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Title: The Most Vulnerable Victims: Children of Methamphetamine Users Plus: An Update on Adolescent Substance Abuse Treatment


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Oregonian HeadlineMarch 3, 2006
3
The Most Vulnerable Victims Children of
Methamphetamine Users Plus An Update on
Adolescent Substance Abuse Treatment
  • OPA Spring Meeting
  • March 3-4, 2006

Keith Cheng MD Medical Director, Trillium Family
Services Adjunct Associate Professor Department
of Psychiatry Oregon Health Sciences University
4
The Most Vulnerable Victims Children of
Methamphetamine Users
  • In Utero Exposure to Meth Using Parents
  • Childhood Exposure Meth Using Parents
  • Adolescent Exposure Meth Using Parents

5
In Utero Exposure
  • The effects of prenatal methamphetamine exposure
    on the developing fetus have not been well
    characterized.
  • There are conflicting studies, findings are
    confounded by the observations that approximately
    80 of the methamphetamine-using women also used
    nicotine and alcohol
  • Methamphetamine use during pregnancy is
    associated with an increased incidence of
    premature delivery, birth weights, head
    circumference, and placental abruption.
  • Cases of cardiovascular collapse and seizures
    have also been reported in women using
    methamphetamine during pregnancy.
  • Isolated cases of cardiac defects, cleft lip, and
    biliary atresia have been reported in infants
    exposed to methamphetamine in utero.

6
Prenatal Exposure StudySmith et al (2003)
Effects of Prental Methamphetamine Exposure on
growth and withdrawal sxs in infants born at
term. Developmental and Behavioral Pediatrics.
24(1)17-23
  • Study done at UCLA Meth Exposed n134, Meth
    Unexposed n160
  • Apgar Scores Birth Weight and Length were not
    significantly different from unexposed controls
  • Methamphetamine-exposed infants whose mothers
    smoked had significantly decreased growth
    relative to infants exposed to methamphetamine
    alone
  • Withdrawal symptoms requiring pharmacologic
    intervention were observed in 4 of
    methamphetamine exposed infants

7
Childhood ExposureIn These Bleak Days Parent
Methamphetamine Abuse and Child Welfare in the
Rural Midwest, in press Journal of Children and
Youth Services Review
  • Profound neglect and abuse
  • Physical danger resulting from in-house
    manufacture of the drug
  • Parents teaching their children criminal behavior
    and a paranoid distrust of authority

8
Childhood Exposure
  • Children becoming surrogate parents to younger
    siblings
  • Children Exposed to toxic fumes and the danger of
    explosions or fires
  • Children asked to steal items needed for making
    the drug or to stand guard, armed with a gun,
    looking out for police or other authorities

9
Children in State Care
  • Oregon's Meth Epidemic creates thousands of
    "orphans," abused and neglected children who fall
    into the state's care after their parents are
    arrested
  • Department of Human Services conducted its first
    statewide analysis last year, when 5,438 children
    entered state foster homes, up from 4,906 in
    2003.
  • Last year, roughly 2,750 children -- more than
    half of all foster cases -- were taken from
    parents using or making the potent drug, the
    study found
  • The Children of Meth,---Joseph Rose, Oregonian,
    August 28, 2006

10
Case Vignette 3 Admissions for Residential
Placement in 1 Week period
  • Ages 7-10 years
  • All referred from DHS
  • All came from emergency foster placements
  • All were abandoned by Meth using mothers
  • All had previous foster placements
  • All had become too physically aggressive to be
    managed in their emergency foster home
  • All had to wait 1-3 months before a new placement
    could be found

11
Adolescent Exposure
  • No Specific data or publications in peer review
    journals
  • Questions Are they more likely to use meth
    themselves? Are they more likely to drop out of
    school? Are they more likely to have a criminal
    record? Are they more likely to require long-term
    care?

12
Adolescent Case Vignette
  • Ryan 17 year old male referred for admission from
    OYA for evaluation of psychosis
  • Exposed in utero to meth and other drugs
  • Mother continued to use till he was age 5 yrs, I
    was brought up by my sister till I was 8 years
    then I took care of my mother.
  • Mother had bilateral bka for complications of
    diabetes
  • Mother died of diabetes when Ryan was 10 yrs,
    Father died from cirrhosis when Ryan was 13
  • Had ADHD sxs since first grade
  • Started using tobacco and marijuana at age 7
    years, Meth at age 13. Hasnt been in school for
    two years.
  • Used Meth for 2 years says he quit for 4 months
    till present. I decided I wanted a future.

