Substance abuse prevalence and comorbidity with other psychiatric disorders among adolescents with severe emotional disturbances

JK, Vardhanan YS. Exploration of Adverse Childhood Experiences (ACEs) and Health Risk Behaviors (HRBs) in Male Recidivist Violent Offenders: Indian Scenario

Aggression and violent behavior are widespread in the world and cause serious threats to public safety. Violent criminal recidivism rates remain very high among certain groups of offenders. In India, the quantum of total violent crimes is continuously increasing from 2009 to 2019. Adverse childhood experiences can affect the development of a child in many ways, leading to highly maladaptive behaviors, such as serious, violent, and chronic (SVC) delinquency. This study was done as a case-control method among recidivist violent offenders and controls to examine the effects of adverse childhood experiences (ACEs) on violent criminality. The questionnaire included the World Health Organization Adverse Childhood Experiences International Questionnaire (ACE- IQ) and standardized measures of Health Risk Behaviors (HRBs). Thirteen categories of adverse childhood experiences of the recidivist violent offenders and controls were measured. Bivariate analysis showed that there was a significant relation (p < 0.001) between ACEs and violent criminality in cases (M = 72.14, SD = 6.80, N = 35) and controls (M = 44.91, SD = 5.39, N = 32). The largest correlation was found between collective violence and household violence (r = 0.813). Bivariate correlation analyses were highly significant between total ACE score and criminality (r (35) = 0.927, p < 0.001). The results reveal that household violence, community violence and collective violence experienced by recidivist violent offenders were nearly double the rate of the control group. Findings emphasize the need for evaluations of ACEs in recidivist offenders for better rehabilitation strategies and also the necessity for preventive efforts at all levels.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-021-00434-1.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

Principal component analysis of early alcohol, drug and tobacco use with major depressive disorder in US adults

Early alcohol, tobacco and drug use prior to 18 years old are comorbid and correlated. This study included 6239 adults with major depressive disorder (MDD) in the past year and 72,010 controls from the combined data of 2013 and 2014 National Survey on Drug Use and Health (NSDUH). To deal with multicollinearity existing among 17 variables related to early alcohol, tobacco and drug use prior to 18 years old, we used principal component analysis (PCA) to infer PC scores and then use weighted multiple logistic regression analyses to estimate the associations of potential factors and PC scores with MDD. The odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. The overall prevalence of MDD was 6.7%. The first four PCs could explain 57% of the total variance. Weighted multiple logistic regression showed that PC1 (a measure of psychotherapeutic drugs and illicit drugs other than marijuana use), PC2 (a measure of cocaine and hallucinogens), PC3 (a measure of early alcohol, cigarettes, and marijuana use), and PC4 (a measure of cigar, smokeless tobacco use and illicit drugs use) revealed significant associations with MDD (OR = 1.12, 95% CI = 1.08-1.16, OR = 1.08, 95% CI = 1.04-1.12, OR = 1.13, 95% CI = 1.07-1.18, and OR = 1.15, 95% CI = 1.09-1.21, respectively). In conclusion, PCA can be used to reduce the indicators in complex survey data. Early alcohol, tobacco and drug use prior to 18 years old were found to be associated with increased odds of adult MDD.

Disentangling Adolescent Substance Use and Problem Use within a Clinical Sample

Studies have sought to disentangle predictors of adolescent substance use versus problem use, yet research has not examined this question in a clinical sample and usually does not control for the effects of consumption level. The authors tested whether psychosocial variables showed direct relations to substance use, and direct, indrect, and interactive relations to use-related negative consequences within a clinical sample of youth. Psychopathology, temperamental disturbances, use motives, expectancies, and socialization influences showed indirect relations to problem use because they were associated with heavy consumption. Psychopathology, expectancies, and socialization influences also related directly to problem use, controlling for consumption level. Psychopathology, temperamental disturbances, use motives, and socialization influences moderated the relation between consumption and problems. Results support the assertion that psychosocial variables are related to problem use above and beyond the simple indirect effect via consumption level.

Youth services: meeting the mental health needs of adolescents

Objectives

Youth mental health services are poised for a paradigm shift. Recent epidemiological evidence confirms the seriousness of adolescence as a risk period for mental ill-health - 50% of all adult mental disorders begin before the age of 16% and 75% before the age of 25. Here, we identify issues with transition of care between CAMHS-AMHS service, and effectiveness of early intervention services.

Methods

We provide a selective review providing evidence of adolescence as a risk period, discuss CAMHS-AMHS service transition problems, and discuss avenues for change to implement the early intervention model across youth mental health.

Results

Traditional service structures,with paediatric -adult split at 16–18 years increasingly appear not fit for purpose. A radical redesign of youth mental health services is not only necessary, it is also feasible and achievable, as illustrated by a pilot Birmingham youth service – Youthspace.

Conclusions

Pilot youth mental projects currently underway can help radically redesign the existing child and adolescent services. This will in turn lead to an improvement in the young people's experience of engagement with the services so that they too have a positive future.

ADHD symptoms, autistic traits, and substance use and misuse in adult Australian twins

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder frequently co-occur. Several studies show increased risk of substance use disorders in ADHD, yet there is limited information related to how ADHD symptoms, autistic traits, and their combined effects are associated with nicotine, alcohol, and cannabis use and use disorders in the general population.

METHOD

Cross-sectional interview and self-report questionnaire data from 3,080 young adult Australian twins (mean age 31.9 years) were used to assess ADHD symptoms, autistic traits, substance use, and substance use disorders. Substance use disorders-based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria-were assessed in the full sample as well as in those who reported substance use. Logistic regression analyses were used for comparing the associations between ADHD symptoms, autistic traits, substance use, and substance misuse after conduct disorder, sex, age, and zygosity were controlled for.

