine if the child is reacting to some outside pressure. Does the child have a problem with impulsivity or a learning disability that may impair their ability to control behavior?

Several factors tend to put kids at higher risk for more problematic behavior. The child might have a kind of neediness because she doesn’t feel valued or loved while growing up. She steals because she is looking for things to "fill her up," to feel better about herself, or to gain the status of possessing a particular item. Often in these cases, the taking, the gains to self-esteem or social standing, outweighs any guilt. In contrast, if a child feels sufficiently loved and has adequate self-esteem, then the moral price she pays for taking something – the guilt – is greater than the personal value of the item.

For example, a teenager who steals a watch might think: "I really need that watch. That watch is going to make me feel very good about myself. The people who wear that kind of watch are the kind of people I want to be." A lot of these thought processes are subconscious, but often underpin that kind of stealing behavior.

In contrast, an adolescent with good self-esteem might think: "It’s a nice watch and I’d like to have it, but I don’t really need it to feel good about myself. I’m not going to steal it and then feel the guilt and violation of trust with people I love just to have a watch."

Keep in mind that there can be family patterns. In some situations stealing behavior runs in families. Some studies suggest a genetic component, but it’s really unknown how genetics, biochemical factors, or role modeling contribute.

Stealing also can be related to poverty. Under the stress of poverty, the threshold for stealing may be lower. There are a lot of very poor people who would never steal; however, the rate of stealing is higher in poor communities. There are contributing factors that are hard to sort apart, such as inferior schools, fewer afterschool activities, higher dropout rates, gang formation, and so forth.

There is a subgroup of kids who lie and steal – and some are physically aggressive or violent – who will in fact go on to a criminal pattern. They will, by the way, have very little remorse. When one of these children is asked why they took another person’s favorite pen, they answer: "Because I needed a pen." Even if informed the pen was a graduation gift with a lot of meaning, they still say: "Hey, I needed a pen." These kids are members of a very difficult-to-treat subgroup who are at greater risk for criminal activity as adults, but they are a small minority. For children who persistently steal, it is certainly worth a lot of effort to try and help. Refer these children to a mental health professional, because the kind of complex psychiatric assessment they require is outside the realm of a typical primary care office.

Dr. Jellinek is a professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital and chief of Clinical Affairs, Partners HealthCare. He has no relevant disclosures. E-mail him at pdnews@elsevier.com.

When a parent comes to you and reports their child is stealing, first determine if it was a single act or part of a pattern. Is the child old enough to understand their action? Have the parents had this concern before? Was the child motivated by peer pressure, like a "dare" to take something? Is the stealing associated with other unacceptable behaviors such as lying or hurting others? Does the child feel remorse or empathy for the victim of the theft?

These are important questions to ask as you figure out the frequency and context of the behavior. On one hand, you do not want to overreact and label the child a future felon. On the other hand, you do not want to miss the early signs pointing to a serious, persistent pattern of stealing.

Children steal for a lot of different reasons. It’s helpful to look at the behavior from a developmental perspective.

Sometimes at very young ages – less than 5 years – children take things because concretely they want them. A 3-year-old does not have much of a concept of theft or violating the property rights of others. If they want a candy bar when they are standing in front of a counter at the grocery store, they may just reach out for it.

At that point, parents will say: "Don’t take that. It’s not yours" or "‘We have to pay for it." This is one of the places where kids learn to control just grabbing and taking. I would not really call this stealing because they are not aware of what they are doing in that context.

In contrast, even in first grade, there are children who consistently take things from other kids.

Stealing as an Isolated Act

As children get older, they may be very attracted to some things. Someone he knows gets a spectacular new pen or cell phone or something else he really wants, and he takes it. There may be an isolated act of stealing when she is 3 or 4 years old, and another when she is 11 or 12 years old. It’s near normal and in the range of what might be expected from children, with the 11-year-old feeling uneasy and guilty about the secret she is trying to contain.

Isolated stealing in childhood does not necessarily mean a child is on track to delinquency. And being a juvenile delinquent certainly does not mean a child will become an adult offender. This information can be very reassuring to parents. As parents find out that their child stole a fancy pen from another child and lied about it to the teacher, they may come to you quite automatically thinking their kid is going to lead a life of crime. As I’ve said in a previous column, one lie does not make a child into a criminal either ("Don\'t Ever Lie to Me!" February 2012, p. 20).

Understanding that there are circumstances at different developmental stages helps parents not consider their child’s action as catastrophic.

Let’s say a young teenager is with a group of friends and they dare him or her to take the teacher’s calculator. Or they dare each other to go into a neighbor’s house and take something they saw and really liked. That is stealing in a social context motivated by peer pressure.

There may also be a group of kids who want potato chips and they don’t have the needed money. They go into a grocery store, cause a distraction, and shoplift. Again, ideally you don’t want them to do that, but groups of kids sometimes act on a dare because they are egged on by friends, or act on an impulse. This does not point to a life of crime or reach the level of robbing a bank.

For some children and teenagers, stealing is a solution to a problem. One of your jobs as a pediatrician is to figure out what problem the kid is trying to solve.

