Psychiatric comorbidity with substance misuse in children and teenagers

An examination of early socioeconomic status and neighborhood disadvantage as independent predictors of antisocial behavior: A longitudinal adoption study

The present study examined early socioeconomic status (SES) and neighborhood disadvantage (ND) as independent predictors of antisocial behavior (ASB) and addressed the etiology of the associations (i.e., genes versus the environment) using a longitudinal adoption design. Prospective data from the Colorado Adoption Project (435 adoptees, 598 nonadopted children, 526 biological grandparents of adoptees, 481 adoptive parents, and 617 nonadoptive parents including biological parents of unrelated siblings of adoptees) were examined. SES and ND were assessed during infancy and ASB was evaluated from ages four through 16 using parent and teacher report. Associations between predictors and ASB were compared across adoptive and nonadoptive families and sex. Early SES was a nominally significant, independent predictor of antisocial ASB, such that lower SES predicted higher levels of ASB in nonadoptive families only. ND was not associated with ASB. Associations were consistent across aggression and delinquency, and neither SES nor ND was associated with change in ASB over time. Nominally significant associations did not remain significant after controlling for multiple testing. As such, despite nonsignificant differences in associations across sex or adoptive status, we were unable to make definitive conclusions regarding the genetic versus environmental etiology of or sex differences in the influence of SES and ND on ASB. Despite inconclusive findings, in nonadoptees, results were consistent-in effect size and direction-with previous studies in the literature indicating that lower SES is associated with increased risk for ASB.

The Efficacy of Two Group Interventions on Mental Representations, Attachment Security, and Trauma Symptoms in Ethnically and Socioeconomically Minoritized Young Adolescents in an Urban Middle School

Symptoms resulting from childhood trauma can negatively impact socioemotional well-being and school performance during early adolescence unless positive changes in attachment security and mental representations of significant relationships occur. A sample of 109 eighth grade urban students were randomly assigned to one of two weekly, one-hour, school-based group interventions-Storytelling/Story-Acting for Adolescents (STSA-A) or Mentalization-Based Treatment Group Intervention (MBT-G). The Object Relations Inventory (ORI), Adolescent Attachment Questionnaire (AAQ) and Child PSTD Stress Scale (CPSS) were administered to students and their primary group leaders at the beginning (October) and end (May) of the intervention protocol as outcome variables. Participants in both the STSA-A and MBT-G intervention conditions experienced significant increases in attachment security and decreases in trauma symptoms. Over the course of eight months of group intervention, affective valence of paternal mental representations significantly decreased for boys and for participants in the STSA-A condition, while affective valence of primary group leader mental representations significantly decreased for participants in the MBT-G condition. STSA-A and MBT-G were found to be efficacious at improving attachment security and reducing trauma symptoms in young adolescents. The strengths of each group intervention for addressing interpersonal issues unique to specific types of adolescents are discussed.

Factors Predicting Trial Engagement, Treatment Satisfaction, and Health-Related Quality of Life During a Web-Based Treatment and Social Networking Trial for Binge Drinking and Depression in Young Adults: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mental health and alcohol use problems are among the most common causes of disease burden in young Australians, frequently co-occur (comorbidity), and lead to significant lifetime burden. However, comorbidities remain significantly underdetected and undertreated in health settings. Digital mental health tools designed to identify at-risk individuals, encourage help-seeking, or deliver treatment for comorbidity have the potential to address this service gap. However, despite a strong body of evidence that digital mental health programs provide an effective treatment option for a range of mental health and alcohol use problems in young adults, research shows that uptake rates can be low. Thus, it is important to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e-mental health interventions for comorbidity.

OBJECTIVE

In this study, we seek to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e-mental health interventions for comorbid alcohol and mood disorders. The aim is to determine the importance of personality (ie, Big Five personality traits and intervention attitudes), affective factors (ie, depression, anxiety, and stress levels), and baseline alcohol consumption in predicting intervention trial engagement at sign-up, satisfaction with the online tool, and quality of life at the end of the iTreAD (Internet Treatment for Alcohol and Depression) trial.

METHODS

Australian adults (N=411) aged between 18 and 30 years who screened positive for depression and alcohol use problems signed up for the iTreAD project between August 2014 and October 2015. During registration, participants provided information about their personality, current affective state, alcohol use, treatment expectations, and basic demographic information. Subsequent follow-up surveys were used to gauge the ongoing trial engagement. The last follow-up questionnaire, completed at 64 weeks, assessed participants' satisfaction with web-based treatment and quality-of-life outcomes.

