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Adolescents and Substance Abuse

Adolescents and Substance Abuse. Cigarette smoking

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Adolescents and Substance Abuse

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  1. 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%).

  2. 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.

  3. 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.

  4. 2005 “Monitoring the Future” Survey • Drinking in last month • 8th grade 17% • 10th grade 33.2% • 12th grade 47% • 28% of seniors binge drink • Tried an illicit drug • 8th grade 21% • 10th grade 38% • 12th grade 50%

  5. 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.

  6. 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.

  7. 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.

  8. 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

  9. Prevention in Children and Adolescents • Risk factors: • 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)

  10. 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

  11. 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.

  12. Substance Abuse and Mental Health Services Administration

  13. 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.

  14. 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? • Total 25.3% • Boys 17.6% • Girls 33.5% • Junior year the worst

  15. 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.

  16. 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.

  17. 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.”

  18. 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.

  19. 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

  20. 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.

  21. 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

  22. 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

  23. 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.

  24. 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.

  25. 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 • Trauma re-enactment • Bargaining and magical thinking • Self-control • Control of others

  26. 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.

  27. Warning Signs • 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

  28. Suicide first arises as a public health problem at 12 years old.

  29. Suicide Rates: 1981-2001

  30. Adolescent Suicidal Behavior: 2001 U.S. Data

  31. 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.

  32. 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: • AODA • Severe and enduring hopelessness • Isolation • Reluctance to discuss suicidal thoughts • Psychopathology

  33. 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 • 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

  34. 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.

  35. Risk Factors for Adolescents • Imitation • Family history • Sexual orientation issues • Sexual abuse • Other stressors • Interpersonal losses • Bullying (perpetrator or victim) • Lack of affiliation • Males after romantic breakup

  36. 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.

  37. 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!!

  38. 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.

  39. Risk Assessment in Adolescents • Consider the following: • Predictability of the youngster • Circumstances of suicidal behavior • Intent to die • Psychopathology • Coping mechanisms • Communication • Family support • Environmental stress

  40. 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

  41. 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.

  42. 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.

  43. 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.

  44. 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: • 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.

  45. 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.

  46. 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 non-existent. • The diagnosis has increased 26% from 2002 to 2004!

  47. 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.

  48. Dr. GellerWashington 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: • Excessive giddiness • Severe irritability • Grandiosity • Fragmented thought • Aggression

  49. 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

  50. 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.

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