Child/Youth & Co-Occurring Disorders
2014 4th ANNUAL DC SUMMIT
Objectives
 Review the prevalence of co-occurring substance use and
psychiatric disorders in youth.
 Review the relationship between substance use and
specific co-occurring mental health disorders.
 Understand effective treatment approaches and
challenges for youth with co-occurring disorders.
Introduction
 Psychiatric disorders
 3/4 by age 24
 Most adults with SUD started using as adolescents
 60-85% adolescents with SUD have co-occurring psychiatric
disorder(s).
Co-Occurrence of MH & SUD
 Substance abuse treatment helps to reduce the frequency of use
and the number of abuse/dependence symptoms but has only
indirect impact on emotional and behavioral problems (M.
Dennis, 2004)
 Psychiatric treatment alone for youth with mood disorders and
co-occurring SUD does not significantly reduce substance use
(Geller et al., 1998)
Risk Factors:
Familial Influence on Substance Use
 Familial influence—biological and behavioral
 A common genetic influence accounts for comorbid substance
use during adolescence, specifically problem use of tobacco,
alcohol, and cannabis.
 Approximately 50% of the risk of substance abuse or
dependence in adolescence is genetically influenced.
 Exposure to parental substance use increases children’s risk
A Day in the Life of American
Adolescents: Substance Use Facts
Table 1. Illicit drug use in the past month among
individuals aged 12 or older: 2013
Substance
Aged 12 or older
Number
Percent
(in
thousands)
Aged 12 to 17
Number
Aged 18 or older
Percent
(in thousands)
Number
Percent
(in thousands)
Illicit drug use
24,573
9.4
2,197
8.8
2,2376
9.4
Marijuana and hashish
19,810
7.5
1,762
7.1
18,048
7.6
1,549
0.6
43
0.2
1,505
0.6
496
0.2
121
0.5
375
0.2
1,333
0.5
154
0.6
1,179
0.5
289
0.1
13
0.1
277
0.1
Nonmedical use of
prescription-type
drugs
6,484
2.5
549
2.2
5,935
2.5
Pain relievers
4,521
1.7
425
1.7
4,096
1.7
Cocaine
Inhalants
Hallucinogens
Heroin
SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH )
Substance use disorder (SUD) in the past year
among individuals aged 12 or older: 2013
Mental health issues in the past year among adolescents
aged 12 to 17 and adults aged 18 or older: 2013
Co-occurring Substance Use Disorders and Mental
Health Issues among Adolescents and Adults
4,333 Total Child/Youth Served (DBH) - FY13
MH
• 3693
SUD
• 640
COD
• 221
• 5%
Primary Substance Type
Substance Type
Alcohol
Count
10
Percentage
5%
Cocaine/Crack
5
2%
Heroin
1
0%
120
54%
Other
8
4%
Other Opiates and Synthetics
2
1%
Other Stimulants
3
1%
PCP
9
4%
No Primary Listed
63
29%
Total
221
100%
Marijuana/Hashish/THC
Diagnoses vs. Medications
5 Most Common Diagnoses in FY13
5 Most Common Medications in FY13
(n=459)
300
1500
1000
252
Number of Youth
Number of Youth
1311 (34%)
907 (24%)
150
483 (13%)
500
79
347 (9%)
48
215 (6%)
39
27
0
0
ADHD
Depressive Adjustment Mood
Disorder Disorder Disorder
ODD
Concerta Risperidone
(Risperdal)
Ritalin
Aripripazole Citalopram
(Abilify)
(Celexa)
CFSA Youth with Co-occurring Disorders
Trauma- & Stress-related Disorders
Neurodevelopmental Disorders
Disruptive, Impulse-Control, & Conduct Disorders
Depressive Disorders
Bipolar & Related Disorders
Academic Problem
0
Primary Substance
Marijuana
Other
2
# Youth
21
1
No Primary Substance Listed
1
Total FY13 CFSA Youth Matched
23
4
6
8
10
12
14
PIW Stats
 75-85% of children/adolescents treated at PIW have past or
current substance use issues
Chicken or Egg?