RESULTS

Multiple linear regression analyses were used to assess the relative influence of predictor variables on trial engagement, treatment satisfaction, and quality-of-life outcomes. The analyses revealed that the overall predictive effects of personality and affective factors were 20% or lower. Neuroticism constituted a unique predictor of engagement with the iTreAD study in that neuroticism facilitated the return of web-based self-assessments during the study. The return of incentivized follow-up assessments predicted treatment satisfaction, and state-based depression predicted variance in quality-of-life reports at study completion.

CONCLUSIONS

Our findings suggest that traditional predictors of engagement observed in face-to-face research may not be easily transferable to digital health interventions, particularly those aimed at comorbid mental health concerns and alcohol misuse among young adults. More research is needed to identify what determines engagement in this population to optimally design and execute digital intervention studies with multiple treatment aims.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN): 12614000310662; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365137&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-015-2365-2.

Neurochemical and Behavioral Characterization after Acute and Repeated Exposure to Novel Synthetic Cannabinoid Agonist 5-MDMB-PICA

Since the early 2000s, herbal mixtures containing synthetic cannabinoids (SCs), broadly known as Spice/K2, have been marketed as a legal marijuana surrogate and have become very popular among adolescents. Adolescence is a critical period of development, which is associated with an increased vulnerability to the central effects of drugs. Despite growing concerns about the negative effects of the use of SCs, newly synthetized compounds are increasingly detected in drugs seized by the authorities, posing a serious threat to public health. 5F-MDMB-PICA has been recently detected and classified as a highly potent agonist of CB1 and CB2 cannabinoid receptors. Here, we first investigated the rewarding properties of 5F-MDMB-PICA in C57BL/6 adolescent and adult mice by in vivo brain microdialysis. Data showed that acute administration of a selected dose of 5F-MDMB-PICA (0.01 mg/kg i.p.) stimulates the release of dopamine in the nucleus accumbens shell of adolescent, but not of adult, mice. To further investigate the consequences of repeated exposure to this dose of 5F-MDMB-PICA, a separate group of adolescent mice was treated for 14 consecutive days and evaluated for behavioral abnormalities at adulthood, starting from 7 days after drug discontinuation. Data showed that this group of adult mice displayed an anxiety-like and compulsive-like state as revealed by an altered performance in the marble burying test. Our study suggests an alarming vulnerability of adolescent mice to the effects of 5F-MDMB-PICA. These findings provide a useful basis for understanding and evaluating both early and late detrimental effects that may derive from the use of SCs during adolescence.

Attachment Patterns in Subjects Diagnosed With a Substance Use Disorder: A Comparison of Patients in Outpatient Treatment and Patients in Therapeutic Communities

The purpose of the present study is to analyze the quality of attachment in substance abuse patients in outpatient treatment vs. patients in therapeutic communities in order to identify the role of attachment insecurity in choosing a care system. The sample consisted of 127 subjects (107 males and 20 females); 97 were outpatients (83 males) and 30 therapeutic community patients (24 males). Attachment with respect to current, significant relationships was assessed using the Relationship Questionnaire. In the outpatient subgroup, the prevailing attachment style was preoccupied; for the therapeutic community patients, the prevailing attachment style was dismissive. The dimensions of care (how the caregiver is perceived as loving and caring) and overprotection (how the caregiver is perceived as intrusive and interfering)-evaluated by means of the Parent Bonding Instrument-were higher in the outpatient subgroup. Scores were higher with respect to maternal subscales regardless of treatment modality. No differences emerged with respect to self-perceived symptoms (SCL-90-R) between the subgroups; however, fearful-avoidant and dismissive-avoidant individuals reported higher self-perceived symptom regardless of treatment modality. Understanding the distribution of different attachment patterns with respect to the treatment modality may improve efficacious interventions, attuning them to the individual and his or her developmental environment.

Substance misuse in adolescents

There is increasing evidence that substance misuse among British adolescents is escalating (Miller & Plant, 1996; Sutherland & Willner, 1998). Swadi (1992) found that, among adolescents aged 12–17 years referred to mental health services, the prevalence of drug use was 13.1% (16.3% among boys and 9.3% among girls). Despite this relatively high prevalence, there are very few organised treatment services for adolescents in the UK. Instead, there is extensive emphasis on prevention even though there is no universal agreement on what prevention can achieve. This approach also overlooks the fact that a significant number of adolescents fail to respond to preventive measures in any form.

The Comorbidity of Psychiatric and Substance Use Disorders Among Hispanic Adolescents

OBJECTIVE

The comorbidity of psychiatric disorders and substance abuse disorders among adolescents and adults is well-documented in the literature. The current study investigates the relationship between psychiatric and substance use disorders in a sample of treatment-seeking Hispanic adolescents.

