Concordance between DSM-III-R and DSM-IV diagnoses of substance use disorders in adolescents

Except for cannabis and alcohol, concordance between DSM-III-R and DSM-IV substance use disorder diagnoses has not been reported in adolescents. We assessed a clinical sample of 102 adolescents using CIDI-SAM. Prevalence of either an abuse or dependence diagnosis was lower with DSM-IV than DSM-III-R except for cannabis and alcohol, and concordance rates were better for dependence than for abuse. For most substances, rates of DSM-IV withdrawal were lower than in DSM-III-R, but rates of DSM-IV physiological dependence remained high. Changes in DSM-IV criteria appear to have impacted diagnoses in these adolescents, particularly for the substances they use most--i.e. alcohol, tobacco, and cannabis.     

The DSM-IV criteria for adolescent alcohol and cannabis use disorders.

OBJECTIVE: The aims of this study are to compare DSM-IV criteria for alcohol and cannabis use disorders with its predecessor, DSM-III-R, and to examine the validity of the new criteria in an adolescent drug clinic sample. METHOD: During evaluation, a sample of 772 adolescents (63% boys, 77% white) were administered a structured interview of diagnostic symptoms and additional problem severity measures. Independent staff ratings of problem severity and treatment referral were collected as well. RESULTS: Compared to its predecessor, DSM-III-R, application of the DSM-IV criteria for alcohol and cannabis users resulted in more abuse assignments and fewer dependence assignments. The shift in assignments appeared to be largely due to a lowering of the abuse threshold, rather than to a tightening of the dependence criteria. The external validity data generally supported the DSM-IV abuse and dependence distinction in adolescents, and the newer criteria were as valid as the older criteria. CONCLUSIONS: In contrast to DSM-III-R, the DSM-IV system yields more abuse cases and fewer dependence cases among adolescent alcohol and cannabis abusers. Validity evidence for the new criteria are defensible, yet the findings are seen as a starting point for discussing the need for tailoring substance use disorder criteria for adolescents.     

Cannabis dependence,withdrawal, and reinforcing effects among adolescents with conduct symptoms and substance use disorders

The prevalence of cannabis use is rising among adolescents, many of whom perceive little risk from cannabis. However, clinicians who treat adolescent substance users hear frequent reports of serious cannabis-use disorders and problems. This study asked whether cannabis produced dependence and withdrawal among such patients, and whether patients' reports supported previous laboratory findings of reinforcing effects from cannabis. This was a screening and diagnostic study of serial treatment admissions. The diagnostic standard was the DSM-III-R dependence criteria, and the setting was a university-based adolescent substance treatment program with male residential and female outpatient services. The patients were 165 males and 64 females from consecutive samples of 255 male and 85 female 13–19-year-olds referred for substance and conduct problems (usually from social service or criminal justice agencies). Eighty-seven patients were not evaluated, usually due to early elopement. Twenty-four others did not meet study admission criteria: ≥one dependence diagnoses and ≥three lifetime conduct-disorder symptoms. The main measures were items from diagnostic interview instruments for substance dependence, psychiatric disorders, and patterns of substance use. Diagnoses were substance dependence, 100%; current conduct disorder, 82.1%; major depression, 17.5%; attention-deficit/hyperactivity disorder, 14.8%. The results show that most patients claimed serious problems from cannabis, and 78.6% met standard adult criteria for cannabis dependence. Two-thirds of cannabis-dependent patients reported withdrawal. Progression from first to regular cannabis use was as rapid as tobacco progression, and more rapid than that of alcohol, suggesting that cannabis is a reinforcer. The data indicate that for adolescents with conduct problems cannabis use is not benign, and that the drug potently reinforces cannabis-taking, producing both dependence and withdrawal. However, findings from this severely affected clinical population should not be generalized broadly to all other adolescents.     

