Title: Adolescent Psychotherapeutic Medications Current Approaches
1Adolescent Psychotherapeutic Medications- Current
Approaches
- Merrill Norton Pharm.D. ,D.Ph., NCAC II,CCS
- Clinical Associate Professor
- University of Georgia College of Pharmacy
- Athens, Ga
- Email mnorton_at_rx.uga.edu
2Current Approaches
- Whats New in Child and Adolescence Medications
- David C. Rettew, M.D.
- Rochelle Head-Dunham, M.D., FAPA
3Whats New in Child and Adolescence
Psychotherapeutic Medications
- Focalin XR ( Dexmethylphenidate)
- Methylin Chewable (Methylphenidate)
- Methylin Liquid (Methylphenidate)
- Pristiq (Desvenlafaxine)
- Vyvanse (Lisdexamfetamine)
- Clinical Handbook of Psychotropic Drugs for
Children and Adolescents 2nd Edition ( 3rd
Edition out later this year)
4Adolescent Mood Disorders Management and
Medication
- David C. Rettew, M.D.
- Associate Professor of Psychiatry and Pediatrics
- Director, Pediatric Psychiatry Clinic
- UVM College of Medicine
5Understanding Psychiatric Disorders(New School)
Genetics
Phenotype
Prenatal environment
Comprehensive Treatment
Attachment
Temperament
Parenting
Exposures
SES
6Pediatric DepressionDiagnosis 5 of 9 -
Distinct 2 Week Period
- Depressed mood (Irritability)
- Anhedonia
- Weight change (Failure to make expected gains)
- Sleeping Disturbance
- Psychomotor Agitation/Retardation
- Energy Loss
- Guilt/Worthlessness
- Concentration Impairment/Indecisive
- Suicidal Thoughts/Recurrent Thoughts of Death
7Dysthymia
- Long, term mood symptoms
- More chronic (most days for at least a year),
less intense - Need 2 neurovegetative symptoms
- Studies show equivalent or even greater
impairment compared to depression
8Predictors of Suicidal Behavior
- Prior attempts
- Other psychiatric disorders
- Impulsivity/aggression
- Availability of firearms
- Exposure to negative events
- Family history of suicidal behavior
- Substance abuse
- Attemptcompletion ratio about 60001 in girls
and 4001 in boys
9Pediatric DepressionComorbidity
Spencer T, MGH Study of Depression
10Assessment and Treatment
11Overall Assessment Plan
- Visit 1
- Is there a problem?
- Safety assessment
- Other medical conditions
- Distribute general rating scale
- Visit 2
- Review general rating scale
- Establish primary diagnosis
- Initial treatment plan
-
- Visit 3 and Beyond
- Track progress
- Check gaps and assumptions
From D Rettew, OCD in the Primary Care Setting,
2007
12General Treatment Guidelines
- Medication
- Environment
- Sleep, structure, media
- Psychotherapy (evidence based)
- Parents
- School
- Resources
13Guidelines for Treatment of Adolescent Depression
in Primary Care (GLAD-PC)
- Expert consensus driven guidelines published in
Pediatrics (2007) - Conducted focus groups, surveys, literature
reviews,
http//www.glad-pc.org/documents/GLAD-PCToolkit.pd
f
14GLAD-PC Recommendations
- Identification
- Patients at risk for depression should be
identified and systematically monitored - Assessment/Diagnosis
- High-risk adolescents should be evaluated for
depression as well as those with a chief
complaint of emotional problems - Clinicians should use standardized tools to aid
in the assessment
15GLAD-PC RecommendationsAssessment should include
- Interviews with family members
- Degree of impairment across domains
- Other psychiatric conditions
16GLAD-PC RecommendationsInitial Management
- Educate patient and family about depression
- Outline confidentiality and its limits
- Develop a treatment plan with specific goals in
key areas of functioning - Establish links with resources (mental health,
family members) - Develop a safety plan contract?
