Transcript Preliminary Issues

Adolescents and
Substance Abuse
• Cigarette smoking
– Tobacco use in teens is associated with a wide range of
risk taking behavior, including violence, high risk
sexual activity, and drug use. There is a significant risk
of developing a major depression within one year of
starting to smoke. Children with psychiatric disorders
are also more likely to smoke.
– Teenage smoking reached a peak in Wisconsin in 1999
(38.1% of seniors) and has declined to 20.9%. Girls
(21.9%) have a slightly higher prevalence rate than
boys (19.8%).
Prevention of Cigarette Smoking
• The most effective antidote to smoking is
expensive cigarettes.
• Resistance training skills are helpful to
reduce smoking initiation.
• 75-80% of initially successful quitters
resume smoking within 6 months. If they
can stay abstinent for 5 years, risk of relapse
is negligible.
Drug and Alcohol Abuse
• Drug use increases in adolescents to young
adulthood, then generally declines. In 2005, there
has been a decline in alcohol use, LSD and
cocaine, but an increase in illicit prescription
drugs (oxycodone), marijuana, and club drugs.
The use of inhalants is rising among 8th graders.
• Teenage drinking among girls is rising faster than
boys, in large part because they are being targeted
in alcohol related ads in the magazines they read.
2005 “Monitoring
the Future” Survey
• Drinking in last month
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8th grade
17%
10th grade
33.2%
12th grade
47%
28% of seniors binge drink
• Tried an illicit drug
– 8th grade
– 10th grade
– 12th grade
21%
38%
50%
Drug Abuse in Children and
Adolescents
• 1:5 teens has abused Vicodin or OxyContin. 10%
have abused a stimulant - Adderall is the most
common. 10% have abused cough medicines
• Most of the time, these prescription drugs are in the
family medicine cabinet. There are Internet sites
devoted to how to get and abuse drugs.
• Inhalant abuse can be fatal. Such agents are
commonly found in household - glue, shoe polish,
spray paints, nitrous oxide, correction fluid, etc.
Prevention in Children and
Adolescents
• The younger the child initiates alcohol and
other drug use, the higher the risk for
serious health consequences and adult
substance abuse and dependence.
• Effective prevention and intervention
programs consider cultural context, social
resistance skills, and developmental level of
the child.
Prevention in Children and
Adolescents
• Peers have been successfully used to influence, teach,
and counsel young people. Even though education
about drugs do not contribute greatly to reducing drug
use, the use of peers as facilitators works for the
average student. Adolescents believe their peers’
attitudes against drug use. The lower the perceived
acceptance rate, the less frequent the drug use.
• DARE works better than non-interactive programs,
but not as well as programs involving peer delivery of
information.
•
Prevention in Children and
Adolescents
Most promising preventive measures are:
– Assessment and treatment of psychiatric disorders
– Education that targets knowledge and attitudes
about substances
– Development of proper social and problem solving
skills
– Treatment of family problems
– Increased opportunities for prosocial activities
with peers
– Limited early access to the use of gateway drugs
such as alcohol and nicotine
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Prevention in Children and
Adolescents
Risk factors:
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Poor self-image
Low religiousity
Poor scholl performance
Parental rejection
Family dysfunction
Abuse
Over or under-controlling by parents
Divorce
Externalizing disorders (ADHD has 3x risk substance use.
Those in treatment are at less risk)
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Protective Factors in Children
and Adolescents
Nurturing home with good communication
Teacher commitment
Positive self-esteem
Self-control
Assertiveness
Social competence
Academic achievement
Regular church attendance
Intelligence
Avoiding delinquent peers
Depression
• Depression is a constellation of symptoms
including social isolation, lack of energy,
changes in sleep and appetite, and an
inability to experience pleasure that appear
in addition to a depressed mood.
Substance Abuse and Mental Health
Services Administration
Adolescents with depression in
past year (2004)
14%
12%
10%
8%
6%
4%
2%
0%
13-14
14-15
16-17
SAMHSA - 2004
• 9% of adolescents experienced a depressive
episode over the last year.
• Girls - 13.1% Boys - 5%
• No differences in ethnic group, SES in incidence,
but those with health insurance were more likely
to get treatment.
• <50% received help for depression.
• Those with depression were twice as likely to
smoke, use alcohol and illicit drugs.
Wisconsin High School Survey
2003
• During the last 12 months, have you felt sad or
hopeless for 2 weeks or more so that you
stopped doing social activities?