METHODS

The study uses baseline data (N = 190) from a randomized control trial testing the effectiveness of a family-based treatment for Hispanic adolescents with substance abuse disorder to examine the relationship between psychiatric disorders and substance use patterns at baseline, including types of substances used (both lifetime use and past-month use) and age at onset of substance use, controlling for age and gender.

RESULTS

Linear regression models were used to examine predictors of age at onset, while logistic regression models examined predictors of lifetime substance use. Significant findings predicting age at onset for marijuana and alcohol are discussed. In addition, psychiatric profiles were differentially associated with lifetime use of sedatives, stimulants, and hallucinogens, but not alcohol or marijuana.

CONCLUSIONS

Findings from this study can be used to help inform the treatment of adolescents seeking mental health and substance use services.

Alcohol use and alcohol-related problems among adolescents in China: A large-scale cross-sectional study

Alcohol misuse among adolescents is a common issue worldwide and is an emerging problem in China. This study aimed to investigate the prevalence of alcohol drinking and alcohol-related problems among Chinese adolescents and to explore their risk factors and connections.A cross-sectional study using an anonymous questionnaire was conducted among junior and senior high school students between 2010 and 2012. Data on self-reported alcohol use, alcohol-related problems, school factors, family factors, and psychosocial factors were collected. Descriptive analyses were made of the proportions of sociodemographics, family, school, and psychosocial factors. Multilevel logistic regression models were conducted to analyze the risk factors for alcohol drinking and alcohol-related problems.Of the 105,752 students who ranged in age from 9 to 21 years, the prevalence of current drinking among students was 7.3%, and 13.2% students reported having alcohol-related problems. Male students were 1.78 (95% confidence interval [CI] = 1.69-1.87) times more likely to be involved in current drinking and 1.86 (95% CI = 1.79-1.93) times more likely to have alcohol-related problems. Higher grade level students were at a higher risk of current drinking (adjusted odds ratio [AOR] = 1.09, 95% CI = 1.05-1.13) and having alcohol-related problems (AOR = 1.43, 95% CI = 1.42-1.58). Older students were more likely to report current drinking (AOR = 1.06, 95% CI = 1.04-1.17) and having alcohol-related problems (AOR = 1.83, 95% CI = 1.82-1.85). Having poor classmate relations (AOR = 1.28, 95% CI = 1.03-1.37), having poor relationships with teachers (AOR = 1.08, 95% CI = 1.00-1.16), and below average academic achievement (AOR = 1.50, 95% CI = 1.41-1.59) were positively associated with current drinking. Moreover, students with suicidal ideation were at a higher risk of current drinking (AOR = 1.70, 95% CI = 1.61-1.81) and having alcohol-related problems (AOR = 2.08, 95% CI = 1.98-2.16). Having higher Center for Epidemiology Scale for Depression scores was positively associated with current drinking (AOR = 1.09, 95% CI = 1.05-1.11) and having alcohol-related problems (AOR = 1.08, 95% CI = 1.06-1.18).Alcohol drinking and alcohol-related problems among Chinese adolescents are major public health problems, and effective preventive programs will require full consideration of the individual, social, and environmental factors that facilitate and prevent alcohol use.

Evaluating whether direct-to-consumer marketing can increase demand for evidence-based practice among parents of adolescents with substance use disorders: rationale and protocol

Background

Fewer than one in 10 adolescents with substance use disorders (ASUDs) will receive specialty treatment, and even fewer will receive treatment designated as evidence-based practice (EBP). Traditional efforts to increase the utilization of EBP by ASUDs typically focus on practitioners—either in substance use clinics or allied health settings. Direct-to-consumer (DTC) marketing that directly targets parents of ASUDs represents a potentially complementary paradigm that has yet to be evaluated. The current study is the first to evaluate the relevance of a well-established marketing framework (the Marketing Mix) and measurement approach (measurement of perceived service quality [PSQ]) with parents of ASUDs in need of treatment.

Methods/design

A mixed-methods design is employed across three study phases, consistent with well-established methods used in the field of marketing science. Phase 1 consists of formative qualitative research with parents (and a supplementary sample of adolescents) in order to evaluate and potentially adapt a conceptual framework (Marketing Mix) and measure of PSQ. Phase 2 is a targeted survey of ASUD parents to elucidate their marketing preferences, using the adapted Marketing Mix framework, and to establish the psychometric properties of the PSQ measure. The survey will also gather data on parents’ preferences for different targeted marketing messages. Phase 3 is a two-group randomized controlled trial comparing the effectiveness of targeted marketing messages versus standard clinical information. Key outcomes will include parents’ ratings of PSQ (using the new measure), behavioral intentions to seek out information about EBP, and actual information-seeking behavior.

