Adolescents and Substance Abuse

1
Adolescents and Substance Abuse

• Cigarette smoking
• Tobacco use in teens is associated with a wide
  range of risk taking behavior, including
  violence, high risk sexual activity, and drug
  use. There is a significant risk of developing a
  major depression within one year of starting to
  smoke. Children with psychiatric disorders are
  also more likely to smoke.
• Teenage smoking reached a peak in Wisconsin in
  1999 (38.1 of seniors) and has declined to
  20.9. Girls (21.9) have a slightly higher
  prevalence rate than boys (19.8).

2
Prevention of Cigarette Smoking

• The most effective antidote to smoking is
  expensive cigarettes.
• Resistance training skills are helpful to reduce
  smoking initiation.
• 75-80 of initially successful quitters resume
  smoking within 6 months. If they can stay
  abstinent for 5 years, risk of relapse is
  negligible.

3
Drug and Alcohol Abuse

• Drug use increases in adolescents to young
  adulthood, then generally declines. In 2005,
  there has been a decline in alcohol use, LSD and
  cocaine, but an increase in illicit prescription
  drugs (oxycodone), marijuana, and club drugs. The
  use of inhalants is rising among 8th graders.
• Teenage drinking among girls is rising faster
  than boys, in large part because they are being
  targeted in alcohol related ads in the magazines
  they read.

4
2005 Monitoring the Future Survey

• Drinking in last month
• 8th grade 17
• 10th grade 33.2
• 12th grade 47
• 28 of seniors binge drink
• Tried an illicit drug
• 8th grade 21
• 10th grade 38
• 12th grade 50

5
Drug Abuse in Children and Adolescents

• 15 teens has abused Vicodin or OxyContin. 10
  have abused a stimulant - Adderall is the most
  common. 10 have abused cough medicines
• Most of the time, these prescription drugs are in
  the family medicine cabinet. There are Internet
  sites devoted to how to get and abuse drugs.
• Inhalant abuse can be fatal. Such agents are
  commonly found in household - glue, shoe polish,
  spray paints, nitrous oxide, correction fluid,
  etc.

6
Prevention in Children and Adolescents

• The younger the child initiates alcohol and other
  drug use, the higher the risk for serious health
  consequences and adult substance abuse and
  dependence.
• Effective prevention and intervention programs
  consider cultural context, social resistance
  skills, and developmental level of the child.

7
Prevention in Children and Adolescents

• Peers have been successfully used to influence,
  teach, and counsel young people. Even though
  education about drugs do not contribute greatly
  to reducing drug use, the use of peers as
  facilitators works for the average student.
  Adolescents believe their peers attitudes
  against drug use. The lower the perceived
  acceptance rate, the less frequent the drug use.
• DARE works better than non-interactive programs,
  but not as well as programs involving peer
  delivery of information.

8
Prevention in Children and Adolescents

• Most promising preventive measures are
• Assessment and treatment of psychiatric disorders
• Education that targets knowledge and attitudes
  about substances
• Development of proper social and problem solving
  skills
• Treatment of family problems
• Increased opportunities for prosocial activities
  with peers
• Limited early access to the use of gateway drugs
  such as alcohol and nicotine

9
Prevention in Children and Adolescents

• Risk factors
• Poor self-image
• Low religiousity
• Poor scholl performance
• Parental rejection
• Family dysfunction
• Abuse
• Over or under-controlling by parents
• Divorce
• Externalizing disorders (ADHD has 3x risk
  substance use. Those in treatment are at less
  risk)

10
Protective Factors in Children and Adolescents

• Nurturing home with good communication
• Teacher commitment
• Positive self-esteem
• Self-control
• Assertiveness
• Social competence
• Academic achievement
• Regular church attendance
• Intelligence
• Avoiding delinquent peers

11
Depression

• Depression is a constellation of symptoms
  including social isolation, lack of energy,
  changes in sleep and appetite, and an inability
  to experience pleasure that appear in addition to
  a depressed mood.

12
Substance Abuse and Mental Health Services
Administration
13
SAMHSA - 2004

• 9 of adolescents experienced a depressive
  episode over the last year.
• Girls - 13.1 Boys - 5
• No differences in ethnic group, SES in incidence,
  but those with health insurance were more likely
  to get treatment.
• Those with depression were twice as likely to
  smoke, use alcohol and illicit drugs.