RESULTS

Greater ADHD symptoms and autistic traits scores were associated with elevated levels of regular smoking; cannabis use; and nicotine, alcohol, and cannabis use disorders, even after conduct disorder was adjusted for. In contrast, for alcohol use, those with high autistic traits scores were less likely to report drinking to intoxication. However, upon initiation, and similar to the findings for nicotine and cannabis, they were at elevated risk for developing alcohol dependence.

CONCLUSIONS

Increased liability to ADHD and elevated autistic traits scores were associated with substance use and misuse, with the exception of alcohol use. Given the social underpinnings of drinking, persons with autistic traits may be less likely to engage in it; however, upon engagement in drinking, their vulnerability to alcohol dependence is elevated.

The Influence of Comorbid Depression and Conduct Disorder on MET/CBT Treatment Outcome for Adolescent Substance Use Disorders

Although depression and conduct disorder frequently co-occur with substance use disorders (SUDs), few studies have investigated the individual and interactive effects of these conditions on SUD treatment outcome. Data were collected from 90 adolescents aged 13-21 (M = 17.1, SD = 2.07) who received a brief evidence-based intervention for SUD. Hierarchical regressions assessed the relationship among demographic variables, depression, conduct disorder, and two substance use outcomes (frequency and problems) at two intervals (three months, six months). Results revealed that higher baseline substance use and lower socioeconomic status significantly predicted higher substance problems and frequency at three-months. At six months, higher three month substance problems and lower depressive symptoms predicted substance problems. In addition, an interaction indicated that the effect of conduct disorder on substance problems was greatest at lower levels of depression. Results are discussed in the context of previous research indicating mixed effects of depression on SUD treatment outcome.

Violent conflict and opiate use in low and middle-income countries: a systematic review

BACKGROUND

Violent conflicts disproportionately affect populations in low and middle-income countries, and exposure to conflict is a known risk factor for mental disorders and substance use, including use of illicit opiates. Opiate use can be particularly problematic in resource-limited settings because few treatment options are available and dependence can impede economic development. In this systematic review, we explore the relationship between violent conflict and opiate use in conflict-affected populations in low and middle-income countries.

METHODS

We searched MEDLINE, PsychINFO, SCOPUS, PILOTS, and select grey literature databases using a defined list of key terms related to conflict and opiate use, screened the results for relevant and methodologically rigorous studies, and conducted a forward search of the bibliographies of selected results to identify additional studies.

RESULTS

We screened 707 articles, selecting 6 articles for inclusion: 4 quantitative studies and 2 qualitative studies that examined populations in 9 different countries. All study participants were adults (aged 15-65) living in or displaced from a conflict-affected country. Data sources included death records, hospital records, and interviews with refugees, internally displaced persons, and others affected by conflict. Overall, we found a positive, but ambiguous, association between violent conflict and opiate use, with five of six studies suggesting that opiate use increases with violent conflict. Five key factors mediate the conceptual relationship between opiate use and violent conflict: (1) pre-conflict opiate presence, (2) mental disorders, (3) lack of economic opportunity, (4) changes in social norms or structure, and (5) changes in drug availability.

CONCLUSIONS

The strength and direction of the association between opiate use and violent conflict and the proposed mediating factors may differ between contexts, necessitating country and population-specific research and interventions. Prevalence of opiate use prior to the start of conflict was common to all populations in which conflict induced a change in opiate use, suggesting that interventions to reduce opiate use and future research should focus on such populations. Population-based, longitudinal studies that use systematic measures of exposure to conflict and opiate use are needed to further explore this association and its mediating factors.

The moderating effect of family involvement on substance use risk factors in adolescents with severe emotional and behavioral challenges

OBJECTIVE

The current study longitudinally examined the moderating effects of family involvement, which previous research has shown to be a protective factor against adolescents' substance use involvement, on the associations between internalizing and externalizing problems, respectively, and substance use (alcohol, marijuana, and tobacco) and problems in a unique sample of adolescents with severe emotional and behavioral problems.

METHOD

Adolescents (n=4786) and their parents were assessed at three waves over a 1-year period as part of the SAMHSA funded Comprehensive Community Mental Health Initiative (CMHI). Multilevel growth curve models were estimated using Hierarchical Linear Modeling (HLM) to examine the associations between time-varying internalizing and externalizing problems, respectively, and substance use involvement over time as a function of family involvement at baseline.

RESULTS

Results supported the hypothesis that family involvement protects against adolescent substance use involvement by buffering the adverse effects of both internalizing and externalizing problems. Specifically, for alcohol use, family involvement buffered the negative effects of high externalizing problems. For tobacco use, family involvement buffered the negative effects of both internalizing and externalizing problems, respectively. For substance use problems, family involvement buffered the effects of only internalizing problems. Family involvement did not moderate effects of emotional and behavioral problems on marijuana use, however, a significant main effect was observed such that family involvement was negatively related to marijuana use.

CONCLUSIONS

Results suggest that the beneficial effects of family involvement on at-risk adolescents' substance use involvement are dependent on the type of emotional and behavioral problems the adolescent experiences as well as the type of substance the adolescent uses. Implications for family- and adolescent-focused treatment are discussed.

Are early-onset cannabis smokers at an increased risk of depression spells?