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Total 25.3%
Boys 17.6%
Girls 33.5%
Junior year the worst
Depression
• Depression may manifest itself as irritability and
behavior problems in children and adolescents.
• Research now indicates that substance abuse in
boys and girls, and sexual behavior in girls is a
cause for subsequent depression in adolescents.
Depression can then make teens more vulnerable
to substance abuse and other risky behaviors.
• The use of antidepressants in children and teens is
controversial.
Antidepressants and Suicide
• In the summer of 2004, two reviews by
Columbia University looked at
pharmaceutical industry data from 22
placebo controlled trials involving 4,250
pediatric patients. They found that young
people given antidepressants were 1.8x
more likely to become suicidal as young
people given placebo.
Antidepressants and Suicide
• On October 15, 2004, the FDA issued its
strongest possible warning (black box) for
all antidepressants stating that these
medications may “increase the risk of
suicidal thinking and behavior in children
and adolescents with major depressive or
other psychiatric disorders.”
Antidepressants and Suicide
• The best approach is to monitor everyone
who is started on an antidepressant closely
for the appearance of suicidal ideation,
agitation, and irritability, especially during
the initial months of therapy, and be sure
that the risk is discussed during the
informed consent process.
Self-Injurious Behavior
• SIB - the deliberate alteration or destruction of
body tissue without conscious suicidal intent
• Four types:
– Severe - extensive damage (psychotic)
– Stereotyped - rhythmic (DD, seizure disorders)
– Socially accepted/emblematic - tattooing, piercing,
etc…
– Superficial/moderate
Superficial/Moderate
• Compulsive:
– Habitual, obsessive/comp rather than impulsive. Urge is
resisted. (Ego-dystonic) Intrusive thoughts about
contamination, inadequacy, bodily shame. Nail biting,
trichotillomania, skin picking
• Episodic:
– Occasional impulsive burning and cutting in response to
stress or life events.
• Repetitive:
– Repetitive burning and cutting, rumination about self-abuse
and identification as a cutter or burner. There is little
resistance to the urge. Carefully executed. Has qualities of
addiction.
Superficial/Moderate
• Counter-dissociative:
– An attempt to re-associate self with here and
now reality
• Parasuicidal:
– “suicide gesture” reflecting ambivalence about
suicide or as attempt to communicate to others
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Impulsive, Superficial/ Moderate
SIB
Skin cutting is the most common, followed by
burning and hitting
Commonly comorbid with personality disorders
Typically includes onset in adolescence, multiple
episodes, chronic, associated with depression,
despair, anger, aggression, anxiety, cognitive
constriction
Predisposing factors include lack of social support,
male homosexuality, AODA, suicidal ideation in
women.
Diagnosed as Impulse Control Dis NOS, or BPD
Self-Injurious Behavior
• Worldwide, nonfatal deliberate self-harm is more common in
adolescents, especially young females (11.2% girls, 3.2% boys)
Boys more frequently need medical attention.
• Self-harm in adolescents increased with consumption of
cigarettes, alcohol and drugs in one large study. Having friends
or family members self-harm was also a risk factor. Depression,
anxiety, and impulsivity was a risk for girls, who said they were
trying to punish themselves or get relief from a terrible state of
mind.
• The Internet may normalize and encourage pre-existing SIB in
adolescents.
Self-Injurious Behavior
• There is disagreement about the meaning of the
injury: symbolic, impulse disorder, serotonin deficit,
endorphin dysregulation.
• Adolescents are likely to explain their self-harm by
saying they wanted relief from unpleasant feelings
(depression, anxiety, loneliness, anger) or that the act
was impulsive.
• Childhood abuse is a factor in the descriptive and
empirical literature.
• There are also associations with AODA, PTSD,
intermittent explosive disorder, dissociative disorder.
Summary of Reasons for SIB
• Affect regulation
– Reconnection with the body
– Calming the body during periods of arousal (exhibit decreases in respiration,
skin conductance, heart rate in response to the behavior (like concentration)
– Validating inner pain
– Avoiding suicide
• Communication
– Express things which cannot be said out loud
• Control/punishment
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Trauma re-enactment
Bargaining and magical thinking
Self-control
Control of others
Children and Suicide
• Suicide attempts are statistically insignificant
until the age of 12., but higher in the US in the
last 20 years.
• Suicidal children have a history of impulsive,
aggressive behavior, are taller and physically
more mature than their classmates, more were
more likely to be involved with conflict with
parents, and be in a disciplinary crisis.