Screening adolescents for problem drinking: performance of brief screens against DSM-IV alcohol diagnoses

OBJECTIVE: The performance of three brief screens, the CAGE, TWEAK and Alcohol Use Disorders Identification Test (AUDIT), was evaluated against a DSM-IV diagnosis of alcohol abuse or dependence in an adolescent sample. METHOD: Adolescents (13-19 years old) who presented to an emergency department for treatment of an injury, and who tested negative for blood alcohol concentration at time of admission, were administered a structured diagnostic interview and modified versions of the CAGE, TWEAK and AUDIT. RESULTS: Of the 415 adolescents for whom complete data were available, 18% met criteria for a DSM-IV alcohol use disorder according to the Diagnostic Interview Schedule for Children (version 2.3). Teens who reported alcohol use in the last year (n = 261, 58% male, 71% white) were included in analyses that compared the performance of the three screening instruments. Receiver Operating Characteristic analysis indicated that the AUDIT demonstrated the best performance across the range of its cut-scores, with optimal performance at a cut-score of 4. The TWEAK performed optimally at a cut-score of 2 and the CAGE at a cut-score of 1. CONCLUSIONS: Routine alcohol screening among adolescents seen in a hospital setting is indicated. Two important directions for future research include the identification of adolescent-specific alcohol screening items, and the validation of an adolescent-specific definition of problem drinking that addresses limitations of DSM-IV alcohol diagnoses when applied to adolescents.     

Predictors and consequences of simultaneous alcohol and cannabis use in adolescents

Background/Aims

The simultaneous use of alcohol and cannabis is common among adolescents, but has been little studied. In this study, we examine predictors and consequences of this behavior in a population-based sample of high school students.

Method

Self-reports were obtained from students in Quebec (Canada) followed throughout high school (N = 6589). Logistic regressions were used to test the association between individual, family, and peer-related predictors in grades 7–8 and simultaneous alcohol and cannabis use in grade 10, as well as between simultaneous alcohol and cannabis use in grade 10 and experiencing 3 or more substance-related problems of various types (legal, physical, etc.) in grade 11.

Results

Most predictors in grades 7–8 were associated with simultaneous alcohol and cannabis use in grade 10. Only variables reflecting early-onset substance use involvement — alcohol intoxication, cannabis use, and drug use by close friend(s) — remained predictive in a multivariate model. Simultaneous alcohol and cannabis use was associated with increased substance-related problems in grade 11, above and beyond baseline problems and the concurrent use of the two substances in separate episodes in grade 10.

Conclusions

Simultaneous alcohol and cannabis use 1) is anticipated by multiple psychosocial risk factors which come together with individual and peer substance use in early high school and 2) is independently predictive of subsequent substance-related problems. Providing adolescents with adequate information regarding the potential harm of simultaneous use may be a useful prevention strategy.     

Prevalence and correlates of substance use disorders among older adolescents in Puerto Rico and the United States: a cross-cultural comparison.

Although there are substantial data on adolescent substance use, little systematic research has studied the prevalence of adolescent substance disorders in general populations, let alone cultural differences in disorder prevalence. In this paper we report the prevalence and correlates of alcohol and drug use and disorder among older adolescents on Puerto Rico (PR) and in the United States (US). Data come from an island-wide survey of the PR general residential population (15-18 year old subsample, unweighted N=922) fielded in 1997, and from the National Comorbidity Survey of the US household population (15-18 year old subsample, unweighted N=641), fielded in 1991. Both surveys used a similar standardized interview based on the Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses. Bivariate analyses and logistic regression were used. The major findings are: (1) US youth report higher rates of lifetime alcohol and drug use and substance-related disorder than PR youth; (2) the transition to abuse or dependence occurs for one-third of US drinkers, one-fifth of drinkers in PR, and about one-half of the drug users in both US and PR; (3) there are marked variations across sites in the types of symptoms substance users are likely to experience; (4) with the exception of family income, most correlates operate similarly in both sub-samples; and (5) the majority of both US and PR youth with a past year substance use disorder did not report any service utilization in the past year.     

High prevalence of substance use disorders among adolescents who use marijuana and inhalants

BACKGROUND: We examined the association between the use of inhalants, marijuana, and other drugs and recent DSM-IV substance use disorders among adolescents aged 12-17 years. METHODS: Data were drawn from 2000 to 2001 National Household Surveys on Drug Abuse. Adolescents aged 12-17 years who reported having ever used an illicit drug in their lifetime were categorized into four mutually exclusive groups: inhalant users (16%), marijuana users (53%), inhalant and marijuana users (16%), and other drug users (15%). Logistic regression models were used to estimate associations with recent substance use diagnoses among lifetime adolescent drug users (N=10,180). RESULTS: We found that 31% of lifetime drug users reported having never used marijuana. One half of these atypical drug users were predominantly nonmedical users of pain relievers. Adolescents who used inhalants or other drugs but not marijuana were least likely to report multidrug use. Adolescents who reported using both inhalants and marijuana were most likely to use three or more classes of drugs (73%) and to receive a diagnosis of past year alcohol (35%) and drug (39%) abuse or dependence. CONCLUSIONS: Our study findings suggest that among lifetime adolescent drug users, those who use both inhalants and marijuana are at very high risk for alcohol and drug use disorders.     

