Adolescent Substance Use and
Disruptive Behavior Disorders
Christopher R. Thompson, M.D.
Child & Adolescent and Forensic Psychiatrist
Juvenile Justice Mental Health Program
Los Angeles County Department of Mental Health
Assistant Clinical Professor
Child & Adolescent Division
UCLA Department of Psychiatry
Learning Objectives
1. To identify the rates of use/abuse/dependence in
different groups of adolescents
2. To discuss briefly the diagnosis and treatment of
substance use disorders (SUDs) in adolescents
3. To identify disruptive behavior disorders (DBDs)
likely to co-exist with adolescent SUDs and discuss
the diagnosis and treatment of these disorders in the
context of SUDs
4. To explain special issues related to adolescent SUDs
and the juvenile justice system
2
Definitions (1)
•
Teenager - Colloquial term generally meaning 13-19 year-old
•
Adolescent – Individual in the transition period between
puberty and “full adulthood” or “full maturity”
1) Over the past 50-100 years, this period has generally lengthened
considerably (e.g., increased need for higher education,
individuals have married later, etc.)
2) Absence of single threshold distinguishing adolescence from
adulthood in U.S. (e.g., different voting and drinking ages)
3) Brain not fully myelinated/pruned at least until mid 20’s,
probably later
3
Definitions (2)
•
Minor - person who has not yet reached the age of
majority (which is 18 in most states); minors can be
emancipated or “mature”
•
Juvenile - person who has not yet reached the age at
which s/he is treated as an adult by the criminal
justice system (again, 18 is most states, but 14 or 16
y/o for some crimes); purview of juvenile justice can
continue well after age of majority reached (e.g.,
DJJ-CDCR can hold “juveniles” until their 25th
birthday; known in CA as “juvenile life”)
4
Adolescent Substance Use
•
Some substance use (i.e., experimentation)
is normative for adolescents
•
Risk-taking and individuation are hallmarks of
the adolescent period of development
•
Some evidence suggests that complete abstinence
may be correlated with worse outcomes (e.g., poor
social skills, more anxious, emotionally constricted,
etc.) than experimentation (Shedler 1990)
Shedler J, Block J. (1990). Adolescent drug use and psychological health. Am Psychol 45(5), 612-30.
5
Johnston LD, et al. (2007). Monitoring the Future: National Results on Adolescent Drug Use. Overview of
Key Findings. Ann Arbor, MI. University of Michigan, Institute for Social Research, Survey Research Ctr.
6
Substance Abuse: DSM-IV Criteria
Maladaptive pattern of substance use leading to
clinically significant impairment or distress, as
manifested by one or more of the following,
occurring within a 12-month period:
1) Failure to fulfill major role obligations at work, school,
or home
2) Recurrent substance use in situations in which it is
physically hazardous
3) Recurrent substance-related legal problems
4) Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance
7
Substance Dependence: DSM-IV Criteria
A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as
manifested by three (or more) of the following,
occurring at any time in the same 12-month period:
1)
Tolerance
2)
Withdrawal
3)
Using larger amounts or over a longer period than was intended
4)
Persistent desire or unsuccessful efforts to cut down
5)
A great deal of time is spent in obtaining the substance, using, or recover
from the substance’s effects
6)
Important social, occupational, or recreational activities are given up or
reduced
7)
Continued use despite knowledge of having a persistent or recurrent
physical or psychological problems caused by substance
8
Problems with DSM-IV
•
Does not inform about etiology or suggest treatment
strategies
•
Diagnostic criteria not conceptualized within
developmental framework; therefore, applicability
questionable
•
Certain criteria inappropriate for adolescents 2^ to
very low rate of occurrence (e.g., withdrawal
symptoms)
•
Up to 30% of adolescents in SA treatment are
“diagnostic orphans” (i.e., meet one or two criteria
for Dependence, but none for Abuse) (Pollock 1999)
Pollock NK Martin CS. (1999). Diagnostic orphans: adolescents with alcohol symptoms who do not qualify
for DSM-IV abuse or dependence diagnoses. Am J Psychiatry 156(6), 897-901.
