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

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Oregonian HeadlineMarch 3, 2006
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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
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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

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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.

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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

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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

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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

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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

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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

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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?

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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An Update on Adolescent Substance Abuse Treatment
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SUD Assessment

• History MSE
• SUD Assessment Scales
• Drug Testing
• Risk Factor Analysis

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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.

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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

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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

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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

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Urine Drug Screen Detection
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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

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SUD Treatment

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

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Traditional Treatments

• Alateen
• Narcotics Anonymous
• Group Therapy
• Individual Therapy/Counseling

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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

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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

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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.

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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.

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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

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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.

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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

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Prevention
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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

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Prevention Programs

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

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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

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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

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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

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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

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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

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