The Severity of Dependence Scale (SDS) in an adolescent population of cannabis users: reliability, validity and diagnostic cut-off

The Severity of Dependence Scale (SDS) is a five-item scale that has been reported to be a reliable and valid screening instrument for dependence and a measure of dependence severity in adults across several substance classes. To date no data have been reported on its performance in a population of adolescent cannabis users. The current study assessed the psychometric properties of the SDS in a community sample of 14-18-year-old adolescent cannabis users (n=100). Internal consistency (alpha=0.83) and test-retest coefficients (ICC=0.88) were high and a principal components analysis of the scale found all items to load on a single factor. Total SDS score correlated significantly with frequency of cannabis use and number of DSM-IV dependence criteria met, indicating good concurrent validity. Receiver Operating Characteristic curve analysis was used to determine the most appropriate SDS cut-off score for use as an indicator of cannabis dependence, with optimal discrimination at an SDS score of 4. These findings indicate that the SDS is a reliable and valid measure of severity of cannabis dependence among adolescents, has high diagnostic utility, and that an SDS score of 4 may be indicative of cannabis dependence.     

Psychotropic substance abuse among adolescents: a structural equation model on risk and protective factors

The use of psychotropic substances in adolescents represents a serious public health problem. In this study a representative sample of 485 Austrian students between 14 and 18 years of age were investigated with a semistructured interview about substance-related issues and completed the general health questionnaire. The following rates of regular psychotropic substance use were found: cigarettes 41.4%, alcohol 44.5%, cannabis 10.1%, and other illicit substances 3%. Logistic regression analyses and structural equation modeling revealed the following major risk factors for substance use: peer pressure, negative family atmosphere, school difficulties, and psychopathology. Knowledge about substance use acted as a protective factor. Prevention of adolescent substance use and misuse should aim at these different targets. Information about coping with peer pressure may be a particularly promising route of intervention.     

Psychotropic Substance Abuse1 Among Adolescents: A Structural Equation Model on Risk and Protective Factors

The use of psychotropic substances in adolescents represents a serious public health problem. In this study a representative sample of 485 Austrian students between 14 and 18 years of age were investigated with a semistructured interview about substance-related issues and completed the general health questionnaire. The following rates of regular psychotropic substance use were found: cigarettes 41.4%, alcohol 44.5%, cannabis 10.1%, and other illicit substances 3%. Logistic regression analyses and structural equation modeling revealed the following major risk factors for substance use: peer pressure, negative family atmosphere, school difficulties, and psychopathology. Knowledge about substance use acted as a protective factor. Prevention of adolescent substance use and misuse should aim at these different targets. Information about coping with peer pressure may be a particularly promising route of intervention.     

The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center

Background: The Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale has been validated with high school students, adolescents with criminal justice involvement, and adolescent substance use treatment samples using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R and DSM-IV. This study examines the concurrent validity of the POSIT's standard 17-item substance use/abuse subscale and a revised, shorter 11-item version using DSM-5 substance use disorder diagnoses. Methods: Adolescents (N = 525; 93% African American, 55% female) 12–17 years of age awaiting primary care appointments at a Federally Qualified Health Center in Baltimore, Maryland completed the 17-item POSIT substance use/abuse subscale and items from a modified World Mental Health Composite International Diagnostic Interview corresponding to DSM-5 alcohol use disorder (AUD) and cannabis use disorder (CUD). Receiver operating characteristic curves, sensitivities, and specificities were examined with DSM-5 AUD, CUD, and a diagnosis of either or both disorders for the standard and revised subscales using risk cutoffs of either 1 or 2 POSIT “yes” responses. Results: For the 17-item subscale, sensitivities were generally high using either cutoff (range: 0.79–1.00), although a cutoff of 1 was superior (sensitivities were 1.00 for AUD, CUD, and for either disorder). Specificities were also high using either cutoff (range: 0.81–0.95) but were higher using a cutoff of 2. For the 11-item subscale, a cutoff of 1 yielded higher sensitivities than a cutoff of 2 (ranges for 1 and 2: 0.96–1.00 and 0.79–0.86, respectively). Specificities for this subscale were higher using a cutoff of 2 (ranges for 1 and 2: 0.82–0.89 and 0.89–0.96, respectively). Conclusions: Findings suggest that the POSIT's substance use/abuse subscale is a potentially useful tool for screening adolescents in primary care for AUD or CUD using a cutoff of 1 or 2. The briefer, revised subscale may be preferable to the standard subscale in busy pediatric practices.     

Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C,CRAFFT, RAPS4-QF,FAST, RUFT-Cut,and DSM-IV 2-Item Scale

Background

This study compared six of the briefest screening instruments for detecting DSM-IV-defined Alcohol Use Disorder (AUD) among older adolescents treated in Emergency Departments (ED).

Methods

The AUDIT-C, the RAPS4-QF, the FAST, the CRAFFT, the RUFT-Cut, and 2-Items from the Diagnostic and Statistical Manual IV of the American Psychiatric Association [American Psychiatric Association (1994). Diagnostic and Statistical Manual of Psychiatric Disorders, (1994) (DSM-IV). 4th ed. Washington D.C.: American Psychiatric Association] criteria for AUD (heretofore referred to as the DSM-IV 2-Item Scale) were evaluated against the criterion of a current DSM-IV diagnosis of either alcohol abuse or dependence. The instruments were administered to 181 alcohol-using older adolescents (57% males; age range 18–20 years) in an ED and compared using Receiver Operator Characteristic (ROC) analyses against the criterion of a current DSM-IV diagnosis of alcohol abuse or dependence.

Results

Of these instruments, the DSM-IV 2-Item Scale performed best for identifying AUD (88% sensitivity and 90% specificity), followed by the FAST and the AUDIT-C.

Conclusions

Two items from the DSM-IV criteria for AUD performed best for identifying ED-treated older adolescents with alcohol use disorders. The FAST and AUDIT-C performed well, but are longer and more difficult to score in the hectic environment of the Emergency Department.     

Reliability of DSM-IV diagnostic criteria using the semi-structured assessment for drug dependence and alcoholism (SSADDA)

The semi-structured assessment for drug dependence and alcoholism (SSADDA) yields reliable DSM-IV diagnoses for a variety of psychiatric disorders, including alcohol and drug dependence. This study examines the reliability of individual DSM-IV criteria for lifetime substance dependence diagnoses and the impact of those criteria on diagnostic reliability. METHODS: Two hundred ninety-three subjects (52.2% women; 38.2% African American, 46.8% European American, 7.5% Hispanic) were interviewed twice over a 2-week period to examine the inter-rater reliability (n=173) or test-retest reliability (n=120) of the SSADDA. Cohen's kappa-statistic and its confidence interval were used to assess the reliability of individual diagnostic criteria. RESULTS: Overall, the inter-rater reliability estimates were excellent for individual DSM-IV criteria for nicotine and opioid dependence; good for alcohol and cocaine dependence, and fair for dependence on cannabis, sedatives and stimulants. The impact of any individual criterion on diagnostic reliability was minimal, consistent with the notion that the DSM-IV diagnosis of substance dependence measures an underlying construct that is relatively consistent across specific groups of substances. CONCLUSIONS: These results, combined with results from a study of the SSADDA's diagnostic reliability [Pierucci-Lagha, A., Gelernter, J., Feinn, R., Cubells, J.F., Pearson, D., Pollastri, A., Farrer, L., Kranzler, H.R., 2005. Diagnostic reliability of the semi-structured assessment for drug dependence and alcoholism (SSADDA). Drug Alcohol Depend. 80, 303-312], show that the instrument can be used reliably to assess substance dependence.     