Families must be involved in assessment,
prevention and treatment.
Warning Signs
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Past suicide attempts or threats
Past violent or aggressive behavior
Mental illness or alcohol use
Bringing weapons to school
Recent experience of humiliation, shame loss
Bullying as victim or perpetrator
Victim of abuse/neglect
Themes of depression, death
Vandalism, cruelty to animals, setting fires
Poor peer relationships, cults, no supervision
Suicide first arises as a public
health problem at 12 years old.
Suicide Rates per 100,000
12
8
1.3
10yrs - 14
15yrs-19
20yrs-24
Suicide Rates: 1981-2001
30
25
20
Female
Male
15
10
5
01
20
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
19
83
19
19
81
0
Adolescent Suicidal Behavior:
2001 U.S. Data
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Ideation
Plan
Attempt
Complete
Wisconsin Suicides
• Suicide is the second leading cause of death in
adolescents.
• From 2000-2002, there were 323 suicides (262
homicides.)
• The annual rate is 5.7/100,000 - 36% higher than the
national average. The highest incidence is in northern
Wisconsin.
• Guns are involved in 52%.
• 27% tested positive for alcohol.
Suicidal Ideation
• In teens, suicidal ideation more strongly indicates
antisocial behavior than it does risk of suicide.
Features that may separate those who attempt
from those who don’t:
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AODA
Severe and enduring hopelessness
Isolation
Reluctance to discuss suicidal thoughts
Psychopathology
Gender Issues
• Girls
– Attempts to completions
4,000:1
– A suicide attempt is not a risk factor for suicide. Having a
depressive episode is, often with no precipitating event
– Panic attacks are a risk factor for girls
• Boys
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Attempts to completions
500:1
Rate increased 3x since 1955 - Increased AODA?
Dropped since 1995 - Increased antidepressants?
Usually within hours of event, before consequences, when
anticipatory anxiety is highest. Events include legal
problems, relationship problems, humiliation.
– Aggression is a risk factor for boys
Risk Factors for Adolescents
• Mental illness
– 90% have depression, anxiety, AODA a year before
suicide. It is estimated that 1 million youths suffer from
depression, but 60-80% do not receive help. Fewer than
10% of completed suicides were on antidepressants or
in AODA treatment.
– 50% of teen suicides involve alcohol use.
– Parents frequently do not recognize signs of suicidal
behavior. Most lay people justify depressive symptoms
in themselves and others, blaming it on stress. Stressors
can mislead. It may be the mental illness that is causing
the stress.
Risk Factors for Adolescents
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Imitation
Family history
Sexual orientation issues
Sexual abuse
Other stressors
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Interpersonal losses
Bullying (perpetrator or victim)
Lack of affiliation
Males after romantic breakup
Suicide Attempts (cont)
• Girls attempt mostly by ingestion (55%) or cutting
(31%). Boys by cutting (25%), ingestion (20%),
firearms (15%), hanging(11%).
• Greatest difference in mental state between an
ideater and attempter is the presence of AODA.
Suicidal teens who abuse substances are 12.8x
more likely to make an attempt.
Risk Factors
• Incarceration
– The suicide rate for adolescents in detention
centers is 57/100,000. For adolescents housed
in adult facilities is 2,041/100,000!!
Risk Assessment in Adolescents
• Although suicidal ideation is very common
in this population, suicide should be asked
about and evaluated in the context of an
accompanying mental illness. Depressed
adolescents should always be assessed for
suicidality. It is important to include data
from many sources, including parents,
school, or other significant relationships.
Risk Assessment in Adolescents
• Consider the following:
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Predictability of the youngster
Circumstances of suicidal behavior
Intent to die
Psychopathology
Coping mechanisms
Communication
Family support
Environmental stress
Risk Assessment in Adolescents
• Precipitating factors in vulnerable youth
may increase immediate risk.
– Opportunity
• Access to lethal means, lack of supervision
– Altered states of mind
• Hopelessness, rage, intoxication, mental illness
– Undesirable life events
• Losses, loss of esteem, humiliation, pregnancy,
abuse
Prevention Strategies
• Suicide awareness programs
– Popular with normal teens, but they don’t seem to
increase self-referrals, help-seeking, or help-giving
in adolescents. They may activate suicidal ideation
in disturbed adolescents, whose identity is usually
not known by the instructor. They may contribute
to clustering. They also tend to minimize the role
of mental illness.