Discussion

The current study will inform the field whether a well-established marketing framework and measurement approach can be used to increase demand for EBP among parents of ASUDs. Results of this study will have the potential to immediately inform DTC marketing efforts by professional organizations, federal agencies, clinicians, and clinical researchers.

Relationships between Child Emotional and Behavioral Symptoms and Caregiver Strain and Parenting Stress

Children with emotional and behavioral disturbance often have difficulties in multiple symptom domains. This study investigates the relationships between child symptoms and caregiver strain and parenting stress among 177 youth and their caregivers participating in a school-based system of care. Youth were grouped by symptom domain and included those with low scores on both internalizing and externalizing symptoms, those with only high internalizing symptoms, those with only high externalizing symptoms, and those with high symptoms levels in both internalizing and externalizing domains. Results revealed significant group differences on measures of caregiver strain and parenting stress. Caregivers of youth with symptoms in both internalizing and externalizing domains reported the highest levels of strain and stress; however, there was some variation in group differences by caregiver outcome. The results of this study emphasize the importance of not only providing services for youth, but also providing support services for their caregivers.

Classes of conduct disorder symptoms and their life course correlates in a US national sample

BACKGROUND

Population data on conduct disorder (CD) symptoms can help determine whether hypothesized subtypes of CD are sufficiently disparate in their familial, psychiatric and life course correlates to distinguish separate diagnostic entities.

METHOD

Latent class analysis (LCA) of CD symptoms occurring before age 15 was conducted in a national sample of adults aged 18-44 years from the National Epidemiological Study of Alcohol and Related Conditions. Associations of latent class membership with parental behavior problems, onset of psychiatric disorders and anti-social behaviors after age 15, adolescent life events (e.g. high school drop-out), and past-year life events (e.g. divorce/separation, bankruptcy) were estimated.

RESULTS

LCA identified a no-CD class with low prevalence of all symptoms, three intermediate classes - deceit/theft, rule violations, aggression - and a severe class. The prevalence of CD, according to DSM-IV criteria, was 0% in the no-CD class, between 13.33% and 33.69% in the intermediate classes and 62.20% in the severe class. Latent class membership is associated with all the familial, psychiatric and life course outcomes examined. Among the intermediate classes, risk for subsequent mood/anxiety disorders and anti-social behavior was higher in the deceit/theft and aggressive classes than in the rule violations class. However, risk for adolescent life events is highest in the rule violations class.

CONCLUSIONS

CD symptoms tend to occur in a partially ordered set of classes in the general population. Prognostically meaningful distinctions can be drawn between classes, but only at low levels of symptoms.

Substance use disorders and comorbid Axis I and II psychiatric disorders among young psychiatric patients: findings from a large electronic health records database

This study examined the prevalence of substance use disorders (SUDs) among psychiatric patients aged 2-17 years in an electronic health records database (N=11,457) and determined patterns of comorbid diagnoses among patients with a SUD to inform emerging comparative effectiveness research (CER) efforts. DSM-IV diagnoses of all inpatients and outpatients at a large university-based hospital and its associated psychiatric clinics were systematically captured between 2000 and 2010: SUD, anxiety (AD), mood (MD), conduct (CD), attention deficit/hyperactivity (ADHD), personality (PD), adjustment, eating, impulse-control, psychotic, learning, mental retardation, and relational disorders. The prevalence of SUD in the 2-12-year age group (n=6210) was 1.6% and increased to 25% in the 13-17-year age group (n=5247). Cannabis diagnosis was the most prevalent SUD, accounting for more than 80% of all SUD cases. Among patients with a SUD (n=1423), children aged 2-12 years (95%) and females (75-100%) showed high rates of comorbidities; blacks were more likely than whites to be diagnosed with CD, impulse-control, and psychotic diagnoses, while whites had elevated odds of having AD, ADHD, MD, PD, relational, and eating diagnoses. Patients with a SUD used more inpatient treatment than patients without a SUD (43% vs. 21%); children, females, and blacks had elevated odds of inpatient psychiatric treatment. Collectively, results add clinical evidence on treatment needs and diagnostic patterns for understudied diagnoses.