BACKGROUND

A recent research focus is a set of hypothesized adult-onset mental health disturbances possibly due to early-onset cannabis use (EOCU, onset <18 years). We seek to estimate the suspected EOCU-associated excess odds of experiencing an incident depression spell during adulthood, with comparisons to never cannabis smokers and those with delayed cannabis onset (i.e., not starting to smoke cannabis until adulthood).

METHODS

The National Surveys on Drug Use and Health (NSDUH) assess non-institutionalized community-dwelling residents of the United States after probability sampling each year. In aggregate, the NSDUH analytical sample included 173,775 adult participants from survey years 2005-2009 (74-76% of designated respondents). Standardized computer-assisted interviews collected information on background determinants, age of first cannabis use, and depression spell onset. Logistic regression was used to estimate EOCU-depression spell associations in the form of odds ratios, with statistical adjustment for sex, age, race/ethnicity, years of cannabis involvement, tobacco cigarette onset, and alcohol onset.

RESULTS

About 1 in 10 experienced a depression spell during adulthood, and both early-onset and adult-onset cannabis smokers had a modest excess odds of a depression spell compared to never cannabis smokers, even with covariate adjustment (OR=1.7 and 1.8, respectively; both p<0.001). Estimates for early- and adult-onset cannabis smokers did not statistically differ from one another.

LIMITATIONS

Shared diathesis that might influence both EOCU and adult-onset depression spell is controlled no more than partially, as will be true until essentially all known early-life shared vulnerabilities are illuminated.

CONCLUSION

Cannabis smoking initiated at any age signals a modest increased risk of a spell of depression in adulthood, even when adjusted for suspected confounding variables studied here. Delaying cannabis onset until adulthood does not appear to diminish the cannabis-associated risk.

The parametric, psychological, neuropsychological, and neuroanatomical properties of self and world evaluation

BACKGROUND

As an individual moves from adolescence to adulthood, they need to form a new sense of self as their environment changes from a limited to a more expansive structure. During this critical stage in development the last dramatic steps of neural development occur and numerous psychiatric conditions begin to manifest. Currently, there is no measure that aids in the quantification of how the individual is adapting to, and conceptualizing their role in, these new structures. To fill this gap we created the Self and World Evaluation Expressions Test(SWEET).

METHOD

Sixty-five young adults (20.6 years-old), 36 with a history of drug use, completed the SWEET. A factor analysis was performed on the SWEET and the resultant factors were correlated with psychological, neuropsychological, and neuroanatomical battery that included both T1-wieghted and diffusion tensor magnetic resonance imaging scans.

RESULTS

WE DERIVED FOUR FACTORS: Self, Social-Emotional, Financial-Intellectual, and Spirituality. While showing limited relationships to psychological and neuropsychological measures, both white matter integrity and gray matter density showed significant relationships with SWEET factors.

CONCLUSIONS

These findings suggest that while individual responses may not be indicative of psychological or cognitive processes they may relate to changes in brain structure. Several of these structures, such as the negative correlation of the affective impact of world with the dorsal anterior corpus callosum white matter integrity have been observed in psychiatric conditions (e.g., obsessive-compulsive disorder). Further longitudinal research using the SWEET may help understand the impact of dramatic shifts in self/world conceptualization and potentially link these shifts to underlying changes in brain structure.

A mixture-model approach to linking ADHD to adolescent onset of illicit drug use

Prior research findings have been mixed as to whether attention-deficit/hyperactivity disorder (ADHD) is related to illicit drug use independent of conduct problems (CP). With the current study, the authors add to this literature by investigating the association between trajectories of ADHD symptoms across childhood and adolescence and onset of illicit drug use, with and without controlling for CP. In a longitudinal panel study of a community sample of 754 girls and boys recruited in kindergarten, this research question was examined with a combination of growth mixture modeling (to model parent-reported ADHD symptom trajectories) and survival analysis (to model youth-reported initiation of illicit drug use). Results revealed a 3-class model of ADHD trajectories, with 1 class exhibiting no or minimal symptoms throughout childhood and adolescence, another class showing a convex shape (an increase, then a decrease in symptoms) across time, and a third class showing a concave shape (a decrease, then a slight increase in symptoms) over time. The concave-trajectory class demonstrated significantly earlier onset of illicit drug use than the minimal-problem class, with the convex-trajectory class falling between (but not significantly different from either of the other two classes). These results did not change when the authors added CP to the model as a covariate. Implications of findings for theory and practice are discussed.

Cannabis and suicide: longitudinal study

BACKGROUND

Some studies suggest that cannabis use is associated with suicidal ideation, but no detailed longitudinal study has examined suicide as an outcome.

AIMS

To examine the association between cannabis use and completed suicide.

METHOD

A longitudinal study investigated 50 087 men conscripted for Swedish military service, with cannabis use measured non-anonymously at conscription. Suicides during 33 years of follow-up were identified by linkage with the National Cause of Death Register.

RESULTS

There were 600 (1.2% of cohort) suicides or deaths from undetermined causes. Cannabis use was associated with an increased risk of suicide (crude OR for 'ever use' 1.62, 95% CI 1.28-2.07), but this association was eliminated after adjustment for confounding (adjusted OR = 0.88, 95% CI 0.65-1.20).

CONCLUSIONS

Although there was a strong association between cannabis use and suicide, this was explained by markers of psychological and behavioural problems. These results suggest that cannabis use is unlikely to have a strong effect on risk of completed suicide, either directly or as a consequence of mental health problems secondary to its use.