17GLAD-PC RecommendationsFurther Management
- Mild depression consider active support and
monitoring - Moderate/severe/complicated consider
consultation with a mental health specialist - Establish roles of primary care and mental health
specialist with family - Recommend scientifically tested treatments
- Monitor for adverse effects of treatment
18Severity of Depression
19GLAD-PC RecommendationsFurther Management
- Continue to track outcomes and functional targets
- Reassess diagnosis and treatment if no response
in 6-8 weeks - Consider consultation with mental health
professional if treatments produced only partial
response - Ensure adequate management
20Pharmacotherapy
- Response 40-70 with medications vs 30-60 for
placebo - Remission with medications lower (30-40)
- Little efficacy evidence for non SSRIs
- Bupropion effective in open trials
21Medications in Depression
22Pharmacotherapy Tips
- Half life of antidepressants often shorter in
children and adolescents - Watch for withdrawal symptoms on qd dosing
- Goal for remission at 12 weeks (consider switch
if no or little response at 8 weeks)
23Text of Black Box Warning 2/05
24Proposed Mechanisms of Increased Suicidal
Behavior
- Medication adverse affects insomnia, agitation,
irritability - Switching patients with bipolar disorder
- Acute effects on serotonin that differ from
long-term effects - Greater comfort in disclosing ideation
25Change in Youth Antidepressant Prescribing
Psychiatric News, September 2005
26Official Monitoring Guidelines
FDA AACAP
- Once per week x 4 weeks
- Every 2 weeks for next 8 weeks
- At end of week 12 and regularly thereafter
- More often if problems or questions arise
- No scales recommended
- www.parentsmedguide.org
- www.aacap.org
- Fluoxetine alone, or Fluoxetine CBT, or CBT
alone as 1st line - Monitor consistent with FDA guidelines (though no
specific data to support such frequency of
contact)
- From FDA Proposed Medication Guide About Using
Antidepressants in Children or Teenagers (Center
for Drug Evaluation and Research)
http//www.fda.gov/cder/drug/antidepressants/SSRIM
edicationGuide.htm
27Recent Meta-AnalysisBridge et al., JAMA 2007
- Covered 27 controlled studies in depression and
anxiety - MDD medication response vs placebo 61 vs 50
- Less response for younger children, except with
fluoxetine - Suicidality on medications vs placebo 2 vs 1
(statistically significant across all disorders
but not MDD alone) - More efficacy with shorter depression duration
- Concluded a favorable benefit to risk comparison
for cautious use as first line treatment
28Suicide Rates by CountyGibbons et al, AJP, 2006
- Highest rates often in rural western areas and
lowest in most major cities - More SSRI Rxs, less suicides even after
controlling for mental health care and income
29Pediatric Bipolar Disorder
- One of most controversial topics in child
psychiatry - Underdiagnosed vs. Overdiagnosed?
- In forefront of physician/pharma discussions
30Pediatric Bipolar DisorderCriteria Overlap with
ADHD
- Distractibility
- Increased activity/psychomotor agitation
- Grandiosity
- Flight of ideas
- Activities with painful consequences
- Sleep decrease
- Talkativeness
In children, characterized by ultradian cycling
in about 75 and prominent suicidality in about
25
31Proposed New CategoriesLiebenluft et al., 2003
- Narrow Mood elevation duration
- Intermediate
- Clear symptoms but 1-3 day duration OR
- Clear episodes but irritable
- Broad Chronic, nonepisodic, irritability
32Dilemma in Pediatric Bipolar Disorder
Safety if untreated
Lack of efficacy data
Worse Course?
Increased Stigma
Risks with Medications
33Special CommunicationJAACAP, March 2005
34The FIND ThresholdJAACAP, 2005
- Frequency most days in a week
- Intensity extreme disturbance in one setting or
moderate disturbance in two - Number 3 or more times a day
- Duration occur 4 or more hours a day total
35PsychopharmacologyBipolar 1 in acute phase No
psychosis
- Adequate trial means 4-6 weeks at therapeutic
blood level or therapeutic dose (perhaps 8 weeks
for lithium) - Start with mood stablizer (lithium, valproate,
carbamazapine) or atypical antipsychotic
(risperidone, olanzapine, quetiapine) monotherapy - If no response, switch
- If partial response, augment
- Consensus panel did not/could not favor
particular agent - Trials of lamotragine (Lamictal), oxcarbazepine
(Trileptal), ziprasidone (Geodon), aripiprazole
(Abilify) recommended only after combination
treatment fails
36Antipsychotic FDA Approvalsin Pediatrics
- Risperidone (Risperdal) Schizophrenia (age
13-17) Bipolar Disorder (age 10-17) Autism
irritabiltiy/aggression (age 5-16) - Aripiprazole (Abilify) Bipolar Disorder (ages
10-17) - Olanzapine (Zyprexa) None
- Quetiapine (Seroquel) None
- Ziprasidone (Geodon) None
37Risks of TreatmentInformed Consent
- Weight gain and diabetes new monitoring
protocol published by ADA, 2004 - Cognitive dulling
- Polycystic Ovarian Syndrome
- Hypothyroidism
- Abnormal involuntary movements
- Liver disease
- Pancreatitis
- Prolactin elevation
- Cardiac effects??
