Substance use disorders (SUDs) represent a significant mental health problem in our country today, causing a large toll on our society’s medical, financial, and human resources. Teens in our culture naturally gravitate toward experimenting with risk-taking and deviant behavior, so substance abuse problems-whether defined in DSM-IV (American Psychiatric Association, 1994) as substance abuse or substance depen-

dence-frequently begin in adolescence. Recreational substance use has been recognized as a significant adolescent problem in our society for about the last 40 years. The usual statistics cited state that 90% of American high school seniors have used alcohol recreationally by the time of graduation, while 30-40% have tried marijuana and perhaps 10% have used “harder” illicit drugs (Chatlos, 1996; American Academy of Child and Adolescent Psychiatry, 1997). (Although nicotine is commonly considered a gateway drug, as are alcohol and marijuana, this chapter does not address the issue of cigarette use in adolescents, an important topic in its own right.)

The adolescent psychiatrist will encounter issues of substance abuse frequently-perhaps even daily-in the course of clinical practice. Sometimes SUDs will present to the clinician explicitly and clearly, while at others a substance abuse problem will masquerade as or mingle with a comorbid psychiatric disorder. In either event, the competent adolescent psychiatrist needs to have a ready approach to assessing and treating teens with SUDs and should be able to adapt such an approach to the circumstances of the particular clinical situation. What follows is an approach to dealing with SUDs that has evolved over time in my own practice.