13
Adolescent Case Vignette 2
  • Sheila is 15 in custody of DHS, placed in
    treatment because of runaway behaviors, got
    caught by police for theft
  • Been living on the streets, supports meth habit
    through prostitution, has been in OYA custody in
    the past
  • Uses meth IV, rectally, and thru smoking has been
    using since age 12 yrs, has also used cocaine,
    marijuana, and alcohol
  • Father died when Sheila was 5 yrs old in MVA
  • Mother recently incarcerated for multiple drug
    charges
  • Made suicide attempt by overdose in Nov 2005
  • Gives history that she used to smoke meth with
    mother
  • Ran away from last residential placement has hx
    of multiple residential placements
  • Has not been in school since 7th grade
  • Has history of sexual and physical abuse, PTSD,
    MDD, CD

14
Trillium Experience
  • Psychiatric Residential and Intensive Community
    Based Programs--Not a substance abuse treatment
    center
  • Average Range 350-450 ITS level admissions per
    year the past 4 yrs
  • Four years ago-admissions for children known to
    have Meth using parents approximately
    relatively uncommon, Monthly admissions
  • Currently seems that these admissions are more
    common, Weekly

15
Trends in Use (from MTF Study)
  • Use of amphetamines rose in last half of 1970s
    and peaked in 1981 with 26 use
  • After 1981 there was a steady decline ended in
    1992
  • Use peaked in the lower grades in 1996 and 1997
  • There has been a slow drop off since the mid 1990
  • No significant Changes in 2004

16
Trends in Use
  • Use of amphetamines rose in last half of 1970s
    and peaked in 1981 with 26 use
  • After 1981 there was a steady decline ended in
    1992
  • Use peaked in the lower grades in 1996 and 1997
  • There has been a slow drop off since the mid 1990
  • No significant Changes in 2004

17
Perceived Risk
  • Overall changes in perceived risk have been less
    strongly correlated with changes in usage of
    other drugs
  • However the perceived risk has been rising the
    past several years possibly accounting for the
    decline in use that occurred in 2003 with 12th
    graders

18
Disapproval
  • Disapproval rates have been high 70 - 87
    throughout the life of the study
  • From 1981 to 1992 disapproval rose gradually as
    use steadily declined
  • Disapproval then fell back 6-7 percentage points
    for a few years and the use rate rose slighted

19
Availability
  • In 1975 when MTF started amphetamines had a
    reported high level of availability
  • The level fell 10 in 1977
  • Drifted back up in 1980, then jumped sharply in
    1981
  • Declined slowly till 1991, when there was a
    modest rise then seem to stabilize during the
    late 90s
  • There has been further decline during the first
    year few years of this decade

20
More Oregon Youth being treated for
Methamphetamine Abuse
  • The Oregon Department of Human Services said that
    over the past five years the number of meth
    treatment admissions for boys under age 17 has
    grown steadily, and has skyrocketed 57 percent
    among girls.
  • In 2003 the state Office of Mental Health and
    Addiction Services reported that more than 1,700
    children were treated for methamphetamine misuse
    in the state. Of that number, more than 1,000
    were girls, up from 630 in 1999, and 742 were
    boys, up from 600

21
An Update on Adolescent Substance Abuse Treatment
22
SUD Assessment
  • History MSE
  • SUD Assessment Scales
  • Drug Testing
  • Risk Factor Analysis

23
History/MSE/PE
  • Because substance-using youth commonly keep their
    substance-using behaviors covert, there is a need
    to gather information from multiple sources,
    including parents, siblings, teachers,
    caseworkers, peers if available.
  • Polysubstance use by adolescents is the rule
    rather than the exception therefore, adolescents
    often present with multiple SUD diagnoses.
    Determine how many psychoactive substances are
    being used, and how available they are to the
    youth.
  • Determine whether there is substance use or abuse
    occurring by other members in the home or whether
    there is a lack of rules against substance use by
    juvenile members of the family.
  • Determine who are the youths peers and
    associates and whether they use substances or are
    involved in conduct-disordered and where the
    youth uses substances. Does he or she use alone
    or tend to be with groups of certain people and
    settings?
  • Be sure to assess for other psychiatric
    disorders, as there is a high level of
    comorbidity, and many symptoms of SUD can mimic
    psychiatric symptoms.