 “Substance-induced Mood Disorder”
 There is no Cannabis-induced Depressive D/O
 Not in DSM-IV TR
 Not in DSM-5
 Self-medication
ADHD
 Prevalence approx. 3-5%
 but those receiving medications for ADHD is 1-
20%
 Male:Female is 4:1
 Medication treatment for ADHD is one of the
most studied areas in C&A psychiatry
 Over- vs. under-medication
Course of ADHD
 Rule of 1/3’s:
 1/3 show significant improvement over time
 1/3 have a few symptoms into adulthood (inattention)
 1/3 continue to have significant problems into adulthood
 Untreated:
 Increased risk of MVAs, drop outs, family discord, and
substance use (15% comorbidity)
Stimulant Medications
Absolute Contraindications:
 Cardiovascular disorders, hypertension
 Hyperthyroidism
 Glaucoma
 Active Psychosis
 Co-administration with MAO-Is
Relative contraindications:
 Seizures (no evidence of decreasing sz thresold)
 Drug Abuse
Major Depressive Disorder
 At least 2 wks pervasive change in mood manifested by either:
 Depressed or irritable mood and/or
 Loss of interest/pleasure
 Other sx:
 Same criteria as for adult MDD but presents differently
 Lack of joy • Withdrawal
• Irritability
 Boredom
• Failing grades
• Act out
 Aggression
Treatment Options
 Mild-moderate depression: psychotherapy
 Cognitive Behavior Therapy (CBT)
 Moderate-severe: pharmacotherapy + psychotherapy
 Pharmacotherapy may not be sufficient alone due to strong
psychosocial influences
Pharmacotherapy
 SSRIs are the predominant medications used for both depressive
disorders and anxiety disorders
 Older antidepressants (TCAs) have not shown much benefit and
have more side effects
FDA Black Box Warning
 24 placebo-controlled trials, >4400 patients:
 Placebo 2%; on antidepressants 4%
 Double risk of suicidal thinking/behavior
 No completed suicides
 Could be linked to behavioral activation or akathisia
 Impulsive
 Agitated
 UK banned use of all SSRIs except fluoxetine for C/A
Anxiety Disorders
 Probably the 2nd most common group of disorders; however,
do not get recognized so people often do not present for tx
 Prevalence rates from 6-20% for one disorder
 Children/youth may not recognize fear as unreasonable
 Very common to have somatic c/o, crying, irritability,
outbursts
Anxiety Disorders
 Obsessive Compulsive Disorder*
 DSM-5: Obsessive-Compulsive and Related Disorders
 Post Traumatic Stress Disorder*
 DSM-5: Trauma and Stress-Related Disorders
 Separation Anxiety Disorder
 School refusal
 Generalized Anxiety Disorder
 Panic Disorder
 Social Phobia
 Selective mutism
 Specific Phobia
Anxiety Disorders Treatment Guidelines
 Begin with psychotherapy for mild cases:
 CBT- exposure/response prevention
 Family and Parent-Child
 Consider psychotherapy + medication for:
 Acute symptom reduction for moderately-severely anxious child
 BZDs vs. buspirone
 Co-morbid disorder that requires treatment
 Partial response to psychotherapy
 Potential for improved outcome with combination
Bipolar Disorder
 Commonly has onset in adolescence
 Gen population lifetime prevalence for Bipolar I is 0.4%-
1.6%
 For C/A ranges from 1%-13%
 Overall affects both sexes equally, early-onset predominantly male (esp. onset <13yo)
 20% of youths with MDD develop Mania by adult
FIND Guidelines
Frequency: most days in a week
Intensity: severe enough to give extreme disturbance in one domain or
moderate in 2 or more domains
Number: sx occur 3-4 times a day
Duration: sx occur ≥ 4 hrs a day in total, not necessarily consecutive
(Kowatch, et al)
Bipolar Disorder-TX of Co-morbidities
 Most C/A will have co-morbid d/o: ADHD, ODD, CD, Anxiety,