Adolescents' alcohol and drug use trajectories in the year following treatment

OBJECTIVE: Beyond the initial relapse episode, little is known about short-term patterns of alcohol and other drug use in treated adolescents. This study characterized treated teens' short-term alcohol and other drug use trajectories over 1-year follow-up. METHOD: Adolescents (N = 110, ages 12-18, 65% male, 94% white) recruited from addictions treatment, with a current DSM-IV alcohol diagnosis, reported on daily alcohol and other drug use in monthly telephone contacts over 1-year follow-up using the Timeline Follow-Back procedure. Latent class mixture modeling identified trajectories based on maximum number of consecutive abstinent days per month, separately for alcohol and other drugs. RESULTS: Four alcohol trajectories were identified: high abstinence (53%), decreasing abstinence (10%), increasing abstinence (16%) and low abstinence (21%). The alcohol trajectories were distinguished by gender, age, readiness to change substance use and alcohol-related coping. To characterize changes in alcohol abstinence in relation to abstinence from other drugs, four other drug trajectories were identified: high (59%), decreasing (12%), increasing (14%) and low (15%) abstinence. Cross-classification of the alcohol and drug trajectories indicated a moderate level of concordance (kappa = 0.49). CONCLUSIONS: Multiple pathways of short-term change in alcohol and other drug use were identified. Although changes in abstinence from alcohol and other drug use tended to co-occur, exceptions were observed. Differences between alcohol trajectories in readiness to change substance use and use of substance coping suggest the potentially positive impact of targeted and effectively timed interventions that focus on motivational enhancement and on improving substance coping for certain adolescent subgroups.     

Bipolar Disorder in a Population of Adolescents with Alcohol Use Disorders

ABSTRACT

Objectives: The objective of this paper is to present the prevalence of Bipolar Disorder (BPD) in a population of adolescents and young adults with alcohol use disorders (AUD) and to compare salient alcohol use, mood, and diagnostic variables between adolescents with BPD, those with Major Depressive Disorder (MDD), and those with AUD without a mood disorder.

Methods: The subjects were 452 adolescents and young adults, age 12.9 to 28.3 years, who met DSM-IV criteria for a lifetime history of either alcohol abuse or alcohol dependence. DSM-IV psychiatric and AUD diagnoses were obtained by semi-structure interviews (K-SADS and SCID) to discern the possible effect of comorbid BPD on alcohol and other drug variables, we compared adolescents or young adults who met DSM-IV criteria for concurrent BPD and AUD with adolescents with MDD plus AUD and those with AUD and no mood disorder. Following one-way ANOVA comparing across the 3 groups, we proceeded with post hoc analysis comparing the BPD+AUD group with either the MDD + AUD or AUD only group.

Results: 6.4% of the subjects met criteria for BPD. While there were no differences between groups on the alcohol consumption variables, subjects with BPD had a significantly earlier onset of an AUD diagnosis than either the MDD group or the AUD only group. The BPD + AUD group had a significantly greater percentage of subjects meeting criteria for alcohol dependence than the AUD only group.

Conclusions: Comorbid mood disorders, particularly Bipolar Disorder, may have an important effect on alcohol and substance use variables and diagnosis. More research is needed to determine the effect of treatments for mood disorder on both mood and substance use variables.     

Clinical characteristics of treatment-seeking adolescents with opioid versus cannabis/alcohol use disorders

ObjectivesTo assess the clinical characteristics of adolescents with DSM-IV opioid use disorder (OUD) and compare them to adolescents with cannabis/alcohol use disorders.Method94 adolescents (ages 14–18 years) with a current OUD and 74 adolescents with a current non-OUD cannabis/alcohol use disorders were recruited from admissions, predominantly residential, to a substance abuse treatment program in Baltimore, ML. Participants were assessed cross-sectionally using standardized interviews and self-reports. Chi-square, t-tests and ANCOVA (adjusting for age, gender and treatment setting, race and residence) were performed to determine group differences on demographic, substance use, psychiatric and HIV-risk behaviors; logistic regression analyses, both unadjusted and adjusted for the above five factors were conducted to assess the strength of associations.ResultsThe OUD group was more likely to be Caucasian, to have dropped out of school and to live in the suburbs (trend). They also had greater substance use severity with higher proportion of current sedative and multiple substance use disorders (SUD). There were generally no differences in rates of criminal behaviors. Both groups had high rates of current psychiatric disorders (83% vs. 78%, n.s.) but the OUD adolescents reported higher depressive symptoms, mostly in the moderate range. Injection drug use (IDU) and needle sharing was almost exclusive to the OUD group, while both groups reported similar high rates of risky sexual behaviors.ConclusionsWhile there were similarities between the two groups, OUD adolescents evidenced greater impairment in academic, substance use, depressive symptom and IDU-related HIV-risk areas. Findings suggest poorer long-term prognosis and highlight the need for specialized interventions for treatment-seeking OUD adolescents.     