24
SUD Assessment Instruments
  • Substance Abuse Rating Instruments can be helpful
    in screening for SUDs and for monitoring
    treatment response. Lie scales can be
    especially helpful in identifying youths that
    deny their substance use
  • There are now several adolescent assessment
    instruments such as CRAFFT, SASSI, PESQ, and ADI

25
CRAFFT Questions (2 or more yes answers
suggests a serious problem warrants further
evaluation)
  • Have you ever ridden in a Car driven by someone
    who was high or had been using alcohol or drugs
  • Do you drink or take drugs to Relax
  • Do you ever drink or take drugs while you are
    Alone?
  • Do you ever Forget things you did while using
    alcohol or drugs
  • Do you Family and Friends ever tell you that you
    should cut down on your use?
  • Have you gotten into Trouble from drinking or
    taking drugs?
  • Kay DL (2004) Office recognition and
    management of adolescent substance abuse. Curr
    Opin Pedia 16532-541

26
Drug Testing
  • Use of urine drug screens can be helpful in
    identifying SUDs in youth that are skilled in
    hiding their drug use from adults. However, a
    single negative drug screen does not rule out
    drug use, abuse, or dependence and a single
    positive drug screen does not establish an SUD

27
Urine Drug Screen Detection
28
Risk Factor Analysis
  • Chaotic home environment
  • Parental Substance Abuse
  • Parental Mental Illness
  • Ineffective Parenting
  • Lack of Parental involvement/supervision
  • Failing School Performance
  • Poor Social Coping Skills
  • Association with Conduct Disordered Peers
  • Perceived parental/peer/community approval of
    drug use

29
SUD Treatment
  • Traditional Treatments
  • Peer Deviancy Training
  • Limitations of Psychoeducational Interventions
  • Medications
  • Community Based Interventions

30
Traditional Treatments
  • Alateen
  • Narcotics Anonymous
  • Group Therapy
  • Individual Therapy/Counseling

31
Peer Deviancy TrainingDishion, T.J., McCord, J.,
Poulin, F. (1999). When interventions harm
Peer groups and problem behavior. American
Psychologist, 54, 755-764
  • Dishion at Oregon Social Learning Center _at_ UO
  • 158 youth grades 6 to 8 studied 83 boys, 75 girls
    in 12 week program to reduce problem behaviors
  • Three study groups peer only, parent and peer
    groups, self study, and no intervention control
    group
  • All study group showed improvement after 12 weeks
  • Peer only groups exhibited significantly worse
    behaviors after one year, and three year
    followup, than similar at risk youths who were
    given prevention materials to study on their own
    or who had no interventions at all
  • For peer only group a 75 higher rate of
    delinquency

32
Medications
  • Evidence for use in children specifically for
    SUDs Meager to date, mostly case reports of
    small sample size studies
  • Treatment of comorbid disorders can help prevent
    development of SUD
  • Needs to be in combination with other
    interventions

33
The Evidence with ADHD Treatment
  • Biederman, J., et al. Pharmacotherapy of
    attention-deficit/hyperactivity disorder reduces
    risk for substance use disorder. Pediatrics
    104(2)e20, 1999
  • 56 boys with ADHD who were being treated with
    either stimulants or TCAs at the beginning of the
    study, 19 boys with ADHD who were not receiving
    any medications, and 137 boys without ADHD. All
    boys were Caucasian and were followed for 4 years
    and then evaluated for abuse of or dependence on
    marijuana, alcohol, hallucinogens, stimulants, or
    cocaine. At the time of evaluation, the boys were
    at least 15 years old.
  • Treating ADHD with medications appeared to reduce
    the tendency to abuse drugs and alcohol. While 75
    percent of the unmedicated ADHD boys had started
    abusing these substances in the previous 4 years,
    this was true of only 25 percent of the medicated
    ADHD boys and 18 percent of the boys without
    ADHD. The researchers calculated that treating
    ADHD with medications reduced the risk of
    substance abuse or dependence by 84 percent.