9
Rates of Substance Use Disorders (SUDs)
in Adolescents (i.e., abuse or dependence)
•
Gen. Pop. (9-17 y/o):
2% (MECA Sample)
•
Gen. Pop. (14-17 y/o):
6% (MECA Sample)
•
W/ Psych. Disorders:
17% (MECA Sample)
•
In Juvenile Detention:
50% (Teplin 2002)
•
In MECA, 76% of individuals with a SUD also had a
comorbid psychiatric disorder
•
Diagnosed by Diagnostic Interview Schedule for
Children Version 2.3 (DISC-2.3)
10
Gender Differences in Rates of
Substance Dependence in 12-17 y/o’s
•
Caucasian (M vs. F):
2.9% vs. 2.8%
•
African-American:
3.2% vs. 1.7%
•
Hispanic:
4.9% vs. 3.0%
•
No gender differences observed when sample not
divided by ethnicity
•
Based on NHSDA data from 1999
Summary of Findings from the 1999 National Household Survey on Drug Abuse. Rockville, Md.: Substance
Abuse and Mental Health Services Administration, National Clearinghouse for Alcohol and Drug
Information, 2000.
11
General Signs of Adolescent SUDs (1)
•
Declining academic performance
•
Tardiness to school or outright truancy
•
Irritability/mood lability; aggressive outbursts
•
Giving up usual activities/hobbies
•
Change in peer group; hesitance to introduce new
friends
•
Theft from family
•
Secretive behavior
12
General Signs of Adolescent SUDs (2)
•
Declining motivation
•
Forgetfulness
•
Change in sleeping habits
•
Depression, anxiety, etc.
13
Diagnosing Adolescent SUDs
•
Routinely asking about substance use history
•
Using screening instruments such as the CRAFFT (see next
two slides)
•
More comprehensive instruments such as Adolescent
Diagnostic Inventory (ADI), Substance Use/Abuse Scale from
Problem Oriented Screening Instrument for Teenagers
(POSIT) or Teen Addiction Severity Index (T-ASI);
•
Drug Use Screening Inventory-Revised (DUSI-R) can identify
youth at high risk for drug abuse and development of SUDs
•
Urine drug screen: remember the length metabolites stay in
urine
•
Hair analysis
14
CRAFFT (1)
15
CRAFFT (2)
Knight JR, Sherritt L, Shrier LA, et al. (2002). Validity of the CRAFFT substance abuse screening test
among adolescent clinic patients. Arch Pediatr Adolesc Med 156(6), 607-14.
16
Are Clinical Impressions of Adolescent
Substance Use Accurate? (Wilson 2004)
•
Study Compared clinicians’ assessments of
substance use with validated, structured diagnostic
interview (ADI)
•
533 youth 14-18 y/o’s presenting to pediatric urgent
care clinic for variety of reasons
•
Substance use rated as None, Minimal, Problem,
Abuse, Dependence
•
109 clinicians; composed of faculty (13%), fellows
(7%), residents (63%), medical students (17%)
Wilson CR, Sherritt L, Gates E, Knight JR. (2004). Are clinical impressions of adolescent substance use
accurate? Pediatrics 114(5), e536-40.
17
18
Treatment of Adolescent SUDs (1)
•
•
•
Pharmacological: Very little data on effectiveness of agents
such as naltrexone, disulfiram, acamprosate, etc. in
adolescents (naltrexone had successful 6-week open label trial,
n=5, in 2005)
Psychological: Fairly good data for effectiveness of
Motivational Interviewing/Enhancement (MI/MET),
Cognitive-Behavioral Therapy (CBT), Parent Management
Training (PMT), and various types of “family therapy” (e.g.,
Functional Family Therapy (FFT), Multi-Dimensional Family
Therapy (MDFT) and Multisystemic Therapy (MST)); pilot
data on Integrated Family CBT (IFCBT) showed promising
results
Little data on effectiveness of 12-step programs for
adolescents, though these are generally encouraged
19
Treatment of Adolescent SUDs (2)
•
Consistently, best results achieved when parents or
caregivers involved in treatment
•
PMT, FFT, MDFT, MST, and IFCBT necessarily
involve family
•
School based treatments (e.g., DARE or Scared
Straight) generally not effective and some even show
harmful effects
•
Confidentiality issues may come into play (see later)
20
Psychiatric Disorders and SUDs (1)
•
Comorbidity is the rule rather than the exception
•
Psychiatric disorder can precede or follow onset of
SUD
•
Questions:
1) If psychiatric disorder precedes, does this lend
credence to “self-medication” hypothesis?