14
Wisconsin High School Survey 2003

• During the last 12 months, have you felt sad or
  hopeless for 2 weeks or more so that you stopped
  doing social activities?
• Total 25.3
• Boys 17.6
• Girls 33.5
• Junior year the worst

15
Depression

• Depression may manifest itself as irritability
  and behavior problems in children and
  adolescents.
• Research now indicates that substance abuse in
  boys and girls, and sexual behavior in girls is a
  cause for subsequent depression in adolescents.
  Depression can then make teens more vulnerable to
  substance abuse and other risky behaviors.
• The use of antidepressants in children and teens
  is controversial.

16
Antidepressants and Suicide

• In the summer of 2004, two reviews by Columbia
  University looked at pharmaceutical industry data
  from 22 placebo controlled trials involving 4,250
  pediatric patients. They found that young people
  given antidepressants were 1.8x more likely to
  become suicidal as young people given placebo.

17
Antidepressants and Suicide

• On October 15, 2004, the FDA issued its strongest
  possible warning (black box) for all
  antidepressants stating that these medications
  may increase the risk of suicidal thinking and
  behavior in children and adolescents with major
  depressive or other psychiatric disorders.

18
Antidepressants and Suicide

• The best approach is to monitor everyone who is
  started on an antidepressant closely for the
  appearance of suicidal ideation, agitation, and
  irritability, especially during the initial
  months of therapy, and be sure that the risk is
  discussed during the informed consent process.

19
Self-Injurious Behavior

• SIB - the deliberate alteration or destruction of
  body tissue without conscious suicidal intent
• Four types
• Severe - extensive damage (psychotic)
• Stereotyped - rhythmic (DD, seizure disorders)
• Socially accepted/emblematic - tattooing,
  piercing, etc
• Superficial/moderate

20
Superficial/Moderate

• Compulsive
• Habitual, obsessive/comp rather than impulsive.
  Urge is resisted. (Ego-dystonic) Intrusive
  thoughts about contamination, inadequacy, bodily
  shame. Nail biting, trichotillomania, skin
  picking
• Episodic
• Occasional impulsive burning and cutting in
  response to stress or life events.
• Repetitive
• Repetitive burning and cutting, rumination about
  self-abuse and identification as a cutter or
  burner. There is little resistance to the urge.
  Carefully executed. Has qualities of addiction.

21
Superficial/Moderate

• Counter-dissociative
• An attempt to re-associate self with here and now
  reality
• Parasuicidal
• suicide gesture reflecting ambivalence about
  suicide or as attempt to communicate to others

22
Impulsive, Superficial/ Moderate SIB

• Skin cutting is the most common, followed by
  burning and hitting
• Commonly comorbid with personality disorders
• Typically includes onset in adolescence, multiple
  episodes, chronic, associated with depression,
  despair, anger, aggression, anxiety, cognitive
  constriction
• Predisposing factors include lack of social
  support, male homosexuality, AODA, suicidal
  ideation in women.
• Diagnosed as Impulse Control Dis NOS, or BPD

23
Self-Injurious Behavior

• Worldwide, nonfatal deliberate self-harm is more
  common in adolescents, especially young females
  (11.2 girls, 3.2 boys) Boys more frequently
  need medical attention.
• Self-harm in adolescents increased with
  consumption of cigarettes, alcohol and drugs in
  one large study. Having friends or family members
  self-harm was also a risk factor. Depression,
  anxiety, and impulsivity was a risk for girls,
  who said they were trying to punish themselves or
  get relief from a terrible state of mind.
• The Internet may normalize and encourage
  pre-existing SIB in adolescents.

24
Self-Injurious Behavior

• There is disagreement about the meaning of the
  injury symbolic, impulse disorder, serotonin
  deficit, endorphin dysregulation.
• Adolescents are likely to explain their self-harm
  by saying they wanted relief from unpleasant
  feelings (depression, anxiety, loneliness, anger)
  or that the act was impulsive.
• Childhood abuse is a factor in the descriptive
  and empirical literature.
• There are also associations with AODA, PTSD,
  intermittent explosive disorder, dissociative
  disorder.

25
Summary of Reasons for SIB

• Affect regulation
• Reconnection with the body
• Calming the body during periods of arousal
  (exhibit decreases in respiration, skin
  conductance, heart rate in response to the
  behavior (like concentration)
• Validating inner pain
• Avoiding suicide
• Communication
• Express things which cannot be said out loud
• Control/punishment
• Trauma re-enactment
• Bargaining and magical thinking
• Self-control
• Control of others

26
Children and Suicide

• Suicide attempts are statistically insignificant
  until the age of 12., but higher in the US in the
  last 20 years.
• Suicidal children have a history of impulsive,
  aggressive behavior, are taller and physically
  more mature than their classmates, more were
  more likely to be involved with conflict with
  parents, and be in a disciplinary crisis.
  Families must be involved in assessment,
  prevention and treatment.