Genetic and environmental influences on externalizing behavior and alcohol problems in adolescence: a female twin study

Genetic and environmental contributions to the observed correlations among DSM-IV ADHD problems [inattentive (INATT) and hyperactive/impulsive (HYP/IMP) behaviors], conduct problems (CDP) and alcohol problems (AlcProb) were examined by fitting multivariate structural equation models to data from the Missouri Adolescent Female Twin Study [N=2892 twins (831 monozygotic pairs, 615 dizygotic pairs)]. Based on results of preliminary regression models, we modified the structural model to jointly estimate (i) the regression of each phenotype on significant familial/prenatal predictors, and (ii) genetic and environmental contributions to the residual variance and covariance. Results suggested that (i) parental risk factors, such as parental alcohol dependence and regular smoking, increase risk for externalizing behavior; (ii) prenatal exposures predicted increased symptomatology for HYP/IMP (smoking during pregnancy), INATT and CDP (prenatal alcohol exposure); (iii) after adjusting for measured familial/prenatal risk factors, genetic influences were significant for HYP/IMP, INATT, and CDP; however, similar to earlier reports, genetic effects on alcohol dependence symptoms were negligible; and (iv) in adolescence, correlated liabilities for conduct and alcohol problems are found in environmental factors common to both phenotypes, while covariation among impulsivity, inattention, and conduct problems is primarily due to genetic influences common to these three behaviors. Thus, while a variety of adolescent problem behaviors are significantly correlated, the structure of that association may differ as a function of phenotype (e.g., comorbid HYP/IMP and CDP vs. comorbid CDP and AlcProb), a finding that could inform different approaches to treatment and prevention.

A tale of two systems: co-occurring mental health and substance abuse disorders treatment for adolescents

Co-occurring disorders present serious challenges to traditional mental health and substance abuse treatment systems. Among adolescents in need of behavioral health services, co-occurring disorders are highly prevalent and difficult to treat. Without effective intervention, youth with co-occurring disorders are at increased risk of serious medical and legal problems, incarceration, suicide, school difficulties and dropout, unemployment, and poor interpersonal relationships. In general, current service systems are inadequately prepared to meet this need due to a variety of clinical, administrative, financial, and policy barriers. This article presents an overview of co-occurring disorders among adolescents, highlights general considerations for co-occurring disorders treatment, reviews selected treatment models and outcomes, and discusses recommendations and best practice strategies.

The relationship between depressive symptom levels and subsequent increases in substance use among youth with severe emotional disturbance

OBJECTIVE

This study examined the relationship between levels of depressive symptoms and subsequent increases in substance use among 784 youth with severe emotional disturbance enrolled in Medicaid-funded behavioral health care plans.

METHOD

Youth at five sites nationwide were interviewed about their emotional and behavior problems, as well as their use of cigarettes, alcohol, and drugs--at both baseline and follow-up.

RESULTS

(1) Levels of depressive symptoms were significantly associated with concurrent substance use at baseline. (2) Baseline levels of depressive symptoms predicted subsequent changes in substance use, especially use of illicit drugs and multiple drugs. (3) These findings remained significant, even after controlling for sociodemographic, family, and individual characteristics.

CONCLUSIONS

These results indicate that depressive symptoms early in life may signal a risk for increasing involvement in substance use among severe emotional disturbed youth. This finding has important clinical implications for the prevention of substance misuse in this population.

Childhood attention deficit hyperactivity disorder and the development of substance use disorders: valid concern or exaggeration?

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder associated with many behavioral problems in adolescence and adulthood. In particular, researchers have identified comorbid substance use disorders in many adolescents and young adults who were diagnosed with ADHD as children. Conflicting reports exist regarding the developmental risk for substance use problems and disorders in these individuals. This paper reviews the recent literature evaluating the relationship between childhood ADHD and substance use. Research suggests that in the absence of conduct disorder, ADHD carries only a moderate risk for subsequent substance use. Degree of risk appears to be related to specific drugs of abuse and particular ADHD symptoms. Additionally, whether stimulant treatment of ADHD symptoms predisposes children to later substance use is an important concern. Currently, little evidence exists to support this notion and most research suggests that stimulant treatment serves as a protective factor for substance use. ADHD is an important precursor to subsequent disorders in children and further research is necessary to diminish the risk for substance use in this population.

ADHD from a socio-economic perspective

AIM

Attention deficit hyperactivity disorder (ADHD) and related disorders affect children's ability to function in school and other environments. Awareness has increased in recent years that the same problems often persist in adulthood. Based on previous studies, we aimed to outline and discuss a descriptive model for calculation of the societal costs associated with ADHD and related disorders.

METHODS

Following a literature review including childhood and adult studies, long-term outcomes of ADHD and associated societal costs were outlined in a simple model.

RESULTS

The literature concerning long-term consequences of ADHD and related disorders is scarce. There is some evidence regarding educational level, psychosocial problems, substance abuse, psychiatric problems and risky behaviour. The problems are likely to affect employment status, healthcare consumption, traffic and other accidents and criminality. A proposed model structure includes persisting problems in adulthood, possible undesirable outcomes (and their probabilities) and (lifetime) costs associated with these outcomes.

CONCLUSIONS

Existing literature supports the conclusion that ADHD and related disorders are associated with a considerable societal burden. To estimate that burden with any accuracy, more detailed long-term data are needed.

Substance abuse among adolescents

Substance use and dependence are among the most prevalent causes of adolescent morbidity and mortality in the United States. This paper provides a review of differences between adolescent and adult substance abuse, prevention and treatment approaches, and future potential directions and needs for more effective programming in the treatment of adolescent substance abuse(1) and dependence on psychoactive substances.