Substance Use
 Stabilize Bipolar D/O first, but must treat co-morbid d/o due to
worse prognosis (attempt psycho-social tx first)
 ADHD:
 most common- 70-90% pre-pubertal, 30-40% adolescents
 tx ADHD sx after Bipolar sx controlled
Disruptive Mood Dysregulation Disorder
(DMDD)
 Added to DSM-5 to address concerns about potential:
 Overdiagnosis
 Overtreatment
 Only applies children/adolescents up to 18 y/o
 Basic criteria
 Persistent irritability
 Frequent episodes of extreme behavioral dyscontrol
Schizophrenia
 Childhood or Very Early Onset Schizophrenia (COS or
VEOS): onset of symptoms before 13 y/o
 Early Onset Schizophrenia (EOS): onset of symptoms before
18 y/o
 Clinically resembles adult form in positive and negative
symptoms, BUT usually has more severe and chronic course
Treatment Considerations
 Youth may be less likely to respond adequately to Rx
 Atypical Antipsychotics as effective for positive sx, and possibly
more effective for negative sx
 Atypicals lower risk of EPS, but significant wt gain
Childhood Schizophrenia:
“Born Schizophrenic – Jani”
http://www.youtube.com/watch?v=35gcBL1ZwY4
New(ish) Drug Crazes
 Alcoholic Energy Drinks
 K2/Spice (Herbal Incense)
 MDMA / “Molly” “Ecstasy”
K2
 Mixture of herbal and spice plant products
 Sprayed with synthetic cannabinoids
 Marketed as incense and “not for human consumption”
 No regulations to list ingredients or age requirements to purchase
 First generation called “K2” or “Spice”
 Second generation called “K3” or “Splice”
 Effects:
 Tachycardia, Heart attack, Dry Mouth, Thought Impairment, Auditory &
visual hallucinations, Delirium, Impaired sense of time, Anxiety, Fear, Panic
attacks, Paranoia, Sedation, Post-intoxication exhaustion, Dissociation
 https://www.youtube.com/watch?v=Af5P1e0Uk-I
Local Case –W.D.
 9th grader with no prior MH or JJ history
 Living with bio. mother and older brother
 Good school attendance, behavior, and grades
 Sudden onset of unusual behavior
 “The world is coming to an end”
 “I’m Jesus”
 Brother took him UMC ER
 U tox positive for MJ
W.D. Case (cont’d)
 Brother reported W.D. has been smoking MJ for the past year
 Discharged home because no SI or HI
 Later that night W.D. climbed up on the roof with a handgun
 MDP responded
 W.D. fired, hitting one officer 3 times in chest
 W.D. charged with Attempted Murder 1
W.D. Case (cont’d)
 While in custody, W.D. continued to act bizarre
 Taken to PIW
 Found to have written (illogically) all over his body with magic
marker
 Didn’t recall anything about the shooting
 “I am God”
 Found incompetent to stand trial
 Treated with antipsychotic medication
 Restored to competence
W.D. Case (cont’d)
 Plead to 2nd Degree Attempted Murder
 Committed to DYRS
 Sent to PRTF
 Continued to have difficulty remembering the shooting
 Recalled smoking K2 prior to the event
“Molly”
 MDMA is man-made…it doesn't come from a plant like marijuana or
tobacco.
 Other chemicals or substances such as caffeine, dextromethorphan (found
in some cough syrups), amphetamines, PCP, or cocaine are sometimes
added to, or substituted for, MDMA in Ecstasy or Molly tablet.
 a “hit” of MDMA lasts for 3 to 6 hours. Once the pill is swallowed, it takes
only about 15 minutes for MDMA to enter the bloodstream and reach the
brain.
 Effects:
 Hyper-alertness, Changes in perception, Anxiety, Agitation, Depression,
Memory impairment, Sweats, Chills, Muscle tension, Nausea, Blurred
vision, Increased heart rate and blood pressure, Feelings of sadness,
depression, and memory difficulties.