27
Warning Signs

• Past suicide attempts or threats
• Past violent or aggressive behavior
• Mental illness or alcohol use
• Bringing weapons to school
• Recent experience of humiliation, shame loss
• Bullying as victim or perpetrator
• Victim of abuse/neglect
• Themes of depression, death
• Vandalism, cruelty to animals, setting fires
• Poor peer relationships, cults, no supervision

28
Suicide first arises as a public health problem
at 12 years old.
29
Suicide Rates 1981-2001
30
Adolescent Suicidal Behavior 2001 U.S. Data
31
Wisconsin Suicides

• Suicide is the second leading cause of death in
  adolescents.
• From 2000-2002, there were 323 suicides (262
  homicides.)
• The annual rate is 5.7/100,000 - 36 higher than
  the national average. The highest incidence is in
  northern Wisconsin.
• Guns are involved in 52.
• 27 tested positive for alcohol.

32
Suicidal Ideation

• In teens, suicidal ideation more strongly
  indicates antisocial behavior than it does risk
  of suicide. Features that may separate those who
  attempt from those who dont
• AODA
• Severe and enduring hopelessness
• Isolation
• Reluctance to discuss suicidal thoughts
• Psychopathology

33
Gender Issues

• Girls
• Attempts to completions 4,0001
• A suicide attempt is not a risk factor for
  suicide. Having a depressive episode is, often
  with no precipitating event
• Panic attacks are a risk factor for girls
• Boys
• Attempts to completions 5001
• Rate increased 3x since 1955 - Increased AODA?
• Dropped since 1995 - Increased antidepressants?
• Usually within hours of event, before
  consequences, when anticipatory anxiety is
  highest. Events include legal problems,
  relationship problems, humiliation.
• Aggression is a risk factor for boys

34
Risk Factors for Adolescents

• Mental illness
• 90 have depression, anxiety, AODA a year before
  suicide. It is estimated that 1 million youths
  suffer from depression, but 60-80 do not receive
  help. Fewer than 10 of completed suicides were
  on antidepressants or in AODA treatment.
• 50 of teen suicides involve alcohol use.
• Parents frequently do not recognize signs of
  suicidal behavior. Most lay people justify
  depressive symptoms in themselves and others,
  blaming it on stress. Stressors can mislead. It
  may be the mental illness that is causing the
  stress.

35
Risk Factors for Adolescents

• Imitation
• Family history
• Sexual orientation issues
• Sexual abuse
• Other stressors
• Interpersonal losses
• Bullying (perpetrator or victim)
• Lack of affiliation
• Males after romantic breakup

36
Suicide Attempts (cont)

• Girls attempt mostly by ingestion (55) or
  cutting (31). Boys by cutting (25), ingestion
  (20), firearms (15), hanging(11).
• Greatest difference in mental state between an
  ideater and attempter is the presence of AODA.
  Suicidal teens who abuse substances are 12.8x
  more likely to make an attempt.

37
Risk Factors

• Incarceration
• The suicide rate for adolescents in detention
  centers is 57/100,000. For adolescents housed in
  adult facilities is 2,041/100,000!!

38
Risk Assessment in Adolescents

• Although suicidal ideation is very common in this
  population, suicide should be asked about and
  evaluated in the context of an accompanying
  mental illness. Depressed adolescents should
  always be assessed for suicidality. It is
  important to include data from many sources,
  including parents, school, or other significant
  relationships.

39
Risk Assessment in Adolescents

• Consider the following
• Predictability of the youngster
• Circumstances of suicidal behavior
• Intent to die
• Psychopathology
• Coping mechanisms
• Communication
• Family support
• Environmental stress

40
Risk Assessment in Adolescents

• Precipitating factors in vulnerable youth may
  increase immediate risk.
• Opportunity
• Access to lethal means, lack of supervision
• Altered states of mind
• Hopelessness, rage, intoxication, mental illness
• Undesirable life events
• Losses, loss of esteem, humiliation, pregnancy,
  abuse

41
Prevention Strategies

• Suicide awareness programs
• Popular with normal teens, but they dont seem to
  increase self-referrals, help-seeking, or
  help-giving in adolescents. They may activate
  suicidal ideation in disturbed adolescents, whose
  identity is usually not known by the instructor.
  They may contribute to clustering. They also tend
  to minimize the role of mental illness.