US patterns of mental health service utilization for transition-age youth and young adults

This study examines rates of admission and patterns of mental health service use by persons of transition age (16-25 years) in the USA based on the nationally representative 1997 Client/Patient Sample Survey and population data from the US Census Bureau. A precipitous decline in utilization was observed at the age of emancipation: the yearly admission rate for inpatient, outpatient, and residential services was 34 per 1,000 for 16- and 17-year-olds and 18 per 1,000 for 18- and 19-year-olds. Among 20- and 21-year-olds, more were referred from criminal justice and fewer from family or friends and social services, and proportionately more were Medicaid recipients. Targeting resources to enhance shared planning between child and adult systems may facilitate continuity of care for young adult clients who are aging out of child mental health systems, as well as for those who experience their first episodes of mental disorder in early adulthood.

US patterns of mental health service utilization for transition-age youth and young adults

This study examines rates of admission and patterns of mental health service use by persons of transition age (16-25 years) in the USA based on the nationally representative 1997 Client/Patient Sample Survey and population data from the US Census Bureau. A precipitous decline in utilization was observed at the age of emancipation: the yearly admission rate for inpatient, outpatient, and residential services was 34 per 1,000 for 16- and 17-year-olds and 18 per 1,000 for 18- and 19-year-olds. Among 20- and 21-year-olds, more were referred from criminal justice and fewer from family or friends and social services, and proportionately more were Medicaid recipients. Targeting resources to enhance shared planning between child and adult systems may facilitate continuity of care for young adult clients who are aging out of child mental health systems, as well as for those who experience their first episodes of mental disorder in early adulthood.

The substances and choices scale (SACS)--the development and testing of a new alcohol and other drug screening and outcome measurement instrument for young people

AIMS

To describe the development and evaluation of the Substances and Choices Scale (SACS), an adolescent alcohol and other drug (AOD) self-report instrument designed in a similar format to the Strengths and Difficulties Questionnaire (SDQ).

DESIGN

A literature review, extensive consultation and discriminant analysis on a pilot sample (n = 61) of adolescents informed the development of the SACS. The psychometric properties of the SACS were then tested in a larger community and clinical sample.

SETTING

Three youth out-patient AOD treatment services and three secondary schools in Auckland, New Zealand.

PARTICIPANTS

13-18-year-old males and females attending the services (n = 120) or schools (n = 531).

MEASUREMENTS

The SACS was administered with the CRAFFT, the Problem Oriented Screening Instrument for Teenagers (POSIT) and the Strengths and Difficulties Questionnaire (SDQ).

FINDINGS

Reliability of the SACS was sound, with coefficient alpha 0.91 and 3-week test-retest correlation 0.88. Congruent validity coefficients of the SACS versus the CRAFFT and the POSIT were 0.79 and 0.91, respectively. A ROC curve demonstrated the SACS as having a predictive value of 92%. Repeat SACS scores in a treatment sample indicated that the SACS had utility in measuring change. Feedback from participants indicated that the SACS was highly acceptable.

CONCLUSIONS

The SACS is a simple AOD instrument that is reliable, valid and acceptable to young people. It has utility in screening and measuring outcome and should enhance the identification and treatment of AOD difficulties in adolescents across a range of health settings.

Adolescents with co-occurring substance use and mental conditions in a private managed care health plan: prevalence, patient characteristics, and treatment initiation and engagement

This study examined the prevalence, patient characteristics, and treatment initiation and engagement of adolescents with co-occurring substance use (SU) and serious mental health (MH) diagnoses in a private, managed care health plan. We identified 2,005 adolescents aged 12-17, who received both SU and MH diagnoses within a 1-year window between 1/1/2000 and 12/31/2002; 57% were girls. Gender variations were found in diagnoses received and point of identification. Being dually diagnosed in specialty departments (rather than Primary Care and Emergency) and receiving both diagnoses within a shorter time period were associated with treatment initiation and engagement.

Behaviorally-based disorders: the historical social construction of youths' most prevalent psychiatric diagnoses

Psychiatry in the USA controls the definitions of mental health disorders and diagnosis through required practice utilization of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and fiscal reimbursement using it. The present sociohistorical research paper presents and critically examines the Manual's systemic and diagnostic development of today's most prevalent youth mental health diagnoses (conduct and oppositional defiant disorders). Through a social construction theoretical paradigm, this research identified diagnostic classification systems, nosology changes, critical time periods, conducive social and cultural conditions, and key individuals involved in the development of these youth behaviorally-based disorders within two distinct historical time frames: 1880 to 1968 and 1969 to 2000. It also identified patterns of nosology system and diagnostic category changes based upon very limited empiricism, inordinately influenced by a limited number of individuals, and understood through a socially constructed framework.

Links between depression and substance abuse in adolescents: neurobiological mechanisms

Adolescence is a high-risk period for development of both depressive and substance use disorders. These two disorders frequently co-occur in adolescents and are associated with significant morbidity and mortality. Given the added economic and psychosocial burden associated with the comorbid condition, identification of risk factors associated with their co-occurrence is of great public health importance. Research with adult animals and humans has indicated several common neurobiological systems that link depressive and addictive disorders. Given the ongoing maturation of these systems throughout adolescence and early adult life, it is not clear how these neurobiological processes influence development and progression of both disorders. A better understanding of the pathophysiological mechanisms leading to the onset and course of these disorders during adolescence will be helpful in developing more effective preventive and treatment strategies, and thereby allow these youth to reach their full potential as adults.