34
Long-term Stimulant Treatment and Brain Size
  • Individuals with ADHD had significantly smaller
    brain volumes in all regions
  • Compared with controls, previously unmedicated
    children with ADHD demonstrated significantly
    smaller total cerebral volumes and cerebellar
    volume
  • Unmedicated children with ADHD also exhibited
    smaller total white matter volumes compared with
    controls and with medicated children with ADHD
  • Castellanos FX, Lee PP, Sharp W et al. (2002),
    Developmental trajectories of brain volume
    abnormalities in children and adolescents with
    attention-deficit/hyperactivity disorder. JAMA
    288(14)1740-1748.

35
Difference in amounts used between addict and
patient
  • Eightball (eighth of an ounce) 3.5
    grams
  • Baggie or Teena (sixteenth of an ounce)
    1.75 grams
  • Desoxyn (methamphetamine)
  • 10 - 40 mg/day
  • 50 - 100 xs larger Dose difference between Meth
    Addict and Patient being treated for ADHD

36
Long-term effects of Amphetamines on the Brain
  • Descriptions from NIDA Website
  • Intense paranoia
  • Visual and auditory hallucinations, and
  • Out-of-control rages that can be coupled with
  • Extremely violent behavior
  • Withdrawal syndrome sxs include depression,
    anxiety, fatigue, paranoia, aggression, and an
    intense craving for the drug.

37
Case Vignettes Antabuse
  • 17 year old Asian female
  • Drinking not part of the family culture
  • History of success in academically
  • Many in peer group used drugs and etoh
  • Wanted to stop after psychiatric admission for
    suicide attempt
  • Did not want parents involved in treatment
  • 17 year old Hispanic
  • Drinking part of the culture of some family
    members
  • Marignally engaged in school
  • Many in peer group used drugs and etoh
  • Wanted to stop etoh after psychiatric admission
    for suicide attempt
  • Allowed parents to be involved in treatment

38
Prevention
39
Psychoeducational Limitations
  • The DARE Story
  • School programs should also enhance academic and
    social competence
  • Education should focus on self-control, emotional
    awareness, communication, social problem-solving,
    and drug resistance skills

40
Prevention Programs
  • Examples of evidence based practice
  • Multisystemic Therapy (MST),
  • Incredible Years,
  • Strengthening Families Program
  • Project Chrysalis

41
Scott Hengglers MST
  • Developed in the late 1970s to address several
    limitations of existing mental health services
    for serious juvenile offender
  • MST interventions aim to attenuate risk factors
    by building youth and family strengths
    (protective factors) on a highly individualized
    and comprehensive basis
  • MST is a family-based treatment model. The
    treatment plan is designed in collaboration with
    family members and is, therefore, family driven
    rather than therapist driven
  • MST services are delivered in the natural
    environment (e.g., home, school, community)
  • The typical duration of home-based MST services
    is approximately 4 months, with multiple
    therapist-family contacts occurring each week
  • Local MST program offered through Options
    503.335.5975

42
NIDA Focus on Prevention
  • Analysis of Risk Factors
  • Prevention programs should enhance protective
    factors and reverse or reduce risk factors
  • An emphasis on Family Interventions and Parental
    Management Training

43
NIDA Prevention Principles Programs Should
  • Enhance protective factors and reverse or reduce
    risk factors
  • Address all forms of drug abuse, alone or in
    combination
  • Address the type of drug abuse problem in the
    local community, target modifiable risk factors
    and strengthen identifiable protective factors
  • Be tailored to address risks specific to
    population or audience characteristics like age,
    gender, or ethnicity

44
NIDA Prevention Principles for Family School
Prevention Programs Should Also
  • In family based prevention programs, enhance
    family bonding, relationships include parenting
    skills training and enforcement of family rules
  • Be designed to intervene as early as preschool to
    address risk factors such as aggression, poor
    social skills academics
  • In school age children target academic and social
    emotion learning and self control skills
  • In adolescent school programs enhance academic
    and social competence and drug resistance skills

45
NIDA Prevention Principles for Community Programs
Should
  • Be aimed at key transition points
  • Combine two or more effective programs
  • Reach populations in multiple settings
  • Adapt to match community norms or differing
    cultural elements
  • Be long-term with repeated interventions.
    Research shows that benefits from early programs
    diminish without followup programs at a later age