Factors that influence trajectories of change in frequency of substance use and quality of life among adolescents receiving a brief intervention

This study aimed to identify factors influencing trajectories of change in two outcome domains, frequency of substance use and quality of life (QOL), among adolescents receiving a brief evidence-based intervention. Participants were 106 adolescents, aged 13 to 21 years, who met criteria for a substance use disorder. The adolescents received a five-session intervention and completed four assessments over 12 months. Based upon a theoretical and empirical review, five putative predictors were tested: gender, age, severity of conduct disorder, severity of depression, and peer substance involvement. Results of a parallel-process latent growth curve model indicated that higher peer substance involvement and conduct severity predicted higher frequency of use at baseline, whereas higher peer substance involvement and depression severity predicted poorer QOL at baseline. Counter to predictions, higher depression severity predicted greater improvements in QOL following substance use treatment. The implications of baseline risk factors on adolescents' response to intervention are discussed.

How does overeaters anonymous help its members? A qualitative analysis

Overeaters Anonymous (OA) is a 12-step, self-help group for individuals who perceive themselves to have problems with compulsive overeating. Despite the popularity of OA and the frequent use of addictions-based treatments for eating disorders, little is known about how OA is helpful. The purpose of this qualitative study was to explore members' experiences with and perceptions of OA. We conducted three focus groups with self-selected members of OA (N = 20). We present three primary themes that emerged from the analysis of the focus groups' discussions, which emphasize why individuals entered OA, OA's 'tools', and how individuals perceived OA to 'work'. Overall, although participants agreed OA was helpful to them, there was no consensus regarding how OA 'works'.

Lessons from an audit of psychoeducation at an older adolescent inpatient unit

OBJECTIVES

The aim of this paper was to determine if patients undergoing treatment at an older adolescent inpatient unit receive psychoeducation according to the unit philosophy of providing timely and pertinent information regarding illness/diagnosis, medication, diet, outpatient follow-up, and alcohol/ drug use.

METHODS

Data were gathered prospectively as part of a quality assurance initiative at the Christchurch Youth Inpatient Unit. Patients were interviewed by a registered nurse using a structured audit tool.

RESULTS

Participants reported receiving adequate information on medication and illness, and most received information on outpatient follow-up and alcohol and drug use. However, the majority reported a lack of information/ advice about diet. Patients' reported awareness of relapse prevention and the relationship of alcohol and other drugs use to medication and treatment was lower than expected.

CONCLUSIONS

The audit highlighted areas of discrepancy between information staff believed they had delivered and information youth perceived as received. Psychiatric staff working with young people need be aware of the timing, language and mode of delivery of psychoeducation to enable their patients to 'take in' the information provided.

Dopamine receptors in the learning, memory and drug reward circuitry

As primary targets of a variety of abused drugs G-protein-coupled dopamine receptors in the brain play an important role in mediating the various drug-induced alterations in neural and psychological processes thought to underlie the transition from voluntary drug use to habitual and progressively compulsive drug-taking. This review considers the functional involvement of the five major dopamine receptor subtypes in drug reinforcement and reward and discusses the development of addiction as a series of learning transitions from initial goal-directed behaviour to pathological stimulus-response habits in which drug-seeking behaviours are automatically elicited and maintained by cues and stimuli associated with drug rewards.

Evaluation of SHINE — Make Every Child Count: a school‐based community intervention programme

Many barriers to health and emotional well‐being for children are prevalent within inner‐city communities, and often result in negative consequences for education. Health promotion strategies have previously cited mentoring schemes as interventions through which targeted pastoral support can be effectively provided to children. This paper draws on detailed focus group interviews in order to evaluate SHINE ‐ Make Every Child Count, a student‐led charity operating five mentoring programmes across the London boroughs of Southwark and Lambeth. Following content analysis, this paper identifies six themes associated with mentor support: rapport; emotional well‐being and development; social behaviour; enabling; emerging ambition; and attitudinal development. Results show participant children have gained considerable enjoyment from mentor support. Successful friendships are built and emotional well‐being supported, with children actively including mentors as part of their support network. Children recognise the impact of a mentor on relationships with peers, behaviour within the classroom and social responsibility, in addition to direct educational support. Children also show an increased interest in learning, and evidence of considering ‐ often for the first time ‐ their own future aspirations. Findings demonstrate the impact of the mentoring programmes, as perceived by participant children. Evaluation can be used to inform future development of the programmes, as well as expansion to further schools, with the organisation working towards achieving long‐term sustainability.

Risk factors for serious alcohol and drug use: the role of psychosocial variables in predicting the frequency of substance use among adolescents

Reviews of the psychosocial risk factors of adolescent alcohol and drug use suggest that the highest risks can be summarized as: 1) psychological functioning, 2) family environment, 3) peer relationships, and 4) stressful life events. The purpose of this study is to describe the relationships among the most common risk factors among a clinical sample (n = 214) and to determine the collective importance of these risk factors on problems with substance use. Collectively, these risk factors were most effective in explaining alcohol use and binge drinking and marijuana use, which were the most frequent types of substance use in this sample. Antisocial peers and delinquent behavior were the strongest predictors of substance use. Implications are that treatment programs target different psychosocial factors depending on the substance being used, and put extra effort on understanding and altering the relationship between an adolescent's choice of peers and their own attitudes toward delinquency and drug use.