Prediction of drug and alcohol abuse in hospitalized adolescents: Comparisons by gender and substance type

The authors examined psychosocial correlates of drug and alcohol abuse in 462 hospitalized adolescents, and the extent to which these associations may be affected by gender or by substance type. Participants completed a battery of psychometrically-sound, self-report measures of psychological functioning, environmental stress, drug abuse, and alcohol abuse. Four multiple regression analyses were conducted to determine the joint and independent predictors of drug abuse and alcohol abuse, for males and for females. Multiple regression analysis revealed that seven variables--age, depression, impulsivity, low self-esteem, delinquent predisposition, low peer insecurity, and history of child abuse--jointly predicted both drug and alcohol abuse, for both males and females. However, several differences were found with respect to which variables made independent contributions to the predictive models--with only delinquent predisposition making a significant independent contribution for all four conditions. We found distinct patterns of psychosocial predictor variables for drug and alcohol abuse, as well as distinct patterns for males and females. These results may reflect differing risk factors for drug abuse and alcohol abuse in adolescent psychiatric patients--and differing risk factors for males and females. Such differences have potential implications for prevention and treatment.

Therapeutic challenges of attention-deficit hyperactivity disorder with substance use disorders

Attention-deficit hyperactivity disorder (ADHD), a common neuropsychiatric disorder of childhood, adolescence and adulthood, is frequently comorbid with substance use disorders (SUDs) in both adolescents and adults. This paper will provide an overview of the relationship between ADHD and SUDs and discuss the primary areas of therapeutic challenge in the treatment of individuals with comorbid ADHD and SUDs, including the diagnosis of ADHD in populations with SUDs, selecting appropriate agents for use and prevention of abuse and/or diversion of the therapeutic pharmacological agents used in ADHD treatment. The authors will also provide a discussion on the future of research and treatment in this area and key issues for clinicians.

Attention-deficit hyperactivity disorder in girls: epidemiology and management

Attention-deficit hyperactivity disorder (ADHD) in girls is a topic of growing research and clinical interest. For many years, girls with ADHD have been ignored and overshadowed by hyperkinetic and impulsive boys, but they are now attracting interest in an effort to understand the similarities and differences in the prevalence, symptoms, familial risk, comorbidities and treatment of ADHD in the two sexes. A review of past and current literature finds that the symptoms of ADHD are not sex specific, but that identification of girls with ADHD is hampered by parental and teacher bias, and confusion. Girls are more likely to be inattentive without being hyperactive or impulsive, compared with boys. Girls and boys share the same familial risk patterns, as well as similar, although not identical, comorbidity or impairment patterns. The risk of non-treatment is as great in girls as it is in boys; up to 70-80% of identified children will have persistent symptoms and impairment that extends into adolescence and adulthood. Treatment modalities are equally effective in girls and boys. Stimulants, non-stimulants and behavioural modalities are the mainstays of effective treatment.

Does pervasive developmental disorder protect children and adolescents against drug and alcohol use?

AIM

The aim of this paper is (1) to compare the rates of reported drug and/or alcohol use (DAU) in treatment seeking adolescents with Pervasive Developmental Disorders (PDD), and those with other psychiatric diagnoses (psychiatric controls) seen in tertiary child and adolescent mental health services and (2) to explore the relationship of psychopathology, environmental stressors, and social communication difficulties to DAU.

METHOD

Data from the chart review of children and adolescents aged between 12 and 18 years with psychiatric diagnosis seen in tertiary child and adolescent mental health services between 1992 and 2001 (n=1484) was used to investigate the relationship between DAU, psychopathology, environmental stressors and items related to social communication.

RESULTS

A total of 97 subjects (7%) met criteria for PDD. Subjects with PDD report significantly lower DAU than psychiatric controls, 3% vs. 17% respectively (P<0.000). Factors reflecting PDD such as speech and language difficulties, developmental difficulties, discordant peer relationships in adolescents are negatively associated with DAU, while conduct problems, affective symptoms, inadequate parental supervision or control have positive association with DAU. DAU was present in PDD only when comorbid with Attention Deficit Hyperactivity Disorder (ADHD).

CONCLUSION

Adolescents with speech and language difficulties, developmental difficulties and discordant peer relationships, all reflecting PDD, are less likely to have DAU.

Adolescent Substance Use and Suicidal Behavior: A Review With Implications for Treatment Research

Adolescent substance use (alcohol and other drugs) and suicidal behavior, independently, pose serious public health problems. Youths who report co-occurring substance use and suicidality are a particularly high-risk group. In this review, we explore four areas that are pertinent to research with substance-abusing and suicidal adolescent populations. First, we review epidemiological research that is relevant to the association between substance use and suicidal behavior. Results suggest that substance use heightens statistical risk for suicidal behavior in adolescent clinical and community populations. Alcohol intoxication may serve as a proximal risk factor for suicidal behavior among distressed youths through its psychopharmacological effects on the brain. Substance use may also serve as a distal risk factor for suicidal behavior by increasing stress and exacerbating co-occurring psychopathology. Second, we propose different theoretical models that might explain the high rates of co-occurring substance use and suicidal behavior among adolescents. Substance use may stem from an underlying syndrome of problem behavior among impulsive suicide attempters with predominant externalizing symptoms. In contrast, nonimpulsive suicide attempters with predominant internalizing symptoms may use substances to cope with negative affective states. Third, we explore the status of treatment research with substance abusing and suicidal adolescent populations. Studies of substance abuse treatment and suicidal behavior have neither adequately assessed nor incorporated treatment of the other co-occurring problem. Finally, we conclude with proposed directions for future research, including the development of integrated interventions tailored to adolescents with these co-occurring problems.

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.