46
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Title: The Most Vulnerable Victims: Children of Methamphetamine Users Plus: An Update on Adolescent Substance Abuse Treatment


1
(No Transcript)
2
Oregonian HeadlineMarch 3, 2006
3
The Most Vulnerable Victims Children of
Methamphetamine Users Plus An Update on
Adolescent Substance Abuse Treatment
  • OPA Spring Meeting
  • March 3-4, 2006

Keith Cheng MD Medical Director, Trillium Family
Services Adjunct Associate Professor Department
of Psychiatry Oregon Health Sciences University
4
The Most Vulnerable Victims Children of
Methamphetamine Users
  • In Utero Exposure to Meth Using Parents
  • Childhood Exposure Meth Using Parents
  • Adolescent Exposure Meth Using Parents

5
In Utero Exposure
  • The effects of prenatal methamphetamine exposure
    on the developing fetus have not been well
    characterized.
  • There are conflicting studies, findings are
    confounded by the observations that approximately
    80 of the methamphetamine-using women also used
    nicotine and alcohol
  • Methamphetamine use during pregnancy is
    associated with an increased incidence of
    premature delivery, birth weights, head
    circumference, and placental abruption.
  • Cases of cardiovascular collapse and seizures
    have also been reported in women using
    methamphetamine during pregnancy.
  • Isolated cases of cardiac defects, cleft lip, and
    biliary atresia have been reported in infants
    exposed to methamphetamine in utero.

6
Prenatal Exposure StudySmith et al (2003)
Effects of Prental Methamphetamine Exposure on
growth and withdrawal sxs in infants born at
term. Developmental and Behavioral Pediatrics.
24(1)17-23
  • Study done at UCLA Meth Exposed n134, Meth
    Unexposed n160
  • Apgar Scores Birth Weight and Length were not
    significantly different from unexposed controls
  • Methamphetamine-exposed infants whose mothers
    smoked had significantly decreased growth
    relative to infants exposed to methamphetamine
    alone
  • Withdrawal symptoms requiring pharmacologic
    intervention were observed in 4 of
    methamphetamine exposed infants

7
Childhood ExposureIn These Bleak Days Parent
Methamphetamine Abuse and Child Welfare in the
Rural Midwest, in press Journal of Children and
Youth Services Review
  • Profound neglect and abuse
  • Physical danger resulting from in-house
    manufacture of the drug
  • Parents teaching their children criminal behavior
    and a paranoid distrust of authority

8
Childhood Exposure
  • Children becoming surrogate parents to younger
    siblings
  • Children Exposed to toxic fumes and the danger of
    explosions or fires
  • Children asked to steal items needed for making
    the drug or to stand guard, armed with a gun,
    looking out for police or other authorities

9
Children in State Care
  • Oregon's Meth Epidemic creates thousands of
    "orphans," abused and neglected children who fall
    into the state's care after their parents are
    arrested
  • Department of Human Services conducted its first
    statewide analysis last year, when 5,438 children
    entered state foster homes, up from 4,906 in
    2003.
  • Last year, roughly 2,750 children -- more than
    half of all foster cases -- were taken from
    parents using or making the potent drug, the
    study found
  • The Children of Meth,---Joseph Rose, Oregonian,
    August 28, 2006

10
Case Vignette 3 Admissions for Residential
Placement in 1 Week period
  • Ages 7-10 years
  • All referred from DHS
  • All came from emergency foster placements
  • All were abandoned by Meth using mothers
  • All had previous foster placements
  • All had become too physically aggressive to be
    managed in their emergency foster home
  • All had to wait 1-3 months before a new placement
    could be found

11
Adolescent Exposure
  • No Specific data or publications in peer review
    journals
  • Questions Are they more likely to use meth
    themselves? Are they more likely to drop out of
    school? Are they more likely to have a criminal
    record? Are they more likely to require long-term
    care?

12
Adolescent Case Vignette
  • Ryan 17 year old male referred for admission from
    OYA for evaluation of psychosis
  • Exposed in utero to meth and other drugs
  • Mother continued to use till he was age 5 yrs, I
    was brought up by my sister till I was 8 years
    then I took care of my mother.
  • Mother had bilateral bka for complications of
    diabetes
  • Mother died of diabetes when Ryan was 10 yrs,
    Father died from cirrhosis when Ryan was 13
  • Had ADHD sxs since first grade
  • Started using tobacco and marijuana at age 7
    years, Meth at age 13. Hasnt been in school for
    two years.
  • Used Meth for 2 years says he quit for 4 months
    till present. I decided I wanted a future.