2) If SUD comes first, does this mean that substance use
caused psychiatric disorder (e.g., Substance-Induced
Mood Disorder) or does it just unmask predilection?
3) Are these phenomena causal or just correlated?
21
Psychiatric Disorders and SUDs (2)
•
Abram et al (2003) surveyed 1829 youth aged 10-18
in the juvenile justice system and reported the
following:
1) 25% reported that their major mental disorder (MMD)
preceded their SUD(s) by > 1 year
2) 10% reported that their SUD(s) preceded their MMD
by > 1 year
3) 65% developed their SUD(s) and MMD developed in
the same year
Abram KM, et al. (2003). Comorbid psychiatric disorders in youth in juvenile detention. Arch Gen
Psychiatry 60 (11), 1097-1108.
22
Psychiatric Disorders and SUDs (3)
•
In general population, most common disorders in
children/adolescents are ADHD and anxiety
disorders
•
Most frequent disorders comorbid with SUDs in
children/adolescents are Conduct Disorder, ADHD,
and Anxiety Disorders
•
Girls tend to have more internalizing disorders while
boys have more externalizing disorders
23
Methodology for Epidemiology of Mental
Disorders in Children and Adolescents
(MECA) Data (1)
•
•
•
•
•
Anxiety Disorders
Disruptive Disorders (including ADHD)
Mood Disorders
Substance Use Disorders
Any Disorder
•
Rate is 11% if significant impairment required
13%
10%
6%
2%
21%
Shaffer D, Fisher P, Dulcan MK, et al. (1996). The NIMH Diagnostic Interview Schedule for Children
Version 2.3 (DISC- 2.3): Description, acceptability, prevalence rates, and performance in the MECA
Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the
American Academy of Child and Adolescent Psychiatry 35(7), 865–77.
24
MECA Data (2)
25
Diagnosing Comorbid Psychiatric Disorders
(1)
•
Disruptive Behavior Disorders: ADHD, Conduct
Disorder (CD), Oppositional Defiant Disorder
(ODD)
•
Anxiety Disorders: OCD, PTSD, Social Anxiety
Disorder, Separation Anxiety Disorder, Panic
Disorder, Generalized Anxiety Disorder, Specific
Phobia
•
Mood Disorders: Major Depressive Disorder,
Bipolar Disorder, Substance Induced Mood D/O
•
Psychotic Disorders: relatively rare in this age group
26
Diagnosing Comorbid Psychiatric Disorders
(2)
•
Clinical interview
•
Parent, caretaker, teacher, Probation/DCFS report
•
Rating scales (self report and others report)
1) Disruptive Disorders: SNAP-IV, Conners
2) Anxiety Disorders: SCARED, Liebowitz, CBCL, etc.
3) Mood Disorders: CDI, HAM-D, CBCL
Active substance use complicates process
27
Disruptive Behavior Disorders and SUDs
(1)
•
ADHD, CD, and, to some extent, ODD are
overrepresented in individuals with SUDs in both
children and adolescents (e.g., 35-71% of adult
alcoholics had childhood-onset and persistent
ADHD; Wilens 2004)
•
Converse also true; that is, individuals with ADHD,
CD are more likely to have SUDs (e.g., 17-45% of
ADHD adults have EtOH abuse/dependence and 930% have drug abuse/dependence; Wilens 1995)
Wilens T. (2004). ADHD and the substance use disorders: the nature of the relationship, who is at risk,
and treatment issues. Prim Psychiatry 11, 63-70.
Wilens TE, Spencer TJ, Biederman J. (1995). Are attention-deficit hyperactivity disorder and the
psychoactive substance use disorders really related? Harv Rev Psychiatry 3(3), 160-2.