Substance abuse in patients with attention-deficit hyperactivity disorder : therapeutic implications

Attention-deficit hyperactivity disorder (ADHD) is a common disorder in children that frequently persists into adulthood. Studies have found that substance use disorders (SUD) are seen more commonly in those with ADHD than the general population. Although treatment with stimulant medications has been shown to be effective for individuals with ADHD, concern about the use of these agents in this population persists. This review article highlights the research in this area with a focus on the treatment of individuals who present with concomitant ADHD and SUD. Although stimulants can be abused, studies have shown that adolescents who are prescribed stimulants for ADHD have lower rates of SUD than those who are not treated with stimulants. It may be particularly difficult to evaluate adults for the diagnosis of ADHD when SUD is a co-morbid factor. Studies show that 20--30% of adults presenting with SUD have concomitant ADHD and approximately 20--40% of adults with ADHD have histories of SUD. Therefore, it is critical to perform careful diagnostic interviews to discern if patients have either or both of these disorders. Many clinical experts suggest that adults with ADHD and active SUD be treated for the SUD until a period of sobriety persists prior to initiation of specific treatment for ADHD. Since individuals with ADHD and active SUD are more likely to have more severe SUD and a worse prognosis, this approach may not serve many patients, as they relapse prior to obtaining ADHD treatment. Therefore, research has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD indicates that this is the case. Individuals with ADHD and SUD can present difficult diagnostic and therapeutic challenges. It appears that the most effective treatment option is to create a programme that uses the most effective treatment modalities available, including both behavioural and medical therapies, along with close supervision and monitoring. Newer medical treatment options of long-acting stimulants and non-stimulants (e.g. atomoxetine) offer effective treatment with a lower risk of abuse potential.

Anxiety and risk for substance dependence among late adolescents/young adults

This study examined the relation between comorbid and pure (non-comorbid) anxiety disorders and both substance dependence and substance use problems in a community sample of 1747 young adults ages 18-23 years. Results indicate that collectively anxiety disorders, both pure and comorbid with other psychiatric diagnoses, are predictive of substance dependence. When temporal order was controlled, anxiety disorders generally preceded the onset of substance dependence. However in analyses in which PTSD was excluded, anxiety disorders were no longer predictive of substance dependence, suggesting that the increased risk associated with anxiety disorders is largely if not wholly attributable to PTSD. Finally, comorbid and pure anxiety disorders were found to be predictive of the number of alcohol and drug use problems.

Effects of alcohol and drug use on inpatient and residential treatment among youth with severe emotional disturbance in Medicaid-funded behavioral health care plans

This study examined the use of alcohol and recreational drugs among 875 youth with severe emotional disturbance (SED) enrolled in Medicaid-funded behavioral health care plans, and whether co-occurring SED and substance use affected the subsequent likelihood of receiving inpatient and/or residential treatment. Youth at five sites nationwide were interviewed about their use of drugs and alcohol, while interviews with their caregivers elicited information about youths' service utilization, degree of functional impairment, and a series of demographic and environmental variables. Results indicated that half of the youth (52%) reported lifetime use of alcohol, street drugs, or over-the-counter medications for recreational purposes, while 18% reported use in the past 30 days. Among those reporting recent use, 32% reported using drugs only, 34% alcohol only, and 33% reported use of both drugs and alcohol. In multivariate logistic regression analyses, the effect of recent use was stronger than that of lifetime use; however, the largest effect occurred for those reporting recent use of both drugs and alcohol, versus either alone, or none. Differences remained significant when controlling for managed care versus fee for service enrollment as well as child, family, and environmental characteristics including study site. These results mirror those of prior studies that found an association between substance use and greater likelihood of inpatient services, even in managed care settings.

Indentifying co-occurring disorders in adolescent population

A structured diagnostic interview (Practical Adolescent Diagnostic Interview) designed to gather basic information about substance use disorders, other mental health conditions, and related experiences was used in a variety of clinical settings. Anonymous data from 279 adolescents interviewed as part of routine clinical assessments in a variety of clinical programs were analyzed to assess the ability of the questions to identify potential problem areas and to provide a preliminary exploration of interrelationships between those problems. Results demonstrated that the vast majority of individuals manifested indications of multiple problems. For a given diagnostic condition, the trend is for those meeting at least the minimal DSM-IV criteria to exhibit substantially more than the minimum number of symptoms. Internal consistencies for item groups defining the various conditions range from more than .700 to over .900 indicating adequate to excellent internal consistency and reliability. Utility of the instrument for routine clinical use is also discussed.

Adolescent alcohol misuse: methodological issues for enhancing treatment research

AIMS

The objective of this article is to present an overview of the current state of the field of adolescent alcohol treatment research and to discuss several priorities for future research directions.

METHOD

The authors identified trends in adolescent alcohol treatment research from multiple sources, including searches of the National Institutes of Health grantee listings, proceedings from annual meetings of the Research Society on Alcoholism and relevant English-language journal articles available in MEDLINE and PSYCHLIT databases over the past decade.

RESEARCH RECOMMENDATIONS

This field must build on its major strength, which has been its success in appreciating the unique developmental characteristics of adolescence and meaningfully incorporating them into adolescent alcohol treatment approaches. Priorities for future research include: empirically investigating the potential value of harm reduction approaches for promoting public health and reducing total harm for adolescents; developing efficacious interventions across a wide range of intensities and settings; increasing the reach and relevance of randomized treatment efficacy trials and their products, with a particular focus on enhancing the recruitment and retention of diverse treatment samples; increasing a focus on key individual difference variables such as co-occurring diagnoses, that may serve as the basis for treatment tailoring; and exploration of the potential benefits of transdisciplinary research.