13
Adolescent Case Vignette 2
  • Sheila is 15 in custody of DHS, placed in
    treatment because of runaway behaviors, got
    caught by police for theft
  • Been living on the streets, supports meth habit
    through prostitution, has been in OYA custody in
    the past
  • Uses meth IV, rectally, and thru smoking has been
    using since age 12 yrs, has also used cocaine,
    marijuana, and alcohol
  • Father died when Sheila was 5 yrs old in MVA
  • Mother recently incarcerated for multiple drug
    charges
  • Made suicide attempt by overdose in Nov 2005
  • Gives history that she used to smoke meth with
    mother
  • Ran away from last residential placement has hx
    of multiple residential placements
  • Has not been in school since 7th grade
  • Has history of sexual and physical abuse, PTSD,
    MDD, CD

14
Trillium Experience
  • Psychiatric Residential and Intensive Community
    Based Programs--Not a substance abuse treatment
    center
  • Average Range 350-450 ITS level admissions per
    year the past 4 yrs
  • Four years ago-admissions for children known to
    have Meth using parents approximately
    relatively uncommon, Monthly admissions
  • Currently seems that these admissions are more
    common, Weekly

15
Trends in Use (from MTF Study)
  • Use of amphetamines rose in last half of 1970s
    and peaked in 1981 with 26 use
  • After 1981 there was a steady decline ended in
    1992
  • Use peaked in the lower grades in 1996 and 1997
  • There has been a slow drop off since the mid 1990
  • No significant Changes in 2004

16
Trends in Use
  • Use of amphetamines rose in last half of 1970s
    and peaked in 1981 with 26 use
  • After 1981 there was a steady decline ended in
    1992
  • Use peaked in the lower grades in 1996 and 1997
  • There has been a slow drop off since the mid 1990
  • No significant Changes in 2004

17
Perceived Risk
  • Overall changes in perceived risk have been less
    strongly correlated with changes in usage of
    other drugs
  • However the perceived risk has been rising the
    past several years possibly accounting for the
    decline in use that occurred in 2003 with 12th
    graders

18
Disapproval
  • Disapproval rates have been high 70 - 87
    throughout the life of the study
  • From 1981 to 1992 disapproval rose gradually as
    use steadily declined
  • Disapproval then fell back 6-7 percentage points
    for a few years and the use rate rose slighted

19
Availability
  • In 1975 when MTF started amphetamines had a
    reported high level of availability
  • The level fell 10 in 1977
  • Drifted back up in 1980, then jumped sharply in
    1981
  • Declined slowly till 1991, when there was a
    modest rise then seem to stabilize during the
    late 90s
  • There has been further decline during the first
    year few years of this decade

20
More Oregon Youth being treated for
Methamphetamine Abuse
  • The Oregon Department of Human Services said that
    over the past five years the number of meth
    treatment admissions for boys under age 17 has
    grown steadily, and has skyrocketed 57 percent
    among girls.
  • In 2003 the state Office of Mental Health and
    Addiction Services reported that more than 1,700
    children were treated for methamphetamine misuse
    in the state. Of that number, more than 1,000
    were girls, up from 630 in 1999, and 742 were
    boys, up from 600

21
An Update on Adolescent Substance Abuse Treatment
22
SUD Assessment
  • History MSE
  • SUD Assessment Scales
  • Drug Testing
  • Risk Factor Analysis

23
History/MSE/PE
  • Because substance-using youth commonly keep their
    substance-using behaviors covert, there is a need
    to gather information from multiple sources,
    including parents, siblings, teachers,
    caseworkers, peers if available.
  • Polysubstance use by adolescents is the rule
    rather than the exception therefore, adolescents
    often present with multiple SUD diagnoses.
    Determine how many psychoactive substances are
    being used, and how available they are to the
    youth.
  • Determine whether there is substance use or abuse
    occurring by other members in the home or whether
    there is a lack of rules against substance use by
    juvenile members of the family.
  • Determine who are the youths peers and
    associates and whether they use substances or are
    involved in conduct-disordered and where the
    youth uses substances. Does he or she use alone
    or tend to be with groups of certain people and
    settings?
  • Be sure to assess for other psychiatric
    disorders, as there is a high level of
    comorbidity, and many symptoms of SUD can mimic
    psychiatric symptoms.

24
SUD Assessment Instruments
  • Substance Abuse Rating Instruments can be helpful
    in screening for SUDs and for monitoring
    treatment response. Lie scales can be
    especially helpful in identifying youths that
    deny their substance use
  • There are now several adolescent assessment
    instruments such as CRAFFT, SASSI, PESQ, and ADI

25
CRAFFT Questions (2 or more yes answers
suggests a serious problem warrants further
evaluation)
  • Have you ever ridden in a Car driven by someone
    who was high or had been using alcohol or drugs
  • Do you drink or take drugs to Relax
  • Do you ever drink or take drugs while you are
    Alone?
  • Do you ever Forget things you did while using
    alcohol or drugs
  • Do you Family and Friends ever tell you that you
    should cut down on your use?
  • Have you gotten into Trouble from drinking or
    taking drugs?
  • Kay DL (2004) Office recognition and
    management of adolescent substance abuse. Curr
    Opin Pedia 16532-541

26
Drug Testing
  • Use of urine drug screens can be helpful in
    identifying SUDs in youth that are skilled in
    hiding their drug use from adults. However, a
    single negative drug screen does not rule out
    drug use, abuse, or dependence and a single
    positive drug screen does not establish an SUD

27
Urine Drug Screen Detection
28
Risk Factor Analysis
  • Chaotic home environment
  • Parental Substance Abuse
  • Parental Mental Illness
  • Ineffective Parenting
  • Lack of Parental involvement/supervision
  • Failing School Performance
  • Poor Social Coping Skills
  • Association with Conduct Disordered Peers
  • Perceived parental/peer/community approval of
    drug use

29
SUD Treatment
  • Traditional Treatments
  • Peer Deviancy Training
  • Limitations of Psychoeducational Interventions
  • Medications
  • Community Based Interventions

30
Traditional Treatments
  • Alateen
  • Narcotics Anonymous
  • Group Therapy
  • Individual Therapy/Counseling

31
Peer Deviancy TrainingDishion, T.J., McCord, J.,
Poulin, F. (1999). When interventions harm
Peer groups and problem behavior. American
Psychologist, 54, 755-764
  • Dishion at Oregon Social Learning Center _at_ UO
  • 158 youth grades 6 to 8 studied 83 boys, 75 girls
    in 12 week program to reduce problem behaviors
  • Three study groups peer only, parent and peer
    groups, self study, and no intervention control
    group
  • All study group showed improvement after 12 weeks
  • Peer only groups exhibited significantly worse
    behaviors after one year, and three year
    followup, than similar at risk youths who were
    given prevention materials to study on their own
    or who had no interventions at all
  • For peer only group a 75 higher rate of
    delinquency

32
Medications
  • Evidence for use in children specifically for
    SUDs Meager to date, mostly case reports of
    small sample size studies
  • Treatment of comorbid disorders can help prevent
    development of SUD
  • Needs to be in combination with other
    interventions

33
The Evidence with ADHD Treatment
  • Biederman, J., et al. Pharmacotherapy of
    attention-deficit/hyperactivity disorder reduces
    risk for substance use disorder. Pediatrics
    104(2)e20, 1999
  • 56 boys with ADHD who were being treated with
    either stimulants or TCAs at the beginning of the
    study, 19 boys with ADHD who were not receiving
    any medications, and 137 boys without ADHD. All
    boys were Caucasian and were followed for 4 years
    and then evaluated for abuse of or dependence on
    marijuana, alcohol, hallucinogens, stimulants, or
    cocaine. At the time of evaluation, the boys were
    at least 15 years old.
  • Treating ADHD with medications appeared to reduce
    the tendency to abuse drugs and alcohol. While 75
    percent of the unmedicated ADHD boys had started
    abusing these substances in the previous 4 years,
    this was true of only 25 percent of the medicated
    ADHD boys and 18 percent of the boys without
    ADHD. The researchers calculated that treating
    ADHD with medications reduced the risk of
    substance abuse or dependence by 84 percent.

