Adolescent Psychotherapeutic Medications Current Approaches

1
Adolescent Psychotherapeutic Medications- Current
Approaches

• Merrill Norton Pharm.D. ,D.Ph., NCAC II,CCS
• Clinical Associate Professor
• University of Georgia College of Pharmacy
• Athens, Ga
• Email mnorton_at_rx.uga.edu

2
Current Approaches

• Whats New in Child and Adolescence Medications
• David C. Rettew, M.D.
• Rochelle Head-Dunham, M.D., FAPA

3
Whats New in Child and Adolescence
Psychotherapeutic Medications

• Focalin XR ( Dexmethylphenidate)
• Methylin Chewable (Methylphenidate)
• Methylin Liquid (Methylphenidate)
• Pristiq (Desvenlafaxine)
• Vyvanse (Lisdexamfetamine)
• Clinical Handbook of Psychotropic Drugs for
  Children and Adolescents 2nd Edition ( 3rd
  Edition out later this year)

4
Adolescent Mood Disorders Management and
Medication

• David C. Rettew, M.D.
• Associate Professor of Psychiatry and Pediatrics
• Director, Pediatric Psychiatry Clinic
• UVM College of Medicine

5
Understanding Psychiatric Disorders(New School)
Genetics
Phenotype
Prenatal environment
Comprehensive Treatment
Attachment
Temperament
Parenting
Exposures
SES
6
Pediatric DepressionDiagnosis 5 of 9 -
Distinct 2 Week Period

• Depressed mood (Irritability)
• Anhedonia
• Weight change (Failure to make expected gains)
• Sleeping Disturbance
• Psychomotor Agitation/Retardation

• Energy Loss
• Guilt/Worthlessness
• Concentration Impairment/Indecisive
• Suicidal Thoughts/Recurrent Thoughts of Death

7
Dysthymia

• Long, term mood symptoms
• More chronic (most days for at least a year),
  less intense
• Need 2 neurovegetative symptoms
• Studies show equivalent or even greater
  impairment compared to depression

8
Predictors of Suicidal Behavior

• Prior attempts
• Other psychiatric disorders
• Impulsivity/aggression
• Availability of firearms
• Exposure to negative events
• Family history of suicidal behavior
• Substance abuse
• Attemptcompletion ratio about 60001 in girls
  and 4001 in boys

9
Pediatric DepressionComorbidity
Spencer T, MGH Study of Depression
10
Assessment and Treatment
11
Overall Assessment Plan

• Visit 1
• Is there a problem?
• Safety assessment
• Other medical conditions
• Distribute general rating scale
• Visit 2
• Review general rating scale
• Establish primary diagnosis
• Initial treatment plan

• Visit 3 and Beyond
• Track progress
• Check gaps and assumptions

From D Rettew, OCD in the Primary Care Setting,
2007
12
General Treatment Guidelines

• Medication
• Environment
• Sleep, structure, media
• Psychotherapy (evidence based)
• Parents
• School
• Resources

13
Guidelines for Treatment of Adolescent Depression
in Primary Care (GLAD-PC)

• Expert consensus driven guidelines published in
  Pediatrics (2007)
• Conducted focus groups, surveys, literature
  reviews,

http//www.glad-pc.org/documents/GLAD-PCToolkit.pd
f
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GLAD-PC Recommendations

• Identification
• Patients at risk for depression should be
  identified and systematically monitored
• Assessment/Diagnosis
• High-risk adolescents should be evaluated for
  depression as well as those with a chief
  complaint of emotional problems
• Clinicians should use standardized tools to aid
  in the assessment

15
GLAD-PC RecommendationsAssessment should include

• Interviews with family members
• Degree of impairment across domains
• Other psychiatric conditions

16
GLAD-PC RecommendationsInitial Management

• Educate patient and family about depression
• Outline confidentiality and its limits
• Develop a treatment plan with specific goals in
  key areas of functioning
• Establish links with resources (mental health,
  family members)
• Develop a safety plan contract?