Impact of psychiatric comorbidity on treatment of adolescent drug abusers

Comorbidity of substance abuse disorders (SUD) and psychiatric disorders is one of the most important areas of investigation in contemporary drug abuse treatment research. This study examined the impact of psychiatric comorbidity on the treatment of 182 adolescent drug abusers in a randomized clinical trial comparing family and individual cognitive-behavioral therapy. Three distinct groups of adolescent substance abusers were compared: (1) Exclusive Substance Abusers (SUD only); (2) Externalizers (SUD + externalizing disorder); and (3) Mixed Substance Abusers (SUD + externalizing and internalizing disorder). The purpose of this study was to determine whether adolescents in these comorbid groups differed in clinical presentation and treatment response. More severe comorbidity was associated with greater family dysfunction and being female and younger at intake. An examination of substance use trajectories over time indicated that the Mixed group initially responded to treatment but returned to intake levels of substance use by 1 year post-discharge.

Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up

Research suggests that the sequelae of childhood anxiety disorders, if left untreated, can include chronic anxiety, depression, and substance abuse. The current study evaluated the maintenance of outcomes of children who received a 16-week cognitive-behavioral treatment for primary anxiety disorders (generalized, separation, and social anxiety disorders) an average of 7.4 years earlier. The 86 participants (ages 15 to 22 years; 91% of the original sample) and their parents completed diagnostic interviews and self- and parent-report measures. According to the diagnostic interviews, a meaningful percentage of participants maintained significant improvements in anxiety at long-term follow-up. With regard to sequelae, positive responders to anxiety treatment, as compared with less positive responders, had a reduced amount of substance use involvement and related problems at long-term follow-up. The findings are discussed with regard to child anxiety and some of its sequelae.

Depressive symptoms and health risk among rural adolescents

OBJECTIVE

To determine the stability of depression and its relationship with health risk factors among rural adolescents.

METHODS

A clinic-based longitudinal study was conducted to test for depression and risk factors in 64 participants who attended a rural, primary care, adolescent medicine clinic. The primary measure of risk and depression was the Perkins Adolescent Risk Screen (PARS). Adolescent patients who were aged 12 to 18 years and had PARS assessments during a previous visit to the adolescent clinic were invited to complete a follow-up PARS assessment.

RESULTS

The mean age of adolescents at baseline was 12.79 years; 14.59 years at follow-up. With age and gender being controlled, adolescent depression and various adolescent risk indices were significantly related at baseline. Longitudinally, baseline depression score on PARS were related to follow-up: depression, school problems, substance abuse, tobacco use, sexual activity, and violent behavior scores and a history of physical/sexual abuse. On multivariate analysis controlling for other significantly associated variables, the relationship persisted for baseline depression and follow-up: tobacco, substance abuse, depression, and history of physical/sexual abuse.

CONCLUSION

This study confirms a strong longitudinal relationship between baseline depressive symptoms and several important risk behaviors/factors measured at follow-up in a clinic population of rural adolescents. Also, longitudinal stability of depression over time is supported.

Detection and outcomes of substance use disorders in adolescents seeking mental health treatment

OBJECTIVE

To compare detection rates, service use, and outcomes of substance use disorder (SUD) in adolescents seeking mental health treatment.

METHOD

Adolescents (n = 237) and their parents or caregivers completed parallel, self-administered versions of the Adolescent Treatment Outcomes Module (ATOM) at intake and 6-month follow-up. SUD was assessed using the Diagnostic Interview Schedule for Children (DISC).

RESULTS

Although 42 (16.6%) adolescents seeking mental health treatment met DISC criteria for any SUD at baseline, clinicians detected only 19 of these (kappa = 0.51). Sensitivity and specificity were high for a screening tool for adolescent SUD (95.2 and 82.0, respectively). Adolescents with undetected SUD were less likely to receive SUD services and to have more legal problems at 6-month follow-up compared to adolescents with detected SUD.

CONCLUSIONS

SUD rates may be high in adolescents seeking mental health treatment, confirming the need for routine screening in this population. Results confirm that a large gap exists between the need for and access to SUD treatments, which may contribute to poorer outcomes for all adolescents with SUD.

Relation between childhood disruptive behavior disorders and substance use and dependence symptoms in young adulthood: individuals with symptoms of attention-deficit/hyperactivity disorder and conduct disorder are uniquely at risk

Most prior literature examining the relations among attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and substance use and abuse suggests that CD fully account for the ADHD-substance abuse relation. This study sought to test an alternate theory that individuals with symptoms of both ADHD and CD are at a special risk for substance abuse. Relations between childhood ADHD and CD symptoms, and young adult tobacco, alcohol, marijuana, and hard drug use and dependence symptoms, were examined in a sample of 481 young adults. ADHD and CD symptoms interacted to predict marijuana dependence symptoms and hard drug use and dependence symptoms, such that individuals with high levels of both ADHD and CD had the highest levels of these outcomes.

["Body and soul and friendships destroyed". Behavior therapy of a 14-year-old adolescent with alcohol dependence syndrome]

OBJECTIVES

About 250,000 children and adolescents in Germany are dependent upon alcohol or at severe risk of developing an alcohol disorder. Whereas adults who abuse alcohol benefit from a variety of therapy manuals and numerous institutions offering long-term disorder-specific care, the situation with regard to adolescent patients needs to be upgraded.

METHODS

We present the behavioral therapy of an alcohol-dependent 14-year-old boy, focusing on a version of Petry's therapy manual for alcoholism (1996) that has been adapted for the treatment of adolescents. The efficacy of worksheets as a supplement to the usual behavior therapy, or social or family interventions in the treatment of alcohol-dependent adolescents is discussed.