28
Disruptive Behavior Disorders and SUDs
(2)
•
Both ADHD and CD are risk factors for SUDs, but
latter greater OR; cumulative effects
•
High rate of comorbid SUDs likely multifactorial
(inherent novelty-seeking (?DA deficiency) in both
Conduct Disorder and ADHD, school failure leading
to assoc. w/ anti-social peers, etc.)
•
Treatment of ADHD does not exacerbate SUDs (e.g.,
craving) and is likely protective against development
of SUDs in adolescence (see later slides)
29
Treating Comorbid
Disruptive Behavior Disorders (1)
•
Pharmacological and/or psychological interventions
have shown efficacy for certain disorders (e.g.,
ADHD)
•
Former more likely to be employed in primary care
settings
•
Need to be familiar with treatments/interventions
available and the evidence supporting use
30
Treating Comorbid
Disruptive Behavior Disorders (2)
•
ADHD: Stimulants can be first-line treatment in
many cases; excellent evidence for use; scores, if not
hundreds of RCTs; atomoxetine (Strattera) also
useful; behavioral therapy can be helpful adjunct
•
Conduct Disorder: Little evidence to support
pharmacological treatments (perhaps atypicals
effective for txing aggression assoc. w/ CD); MST,
PMT, CBT show most promise
•
Oppositional Defiant Disorder: PMT, perhaps
CBT/anger mgmt. (e.g., STAR)
31
ADHD (1)
•
Base rate in population around 5-8%
•
2.5x higher rate in boys
•
General domains include hyperactivity, impulsivity,
and ↓attention/concentration
•
Children/adolescents with ADHD, Inattentive Type
are likely to be diagnosed later
32
33
ADHD (2):
Stimulants
•
Stimulants most effective treatment (effect sizes 1.01.3 for stimulants vs. 0.6-0.7 for atomoxetine)
•
Excellent data for use
•
Quick onset of action
•
Excellent safety profile
•
Limited side effects including no significant longterm side effects (? ↓ adult height w/ post-hoc
analysis of MTA data)
34
Conduct Disorder and ADHD:
Stimulant Misuse, Abuse and Diversion
•
Conduct Disorder Domains
1) Aggression to people or animals
2) Destruction of property
3) Deceitfulness or theft
4) Serious violations of rules
•
Some risk of misuse/abuse/diversion with ADHD
patients, but magnified with comorbid SUDs and
Conduct Disorder (see later slides)
35
Definitions
Misuse: Medication used in a manner in which it was not
prescribed
Abuse: Meets DSM-IV TR criteria for abuse (see
previous slide)
Diversion: Transfer of medication from the patient to
another person for any purpose, such as performance
enhancement or recreational use
The term nonmedical use can be used to describe all of
the above.
36
Rates of Diversion of Stimulants among
Canadian HS Students
•
13,549 students sampled; 5.3% on Rxed stimulants
•
14.7% of these gave meds to others
•
7.3% sold meds to others
•
4.3% had their meds stolen
•
3.0% were forced to give up their meds
Poulin C. (2001). Medical and nonmedical stimulant use among adolescents: from sanctioned to
unsanctioned use. Canadian Medical Association Journal 165 (8), 1039-44.
37
Rates of Non-Medical Use of Stimulants
among U.S. College Students (1)
•
10,904 students sampled
•
6.9% lifetime prevalence of non-medical Rx
stimulant use
•
4.1% past year prevalence
•
2.1% past month prevalence
•
Rates ranged from 0-25% at individual colleges
McCabe SE. (2005). Non-medical use of prescription stimulants among US college students: prevalence
and correlates from a national survey. Addiction 100(1), 96-106.
38
39
Rates of Non-Medical Use of Stimulants
among U.S. College Students (2)
•
Increased rates of abuse/diversion if:
1) Male
2) White
3) Member of fraternity or sorority
4) Lower grades
5) College in Northeast with highly-competitive
admissions standards
40
Characteristics of Adolescents with ADHD
Who Divert or Misuse Rxed Stimulant Meds
•
Part of 10-year longitudinal study; 55 ADHD
subjects, 43 controls (receiving meds for other
purposes)
•
11% of ADHD subjects sold medications
•
22% misused medications
•
Of those who misused medications, 83% had SUD or
CD
•
IR formulations most often reported diverted
Wilens TE, et al. (2006). Characteristics of adolescents and young adults with ADHD who divert or
misuse their prescribed medications. J Am Acad Child Adolesc Psychiatry 45(4), 408-14.
41
Minimizing Stimulant Abuse and
Diversion in ADHD Treatment
1) Know your patient’s demographics and history
2) Long-acting preparations generally abused less
3) Open capsules and mix (e.g., Adderall XR, Focalin
XR); prevents attempts at intranasal use/injection
4) Utilize new preparations (e.g., MPH patch
(Daytrana), new AMP prep. lisdexamfetamine
(Vyvanse)
5) When feasible, enlist parents help in dispensing
meds/counting pills
42
Daytrana (MPH Patch)
•
Approved by FDA in 2006
•
10, 15, 20, 30 mg patches (amount delivered over 9 hours), but
each patch actually contains 2.75x the listed amount of MPH
•
Can deliver up to 15 hours of coverage, but generally worn for
9 hours (effects may last 2-3 hours after removing)
•
Somewhat slower onset of action than other long-acting
stimulant preparations
•
After 4-5 weeks, plasma levels may be double of equivalent
dose of oral MPH and dose of medication my need to be
reduced (more efficient delivery)
43
Lisdexamfetamine (Vyvanse)
•
Approved by FDA in 2007, in pharmacies July 2007
•
“Pro-drug” that has an L-lysine attached to Damphetamine; biologically inactive until undergoes
first pass metabolism in small intestine/liver
(hydrolysis)
•
Less abuse potential: longer acting, lower
“likeability rating” than DEX, biologically inactive if
snorted or used IV
•
Comes in 20, 30, 40, 50, 60, 70 mg doses (initially
30, 50, 70 mg but titration was difficult)
•
Lis-DEX 25 mg = DEX 10 mg
44
Dosing Rules of Thumb
•
Shoot for @ 1 mg/kg for: lisdexamfetamine, MPH
products
•
Shoot for @ 0.5 mg/kg for: amphetamine-based
products and dexmethylphenidate (Focalin)
•
Shoot for @ 1.2 mg/kg for atomoxetine (Strattera)
•
For stimulants, titrate up to target dose over 2-3
weeks
•
Can go higher if needed and side effects not
problematic; underdosing probably more prevalent
that overdosing
45
Pharmacotherapy of ADHD Reduces Risk
for SUD (Biederman 1999)
Biederman J, et al. (1999). Pharmacotherapy for ADHD reduces risk for substance use disorder.
Pediatrics 104(2), e20.
46
Pharmacotherapy of ADHD Reduces Risk for
SUD: Four year follow-up (Biederman 2003)
•
Original cohort re-examined four years later
•
Unmedicated ADHD (n=19), Medicated ADHD
(n=56), Control (n=137)
•
Rates of SUDs were:
1) Unmedicated ADHD:
75%
2) Medicated ADHD:
25%
3) Controls:
20%
Biederman J. (2003). Pharmacotherapy for ADHD decreases the risk for substance abuse: Findings from a
longitudinal follow-up of youths with and without ADHD. J Clin Psychiatry 64(suppl. 11), 3-8.
47
Stimulant Therapy and Risk for SUDs in
Adulthood (1)
•
Original cohort re-examined ten years later
•
No protective effect of stimulant treatment against
SUDs found in adulthood
•
Consistent with Wilens finding from meta-analyis
that stimulant-treated subjects were 5.8x less likely
to have SUDs in adolescence, but only 1.4x less
likely in adulthood (Wilens 2003)
•
Only 22% were on stimulant treatment at time of
reassessment
Biederman J, et al. (2008). Stimulant therapy and risk for subsequent substance use disorders in male
adults with ADHD: a naturalistic controlled 10-year follow-up study. Am J Psychiatry 165(5): 597-603.
Wilens TE, et al. (2003). Does stimulant therapy of ADHD beget later substance abuse? A meta-analytic
review of the literature. Pediatrics 111(1): 179-85.
48
Stimulant Therapy and Risk for SUDs in
Adulthood (2)
Hypotheses:
•
Parental monitoring and therefore treatment compliance
better in childhood/adolescence
•
Stimulant treatment may delay rather than prevent SUDs
(i.e., adolescents had not yet fully passed through “risk
period to develop SUDs)
•
Therefore, continued stimulant treatment may be
necessary to reduce risk of SUDs in adulthood
49
Age of Initiation of Stimulant Treatment and
Development of SUDs
•
176 MPH-treated Caucasian male children aged 6-12
w/ ADHD but w/o CD
•
Followed up in late adolescence (mean age=18.4
years) and adulthood (mean age=25.3 years)
•
Subjects with late initiation of stimulant treatment (i.e., at
age 8 or later) had higher rates of non-EtOH SUDs and
ASPD in adulthood
•
Subjects with early initiation of stimulant treatment did
not differ from controls w/r/t rates of SUDs or ASPD
Mannuzza S, et al. (2008). Age of methylphenidate treatment initiation in children with ADHD and later
substance abuse: prospective follow-up into adulthood. Am J Psychiatry 165(5): 604-9.
50
Prevalence of Mental Disorders in the
Juvenile Justice System (1)
•
Approximately 66% of juvenile pre-trial detainees
or delinquents meet DSM-IV criteria for a mental
disorder:
1) Includes substance abuse/dependence and Conduct
Disorder (Grisso 2004)
2) Excluding Conduct Disorder alone as a mental
disorder decreases rates by only approx. 5%
Grisso T. (2004). Double Jeopardy: Adolescent Offenders with Mental Disorders. Chicago: University of
Chicago Press.
51
Prevalence of Mental Disorders in the
Juvenile Justice System (2)
•
•
•
•
•
•
•
•
•
Conduct Disorder
ADHD
Substance Abuse
Personality Disorders
Mental Retardation
Learning Disorders
Mood Disorders
Anxiety Disorders
Psychoses & Autism
50 – 90%
19 – 46%
25 – 50%
02 – 17%
07 – 15%
17 – 53%
32 – 78%
06 – 41%
01 – 06%
Otto R, Greenstein J, Johnson M, Friedman R. (1992). Prevalence of mental disorders among youth in the
juvenile justice system. In J. Cocozza (Ed.), Responding to the mental health needs of youth in the
juvenile system (pp. 7-48). Seattle: National Coalition for the Mentally Ill in the Criminal Justice System.
52
Psychiatric Disorders in Youth In
Juvenile Detention (Teplin 2002)
Teplin LA, et al. (2002). Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry 59(12):
1133-43.
53
Prevalence of Mental Disorders in the
Juvenile Justice System (3)
•
Rates of all disorders higher than that of the general
population; the “big three” are Conduct Disorder,
ADHD, and Substance Abuse/Dependence
•
Higher rates of Learning Disorders (17-53%),
Mental Retardation (7-15%), and generally lower
intelligence levels in juvenile delinquents
54
The Performance of Incarcerated
Juveniles on the MacCAT-CA
WISC-III (or WAIS-III)/WRAT
Ages
9-12
13-14
15-16
17-18
IQ
73.7
74.3
72.6
87.6
Reading
73.0
81.6
82.7
83.4
Spelling
78.6
82.3
84.4
83.9
Math
77.2
80.0
83.0
85.4
Ficke SL, Hart KJ, Deardorff PA. (2006). The performance of incarcerated juveniles on the MacCAT-CA. J
Am Acad Psychiatry Law 34(3), 360-73.
55
Prevalence of Mental Disorders in the
Juvenile Justice System (4)
•
Also more likely to have these risk factors, which
may increase risk of SUDs:
1) Pre-natal exposure to drugs or alcohol
2) Attachment problems arising in infancy
3) Exposure to trauma (violence, abuse, etc.), even if
exposure does not cause PTSD
4) Dysfunctional and chaotic families and neighborhoods
5) Overcrowded schools with limited resources
6) lower intelligence
56
Additional Options in Juvenile Justice System
Pre-adjudication (i.e., diversion) (1)
•
“Drug” Court: Minors with drug-related charges or
significant substance use problems. Generally orders
substance abuse treatment either on outpatient or
residential basis. Typically, random UTS mandatory.
•
Mental Health Court (e.g., Dept. 203 in Los Angeles
County): Handles minors with severe mental
disorders; comorbid SUDs common
57
Additional Options in Juvenile Justice System
Post-adjudication (2)
1. Mandatory mental health treatment in the
community: Can include residential placement,
medication follow-up, different therapy modalities
(including MST, SUDs treatment), wraparound
services
2. Probation Camp System: Minors serve 3-, 6-, or 9month sentences (being increased to 5-7 and 7-9
month sentences); mental health services and SUDs
treatment offered
58
L.A. County Probation Dept.
Camp System (1)
•
Approximately 20 camps in outlying areas of Los
Angeles County
•
Camps currently undergoing re-design with focus on
reducing recidivism and involving parents in
treatment
•
SUDs targeted because of strong link to recidivism
•
“Evidence-based practices” for SUDs (among other
disorders) are being implemented (e.g., MET/MI,
IFCBT, PMT, CBT, etc.)
59
L.A. County Probation Dept.
Camp System (2)
•
Camps Assessment Unit: being phased in at Barry J.
Nidorf Juvenile Hall to provide more comprehensive
psychiatric and educational evaluations of minors
(including evaluating for SUDs); ensures minors are
being directed to the most appropriate camp or other
placement; may use CRAFFT, ADI vs. TASI
•
Camp Holton: Assuming role as camp dedicated to
treating minors with “co-occurring” disorders
•
MST: being implemented on release to decrease risk
of continued anti-social behavior and substance use
60
L.A. County Probation Dept.
Camp System (3)
•
Strong focus on other aftercare options and fostering
linkages to community resources
•
Numerous additional funding sources (MIOCR
grant, MHSA funds) have helped with these
initiatives
•
Numerous outcome variables will be tracked
61
Case Example (1)
•
17 y/o WM, high SES, w/ long history of tic
disorder, ADHD, MDD, LD, and SUDs (Rx
stimulants (snorted D-MPH), MJ, cocaine, EtOH)
and numerous trials of various ADHD medications
from age six (MPH, AMP products, atomoxetine,
clonidine, guanfacine, bupropion XL) with varying
degrees of success at varying times
•
SUDs problematic enough that spent 18 months at
RTF in Utah; now back in Los Angeles; has GED,
will be attending college in seven months; working
at coffee shop; attending AA/NA meetings daily
62
Case example (2)
•
At time of first appt., on BPPXL 450 mg/day,
aripiprazole 20 mg/day, atomoxetine 120 mg/day;
still with significant ADHD sxs (primarily
inattentive domain) impairing work functioning and,
to some extent, impairing fxing at home w/r/t rel.
with parents
•
What do you do next? What are pros and cons of
different treatments?
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Case example (3)
•
Options include:
1) Daytrana or
2) Lisdexamfetamine and
3) Parental monitoring/pill count
•
Ended up using lisdexamfetamine and titrated to 70
mg/day; pt. advised re: lack of biological activity if
used intra-nasally or IV
•
Pt. still ended up attempting to snort large quantities
of lisdex.; currently in Betty Ford completing 90-day
inpt. program
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Take Home Points
1. Make sure to screen for SUDs in adolescents in a
systematic manner (e.g., CRAFFT)
2. Make sure to screen for and treat psychiatric
disorders (or refer for treatment); doing so can lower
the chance of a SUD developing/persisting
(particularly treating ADHD)
3. Remember that there is good empirical support for a
variety of psychotherapeutic modalities in treating
adolescent SUDs; data on pharmacological
treatments (e.g., naltrexone) is much more limited
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Additional Suggested Reading
•
Tarter RE. (2002). Etiology of adolescent substance
abuse: A developmental perspective. Am J Addict
11(3), 171-91.
•
Tarter RE, Kirisci L. (2001). Validity of the Drug
Use Screening Inventory for predicting DSM-III-R
substance use disorders. J Child Adol Subst Abuse
10, 45-53.
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