Stealing, for example, could point to internal family conflict. A teenager might really want something, but their parents say no. In response, he takes an item out of the parent’s car or desk. This is theft motivated by anger in an attempt to "get even" or to assert his autonomy from parental control. Further examples include taking the car keys when a parent says he is not allowed to drive, or secretly taking jewelry or clothing from a parent after being told she is not allowed to wear them.

These are hostile acts and it’s technically stealing, but again understanding the context of the behavior would not connect it to robbing a bank.

Those are examples at different ages of one-off stealing. These children deserve a talking to and maybe even punishment within a family. They should apologize to the victim, acknowledge the harm done, offer to make up for any damage, and promise not to steal again.

When Stealing Persists

Persistent stealing is of much greater concern. When a child steals frequently, he is probably lying all the time as well. He will lie, for example, when asked: "Where did you get that? How did that happen? Did you take it?" or "Have you seen it?"

Be careful not to leap and consider childhood stealing in the context of adult behavior. Instead, look at the family dynamics, evaluate the child’s self-esteem, and determine if the child is reacting to some outside pressure. Does the child have a problem with impulsivity or a learning disability that may impair their ability to control behavior?

Several factors tend to put kids at higher risk for more problematic behavior. The child might have a kind of neediness because she doesn’t feel valued or loved while growing up. She steals because she is looking for things to "fill her up," to feel better about herself, or to gain the status of possessing a particular item. Often in these cases, the taking, the gains to self-esteem or social standing, outweighs any guilt. In contrast, if a child feels sufficiently loved and has adequate self-esteem, then the moral price she pays for taking something – the guilt – is greater than the personal value of the item.

For example, a teenager who steals a watch might think: "I really need that watch. That watch is going to make me feel very good about myself. The people who wear that kind of watch are the kind of people I want to be." A lot of these thought processes are subconscious, but often underpin that kind of stealing behavior.

In contrast, an adolescent with good self-esteem might think: "It’s a nice watch and I’d like to have it, but I don’t really need it to feel good about myself. I’m not going to steal it and then feel the guilt and violation of trust with people I love just to have a watch."

Keep in mind that there can be family patterns. In some situations stealing behavior runs in families. Some studies suggest a genetic component, but it’s really unknown how genetics, biochemical factors, or role modeling contribute.

Stealing also can be related to poverty. Under the stress of poverty, the threshold for stealing may be lower. There are a lot of very poor people who would never steal; however, the rate of stealing is higher in poor communities. There are contributing factors that are hard to sort apart, such as inferior schools, fewer afterschool activities, higher dropout rates, gang formation, and so forth.

There is a subgroup of kids who lie and steal – and some are physically aggressive or violent – who will in fact go on to a criminal pattern. They will, by the way, have very little remorse. When one of these children is asked why they took another person’s favorite pen, they answer: "Because I needed a pen." Even if informed the pen was a graduation gift with a lot of meaning, they still say: "Hey, I needed a pen." These kids are members of a very difficult-to-treat subgroup who are at greater risk for criminal activity as adults, but they are a small minority. For children who persistently steal, it is certainly worth a lot of effort to try and help. Refer these children to a mental health professional, because the kind of complex psychiatric assessment they require is outside the realm of a typical primary care office.

Dr. Jellinek is a professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital and chief of Clinical Affairs, Partners HealthCare. He has no relevant disclosures. E-mail him at pdnews@elsevier.com.

When a parent comes to you and reports their child is stealing, first determine if it was a single act or part of a pattern. Is the child old enough to understand their action? Have the parents had this concern before? Was the child motivated by peer pressure, like a "dare" to take something? Is the stealing associated with other unacceptable behaviors such as lying or hurting others? Does the child feel remorse or empathy for the victim of the theft?

These are important questions to ask as you figure out the frequency and context of the behavior. On one hand, you do not want to overreact and label the child a future felon. On the other hand, you do not want to miss the early signs pointing to a serious, persistent pattern of stealing.

Children steal for a lot of different reasons. It’s helpful to look at the behavior from a developmental perspective.

Sometimes at very young ages – less than 5 years – children take things because concretely they want them. A 3-year-old does not have much of a concept of theft or violating the property rights of others. If they want a candy bar when they are standing in front of a counter at the grocery store, they may just reach out for it.

At that point, parents will say: "Don’t take that. It’s not yours" or "‘We have to pay for it." This is one of the places where kids learn to control just grabbing and taking. I would not really call this stealing because they are not aware of what they are doing in that context.

In contrast, even in first grade, there are children who consistently take things from other kids.

Stealing as an Isolated Act

As children get older, they may be very attracted to some things. Someone he knows gets a spectacular new pen or cell phone or something else he really wants, and he takes it. There may be an isolated act of stealing when she is 3 or 4 years old, and another when she is 11 or 12 years old. It’s near normal and in the range of what might be expected from children, with the 11-year-old feeling uneasy and guilty about the secret she is trying to contain.