Psychiatry in orthodontics. Part 2: Substance abuse among adolescents and its relevance to orthodontic practice

Substance abuse by adolescents is a serious problem that will touch every orthodontic practice. Recent data show that 40% of tenth graders in the United States will use an illicit drug at some time, and 18% will do so in a 30-day period. These are significant figures that should impact orthodontic diagnosis and treatment planning. The nature of orthodontic treatment is unique in that the orthodontist will see relatively healthy adolescent patients on a monthly basis over a period of years. The orthodontist is in a prime position to recognize potential substance abuse problems and make referrals. This article discusses various types of substance abuse, diagnosis, options for referral, and orthodontic implications.

Neurochemical effects of cocaine in adolescence compared to adulthood

Adolescence is a time of high risk behavior and increased exploration. This developmental period is marked by a greater probability to initiate drug use and is associated with an increased risk to develop addiction and adulthood dependency. Human adolescents are predisposed toward an increased likelihood of risk taking behaviors [M. Zuckerman, Sensation-seeking and the endogenous deficit theory of drug abuse. NIDA Res Monogr. 74 (1986) 59-70.], including drug use or initiation. In the present study, adolescent and adult animals were first tested on several behavioral measures (novel environment exploratory behavior, novel object preference, novelty-induced impulsivity and novelty-induced exploration) which were used to categorize them as high- (HR) or low-responders (LR). The purpose of the present study was to characterize the neurochemical responsivity of the nucleus accumbens septi (NAcc) in HR and LR adolescent and adult animals in response to a systemic challenge of cocaine. Regardless of age, animals that were more reactive when placed in a novel environment had greater cocaine-induced increases in dopamine (DA). Several important and complex neurochemical differences existed between adolescent and adult animals. Adolescent animals that rapidly approached the novel object (i.e., HR) were the only group to show greater cocaine-induced responsivity. However, adult animals that spent less time near the novel object (i.e., LR) were the only group to have greater cocaine-induced responsivity. Adolescent animals that approached a novel object faster (HR) showed an increased dopaminergic (DAergic) response to an acute cocaine challenge. In contrast, adolescent animals that spent less time with the novel object had an increased cocaine-induced DAergic response compared to HR adults. Adults that approached the object less had a greater cocaine-induced DA response relative to HR adults. Finally, cocaine yielded a greater DA response in adolescent animals that showed a high novelty-induced exploration and impulsivity response, whereas the opposite was true for adults. The differences in response to cocaine between ages and groups are likely due to ontogenetic differences in brain regions that are involved in reward and/or stress responsivity.

Abuse experiences in a community sample of young adults: relations with psychiatric disorders, sexual risk behaviors, and sexually transmitted diseases

This study documents significant associations among lifetime abuse experiences, psychiatric diagnoses, and sexual risk behaviors in a multiethnic community sample of young men and women (N = 1803) in South Florida. Self-report data were collected via structured interviews as part of a longitudinal follow-up of a larger school-based study. Participants were grouped according to extent of lifetime abuse experiences. Cumulative lifetime abuse experiences were associated with increased risk for a broad range of individual lifetime psychiatric disorders, as well as cumulative lifetime psychiatric disorders. Both cumulative abuse experiences and cumulative psychiatric disorders were independently associated with (a) higher levels of sexual risk behaviors and (b) higher risk for lifetime sexually transmitted diseases (STDs). Implications for selective prevention of sexual risk behaviors and STDs among young adults with histories of abuse and psychiatric disorders are discussed.

Psychiatric comorbidity and substance use treatment outcomes of adolescents

Treatment outcomes of 126 adolescents (13-18 years old) with comorbid substance use disorders (SUDs) and Axis I psychiatric disorders (mood, anxiety, conduct, and attention-deficit/hyperactivity disorders) were compared to 81 SUD adolescents with no additional Axis I disorder. Participants completed structured interviews and symptom measures while participating in an adolescent treatment program and at 6 months following treatment. Results indicated that comorbid youth received more treatment during the outcome period; despite this, more comorbid SUD-Axis I disordered adolescents used substances following treatment than SUD-only youth, even after controlling for socioeconomic status and ethnicity. Among comorbid youth, internalizing disordered adolescents were less likely to use substances during the follow-up period, and externalizing disordered youth returned to substance use most rapidly after discharge from treatment.