34
Long-term Stimulant Treatment and Brain Size
  • Individuals with ADHD had significantly smaller
    brain volumes in all regions
  • Compared with controls, previously unmedicated
    children with ADHD demonstrated significantly
    smaller total cerebral volumes and cerebellar
    volume
  • Unmedicated children with ADHD also exhibited
    smaller total white matter volumes compared with
    controls and with medicated children with ADHD
  • Castellanos FX, Lee PP, Sharp W et al. (2002),
    Developmental trajectories of brain volume
    abnormalities in children and adolescents with
    attention-deficit/hyperactivity disorder. JAMA
    288(14)1740-1748.

35
Difference in amounts used between addict and
patient
  • Eightball (eighth of an ounce) 3.5
    grams
  • Baggie or Teena (sixteenth of an ounce)
    1.75 grams
  • Desoxyn (methamphetamine)
  • 10 - 40 mg/day
  • 50 - 100 xs larger Dose difference between Meth
    Addict and Patient being treated for ADHD

36
Long-term effects of Amphetamines on the Brain
  • Descriptions from NIDA Website
  • Intense paranoia
  • Visual and auditory hallucinations, and
  • Out-of-control rages that can be coupled with
  • Extremely violent behavior
  • Withdrawal syndrome sxs include depression,
    anxiety, fatigue, paranoia, aggression, and an
    intense craving for the drug.

37
Case Vignettes Antabuse
  • 17 year old Asian female
  • Drinking not part of the family culture
  • History of success in academically
  • Many in peer group used drugs and etoh
  • Wanted to stop after psychiatric admission for
    suicide attempt
  • Did not want parents involved in treatment
  • 17 year old Hispanic
  • Drinking part of the culture of some family
    members
  • Marignally engaged in school
  • Many in peer group used drugs and etoh
  • Wanted to stop etoh after psychiatric admission
    for suicide attempt
  • Allowed parents to be involved in treatment

38
Prevention
39
Psychoeducational Limitations
  • The DARE Story
  • School programs should also enhance academic and
    social competence
  • Education should focus on self-control, emotional
    awareness, communication, social problem-solving,
    and drug resistance skills

40
Prevention Programs
  • Examples of evidence based practice
  • Multisystemic Therapy (MST),
  • Incredible Years,
  • Strengthening Families Program
  • Project Chrysalis

41
Scott Hengglers MST
  • Developed in the late 1970s to address several
    limitations of existing mental health services
    for serious juvenile offender
  • MST interventions aim to attenuate risk factors
    by building youth and family strengths
    (protective factors) on a highly individualized
    and comprehensive basis
  • MST is a family-based treatment model. The
    treatment plan is designed in collaboration with
    family members and is, therefore, family driven
    rather than therapist driven
  • MST services are delivered in the natural
    environment (e.g., home, school, community)
  • The typical duration of home-based MST services
    is approximately 4 months, with multiple
    therapist-family contacts occurring each week
  • Local MST program offered through Options
    503.335.5975

42
NIDA Focus on Prevention
  • Analysis of Risk Factors
  • Prevention programs should enhance protective
    factors and reverse or reduce risk factors
  • An emphasis on Family Interventions and Parental
    Management Training

43
NIDA Prevention Principles Programs Should
  • Enhance protective factors and reverse or reduce
    risk factors
  • Address all forms of drug abuse, alone or in
    combination
  • Address the type of drug abuse problem in the
    local community, target modifiable risk factors
    and strengthen identifiable protective factors
  • Be tailored to address risks specific to
    population or audience characteristics like age,
    gender, or ethnicity

44
NIDA Prevention Principles for Family School
Prevention Programs Should Also
  • In family based prevention programs, enhance
    family bonding, relationships include parenting
    skills training and enforcement of family rules
  • Be designed to intervene as early as preschool to
    address risk factors such as aggression, poor
    social skills academics
  • In school age children target academic and social
    emotion learning and self control skills
  • In adolescent school programs enhance academic
    and social competence and drug resistance skills

45
NIDA Prevention Principles for Community Programs
Should
  • Be aimed at key transition points
  • Combine two or more effective programs
  • Reach populations in multiple settings
  • Adapt to match community norms or differing
    cultural elements
  • Be long-term with repeated interventions.
    Research shows that benefits from early programs
    diminish without followup programs at a later age

46
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