Isolated stealing in childhood does not necessarily mean a child is on track to delinquency. And being a juvenile delinquent certainly does not mean a child will become an adult offender. This information can be very reassuring to parents. As parents find out that their child stole a fancy pen from another child and lied about it to the teacher, they may come to you quite automatically thinking their kid is going to lead a life of crime. As I’ve said in a previous column, one lie does not make a child into a criminal either ("Don\'t Ever Lie to Me!" February 2012, p. 20).

Understanding that there are circumstances at different developmental stages helps parents not consider their child’s action as catastrophic.

Let’s say a young teenager is with a group of friends and they dare him or her to take the teacher’s calculator. Or they dare each other to go into a neighbor’s house and take something they saw and really liked. That is stealing in a social context motivated by peer pressure.

There may also be a group of kids who want potato chips and they don’t have the needed money. They go into a grocery store, cause a distraction, and shoplift. Again, ideally you don’t want them to do that, but groups of kids sometimes act on a dare because they are egged on by friends, or act on an impulse. This does not point to a life of crime or reach the level of robbing a bank.

For some children and teenagers, stealing is a solution to a problem. One of your jobs as a pediatrician is to figure out what problem the kid is trying to solve.

Stealing, for example, could point to internal family conflict. A teenager might really want something, but their parents say no. In response, he takes an item out of the parent’s car or desk. This is theft motivated by anger in an attempt to "get even" or to assert his autonomy from parental control. Further examples include taking the car keys when a parent says he is not allowed to drive, or secretly taking jewelry or clothing from a parent after being told she is not allowed to wear them.

These are hostile acts and it’s technically stealing, but again understanding the context of the behavior would not connect it to robbing a bank.

Those are examples at different ages of one-off stealing. These children deserve a talking to and maybe even punishment within a family. They should apologize to the victim, acknowledge the harm done, offer to make up for any damage, and promise not to steal again.

When Stealing Persists

Persistent stealing is of much greater concern. When a child steals frequently, he is probably lying all the time as well. He will lie, for example, when asked: "Where did you get that? How did that happen? Did you take it?" or "Have you seen it?"

Be careful not to leap and consider childhood stealing in the context of adult behavior. Instead, look at the family dynamics, evaluate the child’s self-esteem, and determine if the child is reacting to some outside pressure. Does the child have a problem with impulsivity or a learning disability that may impair their ability to control behavior?

Several factors tend to put kids at higher risk for more problematic behavior. The child might have a kind of neediness because she doesn’t feel valued or loved while growing up. She steals because she is looking for things to "fill her up," to feel better about herself, or to gain the status of possessing a particular item. Often in these cases, the taking, the gains to self-esteem or social standing, outweighs any guilt. In contrast, if a child feels sufficiently loved and has adequate self-esteem, then the moral price she pays for taking something – the guilt – is greater than the personal value of the item.

For example, a teenager who steals a watch might think: "I really need that watch. That watch is going to make me feel very good about myself. The people who wear that kind of watch are the kind of people I want to be." A lot of these thought processes are subconscious, but often underpin that kind of stealing behavior.

In contrast, an adolescent with good self-esteem might think: "It’s a nice watch and I’d like to have it, but I don’t really need it to feel good about myself. I’m not going to steal it and then feel the guilt and violation of trust with people I love just to have a watch."

Keep in mind that there can be family patterns. In some situations stealing behavior runs in families. Some studies suggest a genetic component, but it’s really unknown how genetics, biochemical factors, or role modeling contribute.

Stealing also can be related to poverty. Under the stress of poverty, the threshold for stealing may be lower. There are a lot of very poor people who would never steal; however, the rate of stealing is higher in poor communities. There are contributing factors that are hard to sort apart, such as inferior schools, fewer afterschool activities, higher dropout rates, gang formation, and so forth.

There is a subgroup of kids who lie and steal – and some are physically aggressive or violent – who will in fact go on to a criminal pattern. They will, by the way, have very little remorse. When one of these children is asked why they took another person’s favorite pen, they answer: "Because I needed a pen." Even if informed the pen was a graduation gift with a lot of meaning, they still say: "Hey, I needed a pen." These kids are members of a very difficult-to-treat subgroup who are at greater risk for criminal activity as adults, but they are a small minority. For children who persistently steal, it is certainly worth a lot of effort to try and help. Refer these children to a mental health professional, because the kind of complex psychiatric assessment they require is outside the realm of a typical primary care office.

Dr. Jellinek is a professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital and chief of Clinical Affairs, Partners HealthCare. He has no relevant disclosures. E-mail him at pdnews@elsevier.com.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. 

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. 

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. 

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It’s not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use. For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. For example, a good athlete who joins the varsity team in ninth or tenth grade, or the talented ninth grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer group. Without the judgment of an older child and while trying to "keep up," they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: a patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers’ brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that they may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort or the new AAP mental health primary care toolkit. For example, a general screen of psychosocial functioning such as the Pediatric Symptom Checklist, or a specific screen for depression or substance use, could be built into the annual visit starting at age 12 or 13 years.

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen’s behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent’s developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. E-mail him.