Patterns of sexual risk behaviors and psychiatric disorders in a community sample of young adults

This cross-sectional study documents significant associations between patterns of sexual risk behaviors and psychiatric diagnoses in a multiethnic community sample of young adults (N = 1803) in South Florida. Self-report data regarding sexual behavior and psychiatric symptoms were collected in structured interviews in a follow-up of an earlier school-based study. Cluster analysis was used to group participants with regard to levels of sexual risk behaviors during the past year. Chi-square analysis and ANOVA identified significant associations between cluster membership and (a) lifetime and (b) past year diagnoses for affective disorders, conduct disorder, antisocial personality disorder, alcohol abuse/dependence, marijuana abuse/dependence, and other drug abuse/dependence. In addition, higher levels of sexual risk behaviors were associated with higher levels of cumulative lifetime psychiatric disorders. Implications for selected prevention of sexually transmitted diseases (STDs) and the treatment of psychiatric disorders in young adulthood are discussed.

Comorbidity in young people: perspectives and challenges

Trends in prevalence in substance misuse in young people in the UK are described: increased use over the last decade, the tendency to polydrug use, the narrowing of the gender gap. The complex issues relating to the description, definition and classification, and diagnosis of psychiatric comorbidity and substance misuse are outlined. The fact that there is no uniformly accepted definition of what constitutes 'dual diagnosis' or 'psychiatric comorbidity' in young people is highlighted: this variability impacts upon clinical assessment and study design. Despite these considerable drawbacks, a degree of consistency is beginning to emerge in the co-occurrence of some conditions, e.g. disruptive and suicidal behaviours. It is recognized that psychological distress and substance misuse are also associated with multiple social and physical complications. The rapid advances in treatment options are presented. At present the 'best practice' is implementation of what works for adults with addiction and young people with psychiatric disorder. This includes psychosocial interventions such as motivational enhancement techniques and cognitive behavioural treatment, as well as appropriate safe (usually), short-term use of a range of pharmacological agents. Very few comprehensive designated adolescent addiction services exist, while child and adolescent mental health services are under serious pressure. Thus the need for a longitudinal and multidisciplinary approach, with appropriate assessment instruments in young people, is required to further explore diagnostic classification which will classify the degrees and patterns of relationships between disorders. In this way it may be possible to build up a picture of the nature and extent of numerous complex, and sometimes overlapping, problems and needs in children and adolescents in a variety of settings: primary and secondary care, the criminal justice system and educational establishments. This might strengthen the development of innovative treatment services where novel interventions are tested as a priority.

Mental health and medical problems and service use among adolescent substance users

OBJECTIVE

Adolescents entering the substance abuse treatment system frequently exhibit mental health and medical problems. Because little is known about whether these youths receive services to address these problems, this study examined the services received by youths admitted to substance abuse treatment.

METHOD

Admission and 3-month follow-up reports of mental health, medical problems, and service use were examined within a large cohort (N = 1,088) of 12-19-year-olds admitted to seven inpatient and outpatient substance abuse treatment programs across the United States between 1998 and 2001.

RESULTS

High levels of mental health problems were found at both time points, but few received mental health treatment. In contrast, there were lower rates of medical problems, and more than half received services. Logistic regression predicting mental health treatment receipt found females in residential settings with more current and baseline distress to be more likely to receive services. Ethnicity, baseline behavioral problems, and whether or not currently in substance abuse treatment did not predict service use. A logistic regression predicting medical services showed that females in residential treatment were also more likely to receive medical treatment.

CONCLUSION

Although these results require replication and validation, they suggest that more could be done to take advantage of the opportunity to link youths entering substance use treatment with mental health services.

Developmental neurocircuitry of motivation in adolescence: a critical period of addiction vulnerability

OBJECTIVE

Epidemiological studies indicate that experimentation with addictive drugs and onset of addictive disorders is primarily concentrated in adolescence and young adulthood. The authors describe basic and clinical data supporting adolescent neurodevelopment as a biologically critical period of greater vulnerability for experimentation with substances and acquisition of substance use disorders.

METHOD

The authors reviewed recent literature regarding neurocircuitry underlying motivation, impulsivity, and addiction, with a focus on studies investigating adolescent neurodevelopment.

RESULTS

Adolescent neurodevelopment occurs in brain regions associated with motivation, impulsivity, and addiction. Adolescent impulsivity and/or novelty seeking as a transitional trait behavior can be explained in part by maturational changes in frontal cortical and subcortical monoaminergic systems. These developmental processes may advantageously promote learning drives for adaptation to adult roles but may also confer greater vulnerability to the addictive actions of drugs.

CONCLUSIONS

An exploration of developmental changes in neurocircuitry involved in impulse control has significant implications for understanding adolescent behavior, addiction vulnerability, and the prevention of addiction in adolescence and adulthood.