Prevention Strategies
• Screening
– Assessments of depression, AODA, recent or frequent
suicidal ideation, past suicide attempts. They identify a
number of unknown, untreated cases of depression.
– Screening programs that do not include procedures to
evaluate and refer should not be used.
• Gatekeeper training
– Teachers, counselors, MD’s, youth workers trained to
recognize teens at risk. This may work, but there is no
clear research.
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Prevention
Strategies
Crisis centers and hotlines
– There is little research about the effectiveness of these
centers. Few teenagers use them, and those that do are not
at highest risk (boys).
• Restriction of lethal means/alcohol
– A modest but statistically significant decrease in teen
firearm suicides has been associated with child access
prevention laws.
– Even adolescents without a mental disorder have 13x
greater suicide risk if there is a gun in the home and a 32x
greater risk if it is loaded.
Restriction of Lethal Means
• Firearms
17% of households purchase new guns after a child’s suicide
attempt. But if they are educated, they are 3x more likely to
remove them.
– The following reduce suicide risk in an additive manner:
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Unloading guns
Locking guns
Storing ammunition separately
Locking ammunition
• Alcohol
– States that have increased the minimum drinking age have
seen a 7% suicide reduction in teens.
Prevention Strategies
• Skills training
– Teaching the problem solving and coping skills in the skills. Some
evidence of efficacy.
• Follow-up appointments
– A nighttime phone contact and next day follow-up assures 90% of
teens will stay in treatment after an ER visit.
• Antidepressants
– Caregivers need to be alert for decreasing inhibition, irritability,
change in sleep, agitation in the first weeks after an antidepressant
has been started.
Bipolar Disorder
• Bipolar disorder is a disorder of mood swings, out
of proportion with events in a person’s life. These
swings include mania and depression.
• Bipolar disorder in children is enormously
controversial! Depending on who you listen to,
there is either an epidemic, or it is virtually nonexistent.
• The diagnosis has increased 26% from 2002 to
2004!
Dr. Biederman,
Mass Gen, Boston
• Irritability is the determinant, even in the absence
of depression, elevated mood, grandiosity, or
cycles of behavior.
• These irritable episodes are not just tantrums, but
explosive, long-lasting, and often without triggers.
• This is the “Broad Phenotype” - Bipolar NOS
• Supported by parents, insurance companies, and
by the observation that many of these children
respond to medication.
Dr. Geller
Washington U, St. Louis
• Children must have alternating episodes of mania
and depression. The cycling can be complex and
very short.
• This is the “Narrow Phenotype.”
• Children exhibit:
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Excessive giddiness
Severe irritability
Grandiosity
Fragmented thought
Aggression
Making a Diagnosis
• Besides symptoms, we generally require three
important validators of a diagnosis:
– Family history
– Course of illness
• The first presentation of Bipolar Disorder is depression
• 33-50% of depressed children develop mania in 10-15 yrs.
– Treatment response
• Bad reaction to antidepressant
Bipolar vs. ADHD
• Most children diagnosed with bipolar
disorder appear to also meet ADHD criteria.
• It is rare that children with ADHD meet
bipolar criteria.
• In adults with bipolar disorder, 33% can be
diagnosed retrospectively with ADHD, with
about 10% having current ADHD
symptoms.
Bipolar vs. ADHD?
• It may be that these represent different
developmental presentations of the same
condition:
– Childhood ADHD
– Adolescent anxiety and depression
– Young adult bipolar disorder (mania)
Problems
• Children who get amphetamines may have an
earlier age of onset of mania than those who don’t!
• Amphetamines can be harmful neurobiologically,
especially after adolescent exposure, with
hippocampal atrophy, disturbed dopaminergic
activity, enhanced corticosteroid response to
stress, and increased long-term depressive and
anxiety behaviors.
Distinguishing Bipolar Disorder
from ADHD
• Sleep problems are more common in bipolar.
• Irritability, frustration intolerance and aggression
are present in both.
• Attention problems can be the same.
• Mood symptoms distinguish the bipolar group, but
not until 7 years old.
• Hallucinations, delusions, suicidal and homicidal
behavior is more common in bipolar
Bipolar Disorder
• Treatment is usually with the mood
stabilizer Depakote. ADHD symptoms
usually do not respond to Depakote.
• The best evidence is for lithium.
• Antipsychotics are frequently used, but with
very limited data.