Molly
 https://www.youtube.com/watch?v=90xMmuQtV1M
Changes in Brain Activation Patterns Before and After
Treatment in Adolescents Addicted to Marijuana
Pre-Treatment
Post-Treatment
Before treatment, adolescents
After 16 weeks of CBT adolescents
showed greater brain reward
showed greater activation to marijuana
activation to marijuana cues vs food* vs food in areas of cognitive control
than before treatment
Riggs et al., Drug and Alcohol Dependence,91, 2007
Cannabis Withdrawal
 New to DSM-5
 Cessation after heavy/prolonged use
 Daily/almost daily
 Over at least a few months
Cannabis Withdrawal (cont’d)
 3 or more of the following within 1 wk
 Irritability, anger, or aggression
 Nervousness or anxiety
 Sleep difficulty (e.g., insomnia, disturbing dreams)
 Decreased appetite or weight loss
 Restlessness
 Depressed mood
 At least 1 of the following physical symptoms
 Abdominal pain
Fever
 Shakiness/tremors
Chills
 Sweating
Headache
Behavioral Treatment Interventions
for Adolescents
(Non-Medication Treatment)
Outpatient/Intensive Outpatient /Partial
Hospitalization
 Counseling
 Individual and/or group
 Other behavioral therapies include:
 Adolescent Community Reinforcement Approach (A-CRA)
 Cognitive–behavioral therapy
 Multidimensional family therapy
 Motivational interviewing
 Contingency Management (motivational incentives)
 Community/family-based recovery support systems
 Brief Strategic Family Therapy (BSFT)
 12-Step Participation
 Alcoholics Anonymous
 Narcotics Anonymous
Family Based Approaches
 Community/family-based recovery support systems
 Brief Strategic Family Therapy (BSFT)
 Family Behavior Therapy (FBT)
 Multidimensional Family Therapy (MDFT)
 Functional Family Therapy (FFT)
 MultisystemicTherapy (MST)
Residential/Inpatient Treatment
 Residential/Inpatient Treatment
Therapeutic Community (TC)
Medication-Assisted Treatment (MAT)
 The use of medications, in combination with counseling and
behavioral therapies, to provide a whole-patient approach to
the treatment of substance use disorders
 Research shows that when treating substance-use disorders, a
combination of medication and behavioral therapies is most
successful.
 Clinically driven with a focus on individualized patient care.
MAT
 Has been shown to:
 Improve survival
 Increase retention in treatment
 Decrease illicit opiate use
 Decrease hepatitis and HIV seroconversion
 Decrease criminal activities
 Increase employment
 Improve birth outcomes with perinatal addicts
FDA Approval
 Medications for Dependence
 Off-label for youth under 18 y/o
 Medications for Overdose
 No age restriction
Medications for Alcohol Dependence
 Decrease craving
 Naltrexone
 aka “ReVia or Vivitrol”
 Blocks opioid receptors (antagonist)
 Acamprosate
 Aka “Campral”
 Exact mechanism of action unknown
 Discourage drinking
 Disulfiram
 Aka “Antabuse”
 Inhibits aldehyde dehydrogenase
Medications for Opiate Dependence
 Naltrexone
 Methadone
 Binds to opioid receptors (agonist)
 Buprenorphine
 Aka “Suboxone, Subutex* or Zubsolv*”
 Opioid receptor agonist-antagonist
 Risk of opiate withdrawal if injected!
 Sublingual administration
 Compelling case for use in adolescents…
Adolescent Opiate Use/Abuse
 National trends among high school students
 Decreasing use of cocaine and hallucinogens
 Increasing use of prescribed (and diverted) opiates
 Adolescents under 18 y/o with short addiction histories are
at particularly high risk for:
 Suicide and accidental overdose deaths
 HIV and other infectious diseases
Treating Adolescent Opiate Addiction
 Pharmacologic treatment of adolescent opiate addiction has
not been systematically studied
 Buprenorphine may be preferred to methadone
 Relative ease of withdrawal
 Naltrexone may be a valuable adjunct s/p detox
 No abuse potential
 Opioid antagonism may help prevent relapse
 Particularly effective in treating younger patients early in the
course of addition
Assent vs. Consent
 Confidentiality
 Necessary for therapeutic alliance
 No mandated reporting for substance use
 Unless parents exposing youth to substances
 Most therapists will not break confidence unless there is a safety
issue
 Safety argument could be made for “dangerous” level of abuse
 Informed consent for psychotropic medication
 Minors can only assent
 Parents must consent
Medications for Overdose
 Naloxone
 Aka “Narcan”
 Opioid antagonist
 Eric Holder has called for First Responders to carry
 “has reversed over 10,000 overdoses since 2001”
 Flumazenile
 Aka “Romazicon”
 Benzodiazepine antagonist
 Xanax, Ativan, Klonopin, Ativan, Valium, Versed, etc.
 Anxiolytics!