Substance use problems and associated psychiatric symptoms among adolescents in primary care

OBJECTIVE

Substance use disorders (SUDs) are associated with other mental disorders in adolescence, but it is unclear whether less severe substance use problems (SUPs) also increase risk. Because youths with SUPs are most likely to present first to their site of primary care, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent primary care patients with subdiagnostic use of alcohol or other drugs. The objective of this study was to determine the association between level of substance use and psychiatric symptoms among adolescents in a primary care setting.

METHODS

Patients who were aged 14 to 18 years and receiving routine care at a hospital-based adolescent clinic were eligible. Participants completed the Problem Oriented Screening Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect social and legal problems associated with alcohol and other drugs, and the Adolescent Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8 types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic substance use (NSU), SUP, and SUD with psychiatric symptom presence (any symptoms within each type), score (symptom scores summed across all types), and number of types (number of different symptom types endorsed).

RESULTS

Of 538 adolescents (68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most common (60% of both boys and girls), followed by symptoms of depression among girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%). Compared with those with NSU, youths with SUP and those with SUD were more likely to report symptom presence for several types of psychiatric symptoms. Girls with SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct disorder; girls with SUD were at increased risk for symptoms of depression, eating disorders, and hallucinations or delusions. Boys with SUP had increased odds of ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom scores and reported a wider range of psychiatric symptom types (number of types) compared with youths with NSU.

CONCLUSIONS

Like those with SUD, adolescents with subdiagnostic SUP were at increased risk for experiencing a greater number of psychiatric symptoms and a wider range of psychiatric symptom types than youths with NSU. Specifically, adolescents with SUP are at increased risk for symptoms of mood (girls) and disruptive behavior disorders (girls and boys). These findings suggest the clinical importance of SUP and support the concept of a continuum between subthreshold and diagnostic substance use among adolescents in primary care. Identification of youths with SUP may allow for intervention before either the substance use or any associated psychiatric problems progress to more severe levels.

Ethnic differences in comorbidity among substance-abusing adolescents referred to outpatient therapy

OBJECTIVE

To examine differences in psychiatric comorbidity between African-American and Hispanic substance-abusing adolescents referred for outpatient therapy.

METHOD

Participants were 167 substance-abusing adolescents and their family members who completed an intake assessment. As part of the intake assessment, adolescents and parents were administered the Diagnostic Interview Schedule for Children-Predictive Scales to screen for the presence of nine psychiatric diagnoses representing both externalizing and internalizing disorders.

RESULTS

Both African-American and Hispanic youths presented with high-above-threshold symptom rates of co-occurring disorders. However, both adolescents and parents reported that Hispanic youths (78.3% and 83.9%, respectively) demonstrated greater rates of externalizing symptoms than African-American youths (65.2% and 70.1%, respectively). African-American youths (40%) reported significantly more symptoms of agoraphobia than Hispanic youths (19.5%).

CONCLUSIONS

The presence of high rates of co-occurring internalizing and externalizing problems provides evidence of the need for developing and implementing multifaceted interventions that address the complex emotional and behavioral needs of adolescent substance abusers. Among Hispanic youths in particular, treatments must address constellations of problem behaviors that appear to co-occur and likely represent the child's entrenchment in a deviant subculture.

Recognizing and treating anxiety and depression in adolescents. Normal and abnormal responses

Recognition of depressive and anxiety disorders in adolescents reduces morbidity, mortality, and lifetime risk for psychiatric illness and maladaptive behaviors. Effective treatments for these disorders are available and are associated with minimal severe side effects. Because adolescents tend to underreport their psychologic distress, screening for these disorders in the primary care setting is incumbent on the clinician. Depression or anxiety may be a primary or a secondary condition--with each other and with other medical illness. Substance abuse, including cigarettes, should not be overlooked as an accompanying risk factor for poor health care habits and as an indicator of degree of family (lack of) support. Adolescents at risk should be screened and their symptoms taken seriously. This brief overview does not focus on the need for primary care clinicians to seek assistance and support of psychiatrists in the diagnosis and development of treatment algorithms. All clinicians should be reminded that judgments about peoples' internal mental states and function are difficult to assess objectively and with compassion. Initial assessment in the primary care setting should include a telephone consultation with a reliable psychiatric colleague and referral for more in-depth evaluation in the event of more complicated course. These disorders need to be treated comprehensively because of the lifelong implications that having a chronic disease bear on the individual and his or her physiology. Primary care clinicians are pivotal instruments in engaging adolescents to embrace appropriate therapeutic measures for their current and future health.