- Neuroleptic malignant syndrome
38ADA Protocol Prior to Using Atypical
Antipsychotics
- Personal and family history of obesity, diabetes,
dyslipidemia, hypertension, cardiovascular
disease - Weight, height, BMI,
- Waist circumference at umbilicus
- Blood pressure
- Fasting glucose
- Fasting lipid profile
- Reassess at 4, 8, and 12 weeks
- Switch agents if gains 5 of body weight
39My Treatment Approach
- If meets criteria for narrowly phenotype then
proceed directly to bipolar treatment - If broad phenotype, attempt non-medication and
treatment of other conditions first
4011 Reasons for why the medicine is not working
- Diurnal Variation
- Nonpsychiatric Causes
- Dose and Duration of Treatment
- Comorbidity (child)
- Comorbidity (parent)
- Medication Side Effects
- Compliance
- Multinformant Variation
- Substance abuse
- Medication Limitations
- Lack of Commitment
41Co-Occurring Disorders Commonly Diagnosed During
Childhood and Adolescence
- Rochelle Head-Dunham, M.D., FAPA
- Board Certified Psychiatrist and Addictionologist
- Medical Director
- Louisiana Office of Addictive Disorders
42Goals and Learning Objectives
- Discuss distinguishing features of conditions
commonly diagnosed during childhood and
adolescence - Highlight the complexities of co-occurring drug
use - Discuss treatment implications and sustainability
issues for clinicians
43DSM IV Disorders Diagnosed in Infancy, Childhood,
or Adolescence
- Mental Retardation
- Learning Disabilities
- Motor skills Disorders
- Communication Disorders
- Pervasive Developmental Disorders
- Feeding and Eating Disorders
- Tic Disorders
- Eliminative Disorders
- Other Disorders (Separation Anxiety D/O)
- Attention Deficit Disorder
- Mood Disorders
- Anxiety Disorders
- Substance-Related Disorders
- Disruptive Behavioral Disorders (Conduct and
Oppositional Defiant Disorders) - Psychotic Disorders
- Sleep Disorders
- Eating Disorders
44What is ADHD?
- The most chronic
- neurobiological disorder of
- childhood, characterized by
- inattention, hyperactivity and impulsivity
- Pediatrics, Vol 105, Number 5, 2000 May.
45ADHD DSM IV Criteria
- Either (1) symptoms of inattention, (2) symptoms
of hyperactivity-impulsivity or (3) both - Onset
- 6 months of disturbance
- Cross-situational (home, school, work)
- Impairment in functioning (socially, academically
or occupationally) - Diagnostic and
Statistical Manual, Text Revision,2000.
46Neurobiology of ADHD
- Abnormal brain structure involving dorsolateral
prefrontal-subcortical circuitry - Primary deficiencies
- Executive function (planning, organizing,
sequencing, focusing/attending) - Establishing priorities
- Willcutt EG et al. Biol Psychiatry, 2005.
47Symptom Criteria Common for all Types
- Short attention span
- (poor attention to detail, frequent silly
mistakes) - Distractibility
- (hypersentive to environmental stimuli)
- Poor internal supervision
- (lives in the moment, problems with long-term
goals)
- Organizational problems
- (frequently late, haphazard approach, trouble
focusing on long term goals) - Poor Follow-through
- (multiple interests without completions)
48Causes of ADHD
- Highly Heritable
- The heritability of ADHD is estimated to be 76,
the result of complex genetic mechanisms
involving several genes. - Dysregulation of central dopaminergic and
noradrenergic networks underlie the
pathophysiology. -
- Farone, SV. Biological Psychiatry, 2005.
- Biederman J et al. J Atten Disorders, 2002
49Causes (cont.)
- Prenatal Factors
- Maternal smoking and drinking during pregnancy
increase risk of development of ADHD - Biederman J, et al.. J Am Acad CAPsych, 2002.
- Environmental Factors
- Chaos, psychosocial adversity and family discord
are risk factors for expression without
recognition and adequate treatment for ADHD.
Additionally, lead exposure has been linked to
causality. - Psycho Med. 2002 July, 32.
- Environmental Health Online, 2006.
50Prevalence
- 4-12 of school-aged communities
- 40-60 persistence into adulthood
- 9.3 males and 2.9 females in the general
population - Non-hyperactive boys and all females are
generally under diagnosed - Females primarily exhibit symptoms of the
inattentive type - In relation to Mood Disorders
- 18 Coexistence (1/5)
- Usually the inattentive and combined subtypes
- Pediatrics, Vol 105, Number 5, 2000 May
51Consequences of Underdiagnosing
- 54 develop a history of alcohol or drug abuse
/dependence! - 43 of untreated aggressive hyperactive boys will
be arrested for a felony by age 16! - 75 have interpersonal problems!