42
Prevention Strategies

• Screening
• Assessments of depression, AODA, recent or
  frequent suicidal ideation, past suicide
  attempts. They identify a number of unknown,
  untreated cases of depression.
• Screening programs that do not include procedures
  to evaluate and refer should not be used.
• Gatekeeper training
• Teachers, counselors, MDs, youth workers trained
  to recognize teens at risk. This may work, but
  there is no clear research.

43
Prevention Strategies

• Crisis centers and hotlines
• There is little research about the effectiveness
  of these centers. Few teenagers use them, and
  those that do are not at highest risk (boys).
• Restriction of lethal means/alcohol
• A modest but statistically significant decrease
  in teen firearm suicides has been associated with
  child access prevention laws.
• Even adolescents without a mental disorder have
  13x greater suicide risk if there is a gun in the
  home and a 32x greater risk if it is loaded.

44
Restriction of Lethal Means

• Firearms
• 17 of households purchase new guns after a
  childs suicide attempt. But if they are
  educated, they are 3x more likely to remove them.
• The following reduce suicide risk in an additive
  manner
• Unloading guns
• Locking guns
• Storing ammunition separately
• Locking ammunition
• Alcohol
• States that have increased the minimum drinking
  age have seen a 7 suicide reduction in teens.

45
Prevention Strategies

• Skills training
• Teaching the problem solving and coping skills in
  the skills. Some evidence of efficacy.
• Follow-up appointments
• A nighttime phone contact and next day follow-up
  assures 90 of teens will stay in treatment after
  an ER visit.
• Antidepressants
• Caregivers need to be alert for decreasing
  inhibition, irritability, change in sleep,
  agitation in the first weeks after an
  antidepressant has been started.

46
Bipolar Disorder

• Bipolar disorder is a disorder of mood swings,
  out of proportion with events in a persons life.
  These swings include mania and depression.
• Bipolar disorder in children is enormously
  controversial! Depending on who you listen to,
  there is either an epidemic, or it is virtually
  non-existent.
• The diagnosis has increased 26 from 2002 to 2004!

47
Dr. Biederman, Mass Gen, Boston

• Irritability is the determinant, even in the
  absence of depression, elevated mood,
  grandiosity, or cycles of behavior.
• These irritable episodes are not just tantrums,
  but explosive, long-lasting, and often without
  triggers.
• This is the Broad Phenotype - Bipolar NOS
• Supported by parents, insurance companies, and by
  the observation that many of these children
  respond to medication.

48
Dr. GellerWashington U, St. Louis

• Children must have alternating episodes of mania
  and depression. The cycling can be complex and
  very short.
• This is the Narrow Phenotype.
• Children exhibit
• Excessive giddiness
• Severe irritability
• Grandiosity
• Fragmented thought
• Aggression

49
Making a Diagnosis

• Besides symptoms, we generally require three
  important validators of a diagnosis
• Family history
• Course of illness
• The first presentation of Bipolar Disorder is
  depression
• 33-50 of depressed children develop mania in
  10-15 yrs.
• Treatment response
• Bad reaction to antidepressant

50
Bipolar vs. ADHD

• Most children diagnosed with bipolar disorder
  appear to also meet ADHD criteria.
• It is rare that children with ADHD meet bipolar
  criteria.
• In adults with bipolar disorder, 33 can be
  diagnosed retrospectively with ADHD, with about
  10 having current ADHD symptoms.

51
Bipolar vs. ADHD?

• It may be that these represent different
  developmental presentations of the same
  condition
• Childhood ADHD
• Adolescent anxiety and depression
• Young adult bipolar disorder (mania)

52
Problems

• Children who get amphetamines may have an earlier
  age of onset of mania than those who dont!
• Amphetamines can be harmful neurobiologically,
  especially after adolescent exposure, with
  hippocampal atrophy, disturbed dopaminergic
  activity, enhanced corticosteroid response to
  stress, and increased long-term depressive and
  anxiety behaviors.

53
Distinguishing Bipolar Disorder from ADHD

• Sleep problems are more common in bipolar.
• Irritability, frustration intolerance and
  aggression are present in both.
• Attention problems can be the same.
• Mood symptoms distinguish the bipolar group, but
  not until 7 years old.
• Hallucinations, delusions, suicidal and homicidal
  behavior is more common in bipolar

54
Bipolar Disorder

• Treatment is usually with the mood stabilizer
  Depakote. ADHD symptoms usually do not respond to
  Depakote.
• The best evidence is for lithium.
• Antipsychotics are frequently used, but with very
  limited data.