17
GLAD-PC RecommendationsFurther Management

• Mild depression consider active support and
  monitoring
• Moderate/severe/complicated consider
  consultation with a mental health specialist
• Establish roles of primary care and mental health
  specialist with family
• Recommend scientifically tested treatments
• Monitor for adverse effects of treatment

18
Severity of Depression
19
GLAD-PC RecommendationsFurther Management

• Continue to track outcomes and functional targets
• Reassess diagnosis and treatment if no response
  in 6-8 weeks
• Consider consultation with mental health
  professional if treatments produced only partial
  response
• Ensure adequate management

20
Pharmacotherapy

• Response 40-70 with medications vs 30-60 for
  placebo
• Remission with medications lower (30-40)
• Little efficacy evidence for non SSRIs
• Bupropion effective in open trials

21
Medications in Depression
22
Pharmacotherapy Tips

• Half life of antidepressants often shorter in
  children and adolescents
• Watch for withdrawal symptoms on qd dosing
• Goal for remission at 12 weeks (consider switch
  if no or little response at 8 weeks)

23
Text of Black Box Warning 2/05
24
Proposed Mechanisms of Increased Suicidal
Behavior

• Medication adverse affects insomnia, agitation,
  irritability
• Switching patients with bipolar disorder
• Acute effects on serotonin that differ from
  long-term effects
• Greater comfort in disclosing ideation

25
Change in Youth Antidepressant Prescribing
Psychiatric News, September 2005
26
Official Monitoring Guidelines
FDA AACAP

• Once per week x 4 weeks
• Every 2 weeks for next 8 weeks
• At end of week 12 and regularly thereafter
• More often if problems or questions arise
• No scales recommended

• www.parentsmedguide.org
• www.aacap.org
• Fluoxetine alone, or Fluoxetine CBT, or CBT
  alone as 1st line
• Monitor consistent with FDA guidelines (though no
  specific data to support such frequency of
  contact)

• From FDA Proposed Medication Guide About Using
  Antidepressants in Children or Teenagers (Center
  for Drug Evaluation and Research)
  http//www.fda.gov/cder/drug/antidepressants/SSRIM
  edicationGuide.htm

27
Recent Meta-AnalysisBridge et al., JAMA 2007

• Covered 27 controlled studies in depression and
  anxiety
• MDD medication response vs placebo 61 vs 50
• Less response for younger children, except with
  fluoxetine
• Suicidality on medications vs placebo 2 vs 1
  (statistically significant across all disorders
  but not MDD alone)
• More efficacy with shorter depression duration
• Concluded a favorable benefit to risk comparison
  for cautious use as first line treatment

28
Suicide Rates by CountyGibbons et al, AJP, 2006

• Highest rates often in rural western areas and
  lowest in most major cities
• More SSRI Rxs, less suicides even after
  controlling for mental health care and income

29
Pediatric Bipolar Disorder

• One of most controversial topics in child
  psychiatry
• Underdiagnosed vs. Overdiagnosed?
• In forefront of physician/pharma discussions

30
Pediatric Bipolar DisorderCriteria Overlap with
ADHD

• Distractibility
• Increased activity/psychomotor agitation
• Grandiosity
• Flight of ideas

• Activities with painful consequences
• Sleep decrease
• Talkativeness

In children, characterized by ultradian cycling
in about 75 and prominent suicidality in about
25
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Proposed New CategoriesLiebenluft et al., 2003

• Narrow Mood elevation duration
• Intermediate
• Clear symptoms but 1-3 day duration OR
• Clear episodes but irritable
• Broad Chronic, nonepisodic, irritability

32
Dilemma in Pediatric Bipolar Disorder
Safety if untreated
Lack of efficacy data
Worse Course?
Increased Stigma
Risks with Medications
33
Special CommunicationJAACAP, March 2005
34
The FIND ThresholdJAACAP, 2005

• Frequency most days in a week
• Intensity extreme disturbance in one setting or
  moderate disturbance in two
• Number 3 or more times a day
• Duration occur 4 or more hours a day total

35
PsychopharmacologyBipolar 1 in acute phase No
psychosis

• Adequate trial means 4-6 weeks at therapeutic
  blood level or therapeutic dose (perhaps 8 weeks
  for lithium)
• Start with mood stablizer (lithium, valproate,
  carbamazapine) or atypical antipsychotic
  (risperidone, olanzapine, quetiapine) monotherapy
• If no response, switch
• If partial response, augment
• Consensus panel did not/could not favor
  particular agent
• Trials of lamotragine (Lamictal), oxcarbazepine
  (Trileptal), ziprasidone (Geodon), aripiprazole
  (Abilify) recommended only after combination
  treatment fails

36
Antipsychotic FDA Approvalsin Pediatrics

• Risperidone (Risperdal) Schizophrenia (age
  13-17) Bipolar Disorder (age 10-17) Autism
  irritabiltiy/aggression (age 5-16)
• Aripiprazole (Abilify) Bipolar Disorder (ages
  10-17)
• Olanzapine (Zyprexa) None
• Quetiapine (Seroquel) None
• Ziprasidone (Geodon) None

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Risks of TreatmentInformed Consent

• Weight gain and diabetes new monitoring
  protocol published by ADA, 2004
• Cognitive dulling
• Polycystic Ovarian Syndrome
• Hypothyroidism
• Abnormal involuntary movements
• Liver disease
• Pancreatitis

• Prolactin elevation
• Cardiac effects??
• Neuroleptic malignant syndrome

38
ADA Protocol Prior to Using Atypical
Antipsychotics

• Personal and family history of obesity, diabetes,
  dyslipidemia, hypertension, cardiovascular
  disease
• Weight, height, BMI,
• Waist circumference at umbilicus
• Blood pressure

• Fasting glucose
• Fasting lipid profile
• Reassess at 4, 8, and 12 weeks
• Switch agents if gains 5 of body weight

39
My Treatment Approach

• If meets criteria for narrowly phenotype then
  proceed directly to bipolar treatment
• If broad phenotype, attempt non-medication and
  treatment of other conditions first

40
11 Reasons for why the medicine is not working

• Diurnal Variation
• Nonpsychiatric Causes
• Dose and Duration of Treatment
• Comorbidity (child)
• Comorbidity (parent)

• Medication Side Effects
• Compliance
• Multinformant Variation
• Substance abuse
• Medication Limitations
• Lack of Commitment

41
Co-Occurring Disorders Commonly Diagnosed During
Childhood and Adolescence

• Rochelle Head-Dunham, M.D., FAPA
• Board Certified Psychiatrist and Addictionologist
• Medical Director
• Louisiana Office of Addictive Disorders

42
Goals and Learning Objectives

• Discuss distinguishing features of conditions
  commonly diagnosed during childhood and
  adolescence
• Highlight the complexities of co-occurring drug
  use
• Discuss treatment implications and sustainability
  issues for clinicians

43
DSM IV Disorders Diagnosed in Infancy, Childhood,
or Adolescence

• Mental Retardation
• Learning Disabilities
• Motor skills Disorders
• Communication Disorders
• Pervasive Developmental Disorders
• Feeding and Eating Disorders
• Tic Disorders
• Eliminative Disorders
• Other Disorders (Separation Anxiety D/O)

• Attention Deficit Disorder
• Mood Disorders
• Anxiety Disorders
• Substance-Related Disorders
• Disruptive Behavioral Disorders (Conduct and
  Oppositional Defiant Disorders)
• Psychotic Disorders
• Sleep Disorders
• Eating Disorders

44
What is ADHD?

• The most chronic
• neurobiological disorder of
• childhood, characterized by
• inattention, hyperactivity and impulsivity
• Pediatrics, Vol 105, Number 5, 2000 May.

45
ADHD DSM IV Criteria

• Either (1) symptoms of inattention, (2) symptoms
  of hyperactivity-impulsivity or (3) both
• Onset
• 6 months of disturbance
• Cross-situational (home, school, work)
• Impairment in functioning (socially, academically
  or occupationally)
• Diagnostic and
  Statistical Manual, Text Revision,2000.

46
Neurobiology of ADHD

• Abnormal brain structure involving dorsolateral
  prefrontal-subcortical circuitry
• Primary deficiencies
• Executive function (planning, organizing,
  sequencing, focusing/attending)
• Establishing priorities
• Willcutt EG et al. Biol Psychiatry, 2005.

47
Symptom Criteria Common for all Types

• Short attention span
• (poor attention to detail, frequent silly
  mistakes)
• Distractibility
• (hypersentive to environmental stimuli)
• Poor internal supervision
• (lives in the moment, problems with long-term
  goals)

• Organizational problems
• (frequently late, haphazard approach, trouble
  focusing on long term goals)
• Poor Follow-through
• (multiple interests without completions)

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Causes of ADHD

• Highly Heritable
• The heritability of ADHD is estimated to be 76,
  the result of complex genetic mechanisms
  involving several genes.
• Dysregulation of central dopaminergic and
  noradrenergic networks underlie the
  pathophysiology.
• Farone, SV. Biological Psychiatry, 2005.
• Biederman J et al. J Atten Disorders, 2002

49
Causes (cont.)

• Prenatal Factors
• Maternal smoking and drinking during pregnancy
  increase risk of development of ADHD
• Biederman J, et al.. J Am Acad CAPsych, 2002.
• Environmental Factors
• Chaos, psychosocial adversity and family discord
  are risk factors for expression without
  recognition and adequate treatment for ADHD.
  Additionally, lead exposure has been linked to
  causality.
• Psycho Med. 2002 July, 32.
• Environmental Health Online, 2006.

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Prevalence

• 4-12 of school-aged communities
• 40-60 persistence into adulthood
• 9.3 males and 2.9 females in the general
  population
• Non-hyperactive boys and all females are
  generally under diagnosed
• Females primarily exhibit symptoms of the
  inattentive type
• In relation to Mood Disorders
• 18 Coexistence (1/5)
• Usually the inattentive and combined subtypes
• Pediatrics, Vol 105, Number 5, 2000 May

51
Consequences of Underdiagnosing

• 54 develop a history of alcohol or drug abuse
  /dependence!
• 43 of untreated aggressive hyperactive boys will
  be arrested for a felony by age 16!
• 75 have interpersonal problems!
• 35 never finish high school!

52
ADHD Lifespan Disorder
75
Children with ADHD
Persist
50
Adolescents With ADHD
Persist
Adults with ADHD
Prevalence in Juvenile population 6-9
Prev. in Adults 3-5
53
Lifespan Impairment

Children
ADHD
Academic Limitations
Occupational/ Vocational
Adults
Relationships
Legal Difficulties
Low Self Esteem
Motor Vehicle Accidents
Injuries
Smoking and Substance Abuse
Adolescents
54
Assessment Scales

• Connors Scales
• Conners Teachers Rating Scale (CTRS-R)
• 28-item scale for children 3-17
• Differentiates hyperactive and learning-disabled
  vs. normal
• Sensitive to medication effects
• Conners Parents Rating Scale (CPRS-R)
• 48-item scale
• Distinguishes groups of children vs normal
• Sensitive to effects of treatment
• Conners Adult ADHD Rating Scale (CAARS)
• 93item scale for adults
• Correct classification rate 85
• Connors,CK. J. Clin Psychiatry 1998

55
Psychiatric Disorders and ADHD(Differential
Diagnosis)
56
Childhood ADHD or Bipolar Disorder?

• Overlapping Symptoms
• Irritability
• Hyperactivity
• Accelerated Speech
• Distractibility

• Distinct BPD Symptoms
• Elation
• Grandiosity
• Flight of ideas/racing
• hypersexuality

• Key Points
• Differentiation is extremely difficult
• Stimulant response not diagnostically helpful
• 25 youth with ADHD meet criteria for mania
• Onset of BPD with h/o ADHD is 11-12 yrs of age
• Depressive D/O usually first manifested.
• Landsford, A. Am Academy of Peds, 2005.

57
Practice Guidelines for ADHD

• The American Academy of Pediatrics Recommends the
  following guidelines
• Complete evaluations if symptoms of ADHD and poor
  performance, underachievement behavioral
  problems
• Diagnose using DSMIV-TR criteria
• Obtain information from more than one setting
  (especially schools)
• Always assess for coexisting conditions
• Stimulant medications and behavioral therapy are
  first line

58
Mood Disorders in Youth

• Usually a family history of mood disorders
• Poorer outcomes during adolescents due to
  increased risk of suicides
• Pediatrics, Vol 105, Number 5, 2000 May.

59
MOOD DISORDERS in Youth

• Major Depressive Disorder
• A two week period or more of depressed mood
  associated with hopelessness, despair, impaired
  sleep, appetite, concentration, energy and
  interests
• Bipolar Disorder
• Periods of depression alternating with manic
  periods, which may include irritability, "high"
  or happy mood, excessive energy, behavior
  problems, staying up late at night, and grand
  plans lasting at least one week
• Dysthymia
• Sad, irritable mood most of the time for a
  minimum of one year
• DSMIV, Fourth Edition, 1994.

60
Depression in Childhood

• Symptoms similar to Adults
• sadness
• hopelessness
• feelings of worthlessness
• excessive guilt
• change in appetite
• loss of interest in activities
• recurring thoughts of death or suicide
• loss of energy
• helplessness
• fatigue
• low self-esteem
• inability to concentrate
• change in sleep patterns

61
Depression in Childhood

• Behaviors more common in kids
• a sudden drop in school performance
• inability to sit still, fidgeting, pacing,
  wringing hands
• pulling or rubbing the hair, skin, clothing or
  other objects
• In contrast
• slowed body movements, monotonous speech or
  muteness
• outbursts of shouting or complaining or
  unexplained irritability
• crying
• expression of fear or anxiety
• aggression, refusal to cooperate, antisocial
  behavior
• use of alcohol or other drugs
• complaints of aching arms, legs or stomach, when
  no cause can be found

62
Depression in Childhood
Treatment Psychotherapy Therapy-- essential to
development of necessary academic and social
skills typically responsive (adaptable) teaches
expression of feelings and develops ways of
coping with the illness and environmental
stresses. Medication some children respond to
antidepressant medications must be closely
monitored by a physician with expertise in this
area, usually a child psychiatrist. should not
be the only form of treatment, best combined with
psychotherapy (The American
Academy of Child and Adolescent Psychiatry)
63
Grief

• The emotional suffering and confusion we feel
  after a significant loss of any kind.
• Grief is commonly equated to mean loss of another
  human being, but it also includes a pet, a
  neighborhood, an object of affection
• Grief can last as long as it takes to accept and
  learn to live with the loss. For some that can
  be months, for others, years.

64
Grief vs. Clinical Depression

• Depression Involves
• emotional, behavioral, and physiological changes
  such as hopelessness, appetite and weight and
  activity changes, guilt, poor academic
  performance, aches and pain and possible suicidal
  ideation/attempts
• recurrent, impairment requiring professional
  interventions
• Grief generally resolves with time and
  progression through the four stages of
  acceptance, working through, adjusting to the
  loss, and moving on

65
Youth Suicide Rates

• Suicide rates under age 30 increasing largely due
  to association with alcohol and drug use.
• Among adolescents and young adults suicide is
• 3rd leading cause of death ages 15-24yrs
• 6th leading cause of death ages 5-14yrs
• 50 of teens who commit suicide have a history
  of alcohol and drug use

66
Youth Risk Factors for Attempted Suicide

• depression
• alcohol or other drug use disorder (including
  binge drinking and substance abuse)
• interpersonal problems/loss (parents' divorce,
  family violence, a breakup with a boyfriend or
  girlfriend, stress to perform and achieve, and
  school failure) and
• aggression or disruptive behaviors, prior attempt
• (Roy, 1992)

67
Drug Use Data and Youth Suicide Risk

• Among those with cocaine use disorders, 31
  reported previous suicide attempts, (Darke
  Kaye, 2004).
• Prevalence of cocaine use is reported as 20 in
  completed suicides in New York City (Marzuk et
  al., 1992).
• Methamphetamine-dependent individuals are
• reported to have high rates of depression and
  suicidal
• ideation (Kalechstein et al., 2000 Zweben et
  al., 2004).
• In one study of suicide completers done in Utah,
  the
• prevalence of methamphetamine found by
  toxicology
• screens was 9 in youth and 8 in adults (Callor
  et al.,
• 2005).

68
Drug Use Data and Youth Suicide Risk

• Marijuana (MJ)
• Several studies have linked youth MJ use to
  depression, suicidal thoughts and schizophrenia
• Young people who use MJ weekly have double the
  risk of developing depression
• Teens age 12-17 who smoke MJ weekly are 3xs more
  likely to have suicidal thoughts than non users
• MJ use in some teens has been linked to increased
  risk for schizophrenia in later years
• (Office of National Drug Control
  Policy/ONDCP, 2005)

69
Anxiety Disorders

• 25 Coexistence with ADHD-inattentive and
  combined subtypes (i.e.,obsessive-compulsive
  disorder, generalized anxiety disorder)
• Higher risk of anxiety disorders among relatives,
  however transmission may not be
  genetic Pediatrics, Vol 105, Number 5, 2000
  May.
• Simple phobias and Separation Anxiety Disorder
  are very common in young kids
• Post-traumatic stress disorder (PTSD) is
  particularly problematic post Katrina and Rita

70
What is Post Traumatic Stress Disorder (PTSD)?

• Definition
• An anxiety disorder elicited when anyone
  experiences, witnesses, or is confronted with an
  event or disaster, which entails actual or
  threatened death, or injury or a threat to the
  physical integrity of themselves or others.
• DSMIV-TR, 2000.

71
Post Traumatic Stress Disorder (PTSD)

• Symptoms of PTSD
• Intrusive recollections terrifying memories,
  nightmares, or flashbacks
• Extreme emotional numbing inability to feel
  emotions, diminished interest, sense of impending
  doom
• Extreme attempts to avoid disturbing memories
  substance use problematic
• Hyperarousal panic attacks, rage, irritability,
  violence, poor sleep, concentration, and
  attention
• DSMIV-TR 2000.

72
Predicting Outcome Of Trauma Event Individual
Factors
Individual Factors
Event Factors
Duration
Proximity
Severity
Individual Factors
73
Clinical Outcomes of Trauma

• Severe Anxiety (Generalized and/or PTSD, with
  obsessive traits)
• Severe Depression and/or Grief
• Posttraumatic Stress Disorder (PTSD)
  Dissociation fragmented thoughts, amnesia
• Addictive Disorder and/or Co-occurring D/Os
• Sub-threshold Trauma-based Syndrome (STS)
  experience of clinically disabling feelings and
  behaviors, not sufficient to constitute a
  diagnosis of PTSD, but may impact functioning.

74
Disaster Response in Children and Adolescents

• Psychological impact of disaster on children is
  greater than on adults with similar exposure
• (Davis and Siegel, 2000 LeGreca, 1996 McNally,
  1993 Norris et al, 2000)
• Research supports correlates between traumatized
  parents and their children
• Too few definitive studies for conclusion

75
Victimization Trauma or Bullying

• Victimization is consistently correlated with
  increased co-occurring psychiatric problems,
  substance dependence, negative peer pressure and
  family influence, HIV risk behavior, and health
  problems
• Prevalence Rates for lifetime (67), past 90
  days (36), and acute/ current (48)
  victimization rates are higher than the diagnosis
  of PTSD (28)
• (Grella et al Stevens, Murphy McKnight 2003)

76
Conduct Disorder and Oppositional Defiant
Disorders

• Conduct Disorder (CD)
• a repetitive and persistent pattern of behavior
  in which the basic rights of others or major
  age-appropriate social norms or rules are
  violated
• Largest single group of psychiatric disorders (9
  boys, 2 girls)
• Most likely, an inherited predisposition with
  environmental and parenting influences
• Poorer outcomes combined with ADHD (delinquency,
  substance abuse)
• Behavioral therapy and psychotherapy, group or
  individual Medication for co-morbid conditions
• DSMIV, Fourth Edition, 1994.

77
Conduct Disorder and Oppositional Defiant
Disorders

• Oppositional Defiant Disorder (ODD)
• negativistic, defiant, disobedient, and
  hostile behaviors toward authority figures
• 35 coexistence with ADHD (hyperactive-impulsive
  and combined subtypes)
• 1 co-morbidity with ADHD in adolescents
• Often children with ODD later develop severe
  symptoms consistent with CD
• Pediatrics, Vol 105, Number 5, 2000 May.

78
Learning Disabilities

• 3 of the population 30-50 Psychiatric
  disorders (often autism and hyperkinetic
  disorders)
• 12-60 (reading disorders/dyslexia) coexist with
  ADHD (inattentive and combined types)
• More difficult to assessarticulation and
  professional skill limitations
• IEPs and Special education services required
• Pediatrics, Vol 105, Number 5,
  2000 May.

79
Complexities of Youth Substance Use

• Is ADD a risk factor for substance use?
• Is stimulant treatment for ADD predisposing to
  substance use?
• Is psychiatric co-morbidity a risk factor for
  substance use?
• Are there identified risk and protective factors
  for substance use?

80
ADD and Substance Use

• Findings from a 4 year prospective study of
  adolescents
• Conclusions
• ADHD and PSUD rates are both increased with
  co-existent Conduct Disorder and Bipolar
  Disorder
• Untreated ADHD adolescents are more likely to
  experiment with drugs and alcohol
• Untreated ADHD adults are more likely to become
  dependent on drugs and alcohol
• Biederman J, et al. APP Focus 2003

81
Stimulant Medication and PSUD

• Data collected from 6 studies involving 674
  medicated and 360 non-medicated ADHD adolescents
  over a 4 year period
• Findings
• 1.9 fold decrease in risk of SUD in treated group
• Similar decreased risk of later alcohol and drug
  use disorders
• Conclusion
• Stimulant medication was protective against SUD,
  decreasing the risk of later alcohol and drug
  dependence
• Wilens T E, et al. Pediatrics 2003 Jan.

82
Misuse and DiversionAmong College Students

• Most students not using (93.2) or misusing
  (5.4) stimulants for ADHD
• 2 of 3 prescribed stimulant for ADHD use them for
  medical use only (1.5 vs. 0.7)
• Likelihood of students who use stimulants for
  ADHD being approached about diverting their
  medication
• Twice that of college students in general (54
  vs. 27)
• At least 3 times that for pain medication,
  sedatives/anxiety agents, or sleeping medications
  (54 vs. 19, 19, 14)
• McCabe SE, et al. J Am Coll Health, 2006.

83
PSUD ADHD in Adults

• Study examined association between ADHD, PSUD and
  co-existing conditions in adults
• Conclusions
• ADHD is an independent risk factor for SUD
• ASPD is a risk factor for SUD independent of ADHD
• Mood and Anxiety Disorders are risk factors for
  SUD
• Biederman J et al. AmJPsych 1995.

84
Caring Communities Youth Survey(CCYS) 2002,
2004, 2006

• Report summarizes risk and protective factors
  based on survey responses by 6th, 8th, 10th, and
  12th graders in Louisiana public schools, to drug
  related questions
• Four Domains
• Family Factors
• Community Factors
• School Factors
• Peer/Individual Factors

85
CCYS Risk Factor Scales

• Community Domain
• Low neighborhood attachment
• Community disorganization
• Transitions and mobility
• Laws and norms favorable toward drug use
• Perceived availability of drugs
• Perceived availability of guns
• Family Domain
• Poor family management
• Family conflict
• Family history of antisocial behavior
• Parental attitudes favorable toward drugs
• Parental attitudes favorable toward antisocial
  behavior

• School Domain
• Academic failure
• Low commitment to school
• Peer/Individual Domain
• Rebelliousness
• Early initiation of antisocial behavior
• Early initiation of drug use
• Attitudes favorable toward drug use
• Perceived risks of drug use
• Interaction with antisocial peers
• Friends who use drugs
• Rewards for antisocial behavior
• Depressive symptoms
• Gang involvement
• Intentions to use drugs

86
What Substances Do Adolescents Use?

• National Survey on Drug Abuse and Health (NSDUH)
  2006 Ages 12-17
• Trends 2002-2006 MJ and Nicotine
  (cigarettes)-decline, Alcohol and Cocaine-no
  change
• Increased prescription pain medicine drug use
  (non-medicinal use)
• Illicit Prescription Drug use Gateway to Street
  Drug use

87
What Substances Do Adolescents Use?

• National Survey on Drug Abuse and Health (NSDUH)
  2006 Ages 12-17
• Illegal drugs not perceived as more problematic
  than prescription drugs
• Methamphetamine one time use not perceived as
  dangerous
• 1/3 of all new drug abuse ages 12-13 yrs but as
  early as 10 yrs
• Girls more than boys use prescription drugs
  (especially pregnant teens, and young adults)

88
Access to Drugs

• HOME environment is number one source!
• 50 from family members (medicine
  cabinets/friends or taking it from them degree
  of availability predictive of degree of use
• The Internet .The New Drug Dealer
• (Availability of Addictive opioids (pain meds),
  depressants (alcohol, Xanax), stimulants
  (Ritalin, Adderall, Methamphetamine)

89
Internet Drugs

• Anything Goes scenario
• not requiring prescriptions for purchases.
• online consultations (intended to replace a
  face-to-face evaluation from a physician does
  not constitute a legitimate doctor-patient
  relationship)
• (Alcoholism Drug Abuse Weekly, June 26,
  2006)

90
Internet Drugs

• Benzodiazepines most widely available on Internet
• Xanax and Valium are the most frequently offered
• Breakdown of the classes of drugs available on
  the 185 selling sites
• Benzodiazepines 155
• Opioids 126
• Stimulants 14
• Barbiturates 2
• broad advertising, computer based, with no
  controls to block sales to minors
• 20/185 sites required buyers to have a
  prescription
• 14/20 sites allow buyers to fax prescriptions
• 3/20 sites require a prescription
• 60 now using the online consultation
• National Center on
  Addiction and Substance Abuse at
• Columbia University,
  2004.

91
Internet Drugs What should we do?

• Improved Parental monitoring of and education
  about internet use
• Curriculum development on subject with updates
• Clarification of federal law prohibiting online
  sale or purchase of controlled prescription drugs
  without an original copy of a prescription issued
  by a physician with DEA
• Warnings of illegal use and blockage of sites
  that fail to require a legitimate prescriptions
• Public service announcements on the dangers of
  online purchasing (could appear during Internet
  searches for prescription drugs.)
• a national nonprofit clearinghouse designed to
  identify and shut the operations of illegal
  Internet pharmacies

92
Intervention Strategies

• What can we Do?

93
Prevention

• Identify at risk kids based on risk factors
  typically associated with adverse behaviors.
• Advocate for inclusion of identified protective
  factors in settings you control

94
CCYS Risk Factor Scales

• Community Domain
• Low neighborhood attachment
• Community disorganization
• Transitions and mobility
• Laws and norms favorable toward drug use
• Perceived availability of drugs
• Perceived availability of guns
• Family Domain
• Poor family management
• Family conflict
• Family history of antisocial behavior
• Parental attitudes favorable toward drugs
• Parental attitudes favorable toward antisocial
  behavior

• School Domain
• Academic failure
• Low commitment to school
• Peer/Individual Domain
• Rebelliousness
• Early initiation of antisocial behavior
• Early initiation of drug use
• Attitudes favorable toward drug use
• Perceived risks of drug use
• Interaction with antisocial peers
• Friends who use drugs
• Rewards for antisocial behavior
• Depressive symptoms
• Gang involvement
• Intentions to use drugs

95
What can We Do? CCYS Protective Factor Scales

• School Domain
• Opportunities for prosocial involvement at school
• Rewards for prosocial involvement at school
• Peer/Individual Domain
• Religiosity
• Social skills
• Belief in the moral order
• Interaction with prosocial peers
• Prosocial involvement
• Perceived rewards for prosocial involvement

• Community Domain
• Opportunities for prosocial involvement in the
  community
• Rewards for prosocial involvement in the
  community
• Family Domain
• Family attachment
• Opportunities for prosocial involvement in the
  family
• Rewards for prosocial involvement in the family

96
Treatments

• Aggressive diagnosis of substance abuse problems
  as well as mental health problems (diagnosing
  with expectation, during acute intoxication and
  visits for treatment of psychiatric distress,)
• Appropriate combinations of medication
  management, behavioral interventions and
  psychotherapy.

97
Medication Guidelines

• Medication may be prescribed for psychiatric
  symptoms and
• disorders, including, but not limited to
• Bedwetting - if it persists regularly after age 5
  and causes serious problems in low self-esteem
  and social interaction.
• Anxiety (school refusal, phobias, separation or
  social fears, generalized anxiety, or
  posttraumatic stress disorders)-if it keeps the
  youngster from normal daily activities.

98
Medication Guidelines

• Attention deficit hyperactivity disorder (ADHD)
  -if it interferes with school work and ability to
  get family and friends
• Obsessive-compulsive disorder (OCD) - if
  excessive time is lost to rituals and it
  interfere with a youngster's daily functioning.

99
Medication Guidelines

• Depression - if it results in a decline in school
  work and changes in sleeping and eating habits.
• Bipolar (manic-depressive) disorder if the
  behavior interferes with school performance or
  social functioning or is life threatening

100
Medication Guidelines (cond)

• Eating disorder if behavior is life
  threatening, either self-starvation (anorexia
  nervosa) or binge eating and vomiting (bulimia),
  or a combination of the two.
• Psychosis typically requires medication
  interventions symptoms include irrational
  beliefs, paranoia, hallucinations (seeing things
  or hearing sounds that don't exist) social
  withdrawal, clinging, strange behavior, extreme
  stubbornness, persistent rituals, and
  deterioration of personal habits. May be seen in
  developmental disorders, severe depression,
  schizoaffective disorder, schizophrenia, and some
  forms of substance abuse.
• Autism - (or other pervasive developmental
  disorder such as Asperger's Syndrome) when
  behaviors are harmful typically to self
  characterized by severe deficits in social
  interactions, language, and/or thinking or
  ability to learn, and usually diagnosed in early
  childhood.
• Severe aggression typically requires medication
  to prevent harm to self or others
• Sleep problems if depravation interferes with
  daytime functioning or nighttime behaviors are
  dangerous symptoms can include insomnia, night
  terrors, sleep walking, fear of separation,
  anxiety.

101
Behavioral Therapy

• Consists of interventions designed to modify
  physical and social environments
• Requires training of parents and teachers
• Involves rewards for desired behaviors (positive
  reinforcement) removal of access to positive
  reinforcement (time-out) Withdrawal of rewards
  or privileges contingent on performance (response
  cost) combining positive reinforcement and
  response cost (token economy)
• Pediatrics Vol 108, 2001 October.

102
Healthcare Professional Maintenance and
Sustainability

• Academic
• CEUs/Continuing Education Units (child and
  adolescent specific)
• Journal Subscriptions (Brown University Child
  and Adolescent Pharmacology)
• Multidisciplinary Teams/Consultations, Engage
  professional partners avoid the vacuum!
• Engage Family (expand definition)
• Explore non-traditional approaches/interventions
• Personal
• Do Fearless and Moral Inventory of Strengths and
  Limitationsrespect both!
• Avoid Burnout 3Bs -- Balance, Boundaries,
  Beliefs

103
Questions and Comments