The relationship between cannabis use and other substance use in the general population.

This study examined if (1) there is an association in the general population between cannabis use, DSM-IV abuse and dependence, and other substance use and DSM-IV substance abuse/dependence; (2) if so, is it explained by demographic characteristics or levels of neuroticism? It used data from the Australian National Survey of Mental Health and Well-Being (NSMHWB), a stratified, multistage probability sample of 10 641 adults, representative of the general population. DSM-IV diagnoses of substance abuse and dependence were derived using the Composite International Diagnostic Interview (CIDI). There was a strong bivariate association between involvement with cannabis use in the past 12 months and other substance use, abuse and dependence. In particular, cannabis abuse and dependence were highly associated with increased risks of other substance dependence. These associations remained after including other variables in multiple regression. Cannabis use without disorder was strongly related to other drug use, an association that was not explained by other variables considered here. The high likelihood of other substance use and substance use disorders needs to be considered among persons seeking treatment for cannabis use problems.     

DSM-IV alcohol and substance abuse and dependence in homeless youth

OBJECTIVE: The purpose of this study is to describe endorsement rates of substance use criteria among homeless adolescents and to evaluate the reliability of diagnostic formulations among a group of adolescents who use more frequently and more heavily than other samples of adolescents. METHOD: Substance use rates and DSM-IV abuse and dependence criteria were assessed among 198 (109 male) homeless youths between the ages of 13 and 19, as part of a larger study. Endorsement rates and reliability analyses were completed for diagnostic criteria assessed for alcohol, marijuana, amphetamines and heroin. RESULTS: Consistent with other studies of homeless youth, data revealed high rates of substance use and high rates of substance dependence. Both dependence and abuse diagnoses were associated with greater rates of use. DSM-IV criteria showed acceptable internal reliability, although variability was observed when applied to different substances. Of the drugs assessed, problems with heroin use appeared to be best, and marijuana use least, represented by dependence criteria. Criteria pertaining to continued use despite interference with role obligations and the experience of craving were consistently related to other dependence criteria. CONCLUSIONS: DSM-IV substance dependence criteria appear to have good internal reliability within a sample of adolescents who use at extremely high rates. Continued development of diagnostic systems for adolescent substance use should consider the social context of use, differential patterns of symptoms across different substances and the inclusion of additional criteria found reliable among adolescent samples.     

'Diagnostic orphans' among young adult cannabis users: persons who report dependence symptoms but do not meet diagnostic criteria

OBJECTIVE: To examine the characteristics of 'diagnostic orphans' among cannabis users-those who report one or two symptoms of DSM-IV dependence but do not meet diagnostic criteria for DSM-IV abuse or dependence. METHOD: Data were collected from a representative population cohort of 1601 young adults aged 20-21 years. Those who reported that they had used cannabis at least weekly at some point within the past year were assessed for symptoms of DSM-IV cannabis abuse and dependence using the Composite International Diagnostic Interview. RESULTS: Approximately 2.8% of the cohort could be classified as diagnostic orphans, with another 3.0 and 7.5% meeting criteria for abuse and dependence, respectively. Diagnostic orphans were: similar to those who met criteria for cannabis abuse or dependence in terms of demographic characteristics; similar to those who met criteria for cannabis abuse in terms of cannabis use patterns; and similar to those who met criteria for abuse and dependence in their rates of heavy alcohol use and DSM-IV alcohol dependence. However, they did not appear to have elevated rates of illicit drug use or mental health problems compared to non users. CONCLUSIONS: Diagnostic orphans reported using cannabis in a manner similar to persons meeting criteria for cannabis abuse, and had similar rates of alcohol dependence and other illicit drug use. Strict adherence to DSM-IV diagnoses of abuse and dependence may overlook a substantial proportion of young persons who experience cannabis-related problems. There is a need to consider (a) subthreshold levels of cannabis-related problems among those seeking treatment for other problems; and (b) interventions for this group to prevent escalation of such problems.