- 35 never finish high school!
52ADHD Lifespan Disorder
75
Children with ADHD
Persist
50
Adolescents With ADHD
Persist
Adults with ADHD
Prevalence in Juvenile population 6-9
Prev. in Adults 3-5
53Lifespan Impairment
Children
ADHD
Academic Limitations
Occupational/ Vocational
Adults
Relationships
Legal Difficulties
Low Self Esteem
Motor Vehicle Accidents
Injuries
Smoking and Substance Abuse
Adolescents
54Assessment Scales
- Connors Scales
- Conners Teachers Rating Scale (CTRS-R)
- 28-item scale for children 3-17
- Differentiates hyperactive and learning-disabled
vs. normal - Sensitive to medication effects
- Conners Parents Rating Scale (CPRS-R)
- 48-item scale
- Distinguishes groups of children vs normal
- Sensitive to effects of treatment
- Conners Adult ADHD Rating Scale (CAARS)
- 93item scale for adults
- Correct classification rate 85
- Connors,CK. J. Clin Psychiatry 1998
55Psychiatric Disorders and ADHD(Differential
Diagnosis)
56Childhood ADHD or Bipolar Disorder?
- Overlapping Symptoms
- Irritability
- Hyperactivity
- Accelerated Speech
- Distractibility
- Distinct BPD Symptoms
- Elation
- Grandiosity
- Flight of ideas/racing
- hypersexuality
- Key Points
- Differentiation is extremely difficult
- Stimulant response not diagnostically helpful
- 25 youth with ADHD meet criteria for mania
- Onset of BPD with h/o ADHD is 11-12 yrs of age
- Depressive D/O usually first manifested.
- Landsford, A. Am Academy of Peds, 2005.
57Practice Guidelines for ADHD
- The American Academy of Pediatrics Recommends the
following guidelines - Complete evaluations if symptoms of ADHD and poor
performance, underachievement behavioral
problems - Diagnose using DSMIV-TR criteria
- Obtain information from more than one setting
(especially schools) - Always assess for coexisting conditions
- Stimulant medications and behavioral therapy are
first line
58Mood Disorders in Youth
- Usually a family history of mood disorders
- Poorer outcomes during adolescents due to
increased risk of suicides - Pediatrics, Vol 105, Number 5, 2000 May.
59MOOD DISORDERS in Youth
- Major Depressive Disorder
- A two week period or more of depressed mood
associated with hopelessness, despair, impaired
sleep, appetite, concentration, energy and
interests - Bipolar Disorder
- Periods of depression alternating with manic
periods, which may include irritability, "high"
or happy mood, excessive energy, behavior
problems, staying up late at night, and grand
plans lasting at least one week - Dysthymia
- Sad, irritable mood most of the time for a
minimum of one year - DSMIV, Fourth Edition, 1994.
60Depression in Childhood
- Symptoms similar to Adults
- sadness
- hopelessness
- feelings of worthlessness
- excessive guilt
- change in appetite
- loss of interest in activities
- recurring thoughts of death or suicide
- loss of energy
- helplessness
- fatigue
- low self-esteem
- inability to concentrate
- change in sleep patterns
61Depression in Childhood
- Behaviors more common in kids
- a sudden drop in school performance
- inability to sit still, fidgeting, pacing,
wringing hands - pulling or rubbing the hair, skin, clothing or
other objects - In contrast
- slowed body movements, monotonous speech or
muteness - outbursts of shouting or complaining or
unexplained irritability - crying
- expression of fear or anxiety
- aggression, refusal to cooperate, antisocial
behavior - use of alcohol or other drugs
- complaints of aching arms, legs or stomach, when
no cause can be found
62Depression in Childhood
Treatment Psychotherapy Therapy-- essential to
development of necessary academic and social
skills typically responsive (adaptable) teaches
expression of feelings and develops ways of
coping with the illness and environmental
stresses. Medication some children respond to
antidepressant medications must be closely
monitored by a physician with expertise in this
area, usually a child psychiatrist. should not
be the only form of treatment, best combined with
psychotherapy (The American
Academy of Child and Adolescent Psychiatry)
63Grief
- The emotional suffering and confusion we feel
after a significant loss of any kind. - Grief is commonly equated to mean loss of another
human being, but it also includes a pet, a
neighborhood, an object of affection - Grief can last as long as it takes to accept and
learn to live with the loss. For some that can
be months, for others, years.
64Grief vs. Clinical Depression
- Depression Involves
- emotional, behavioral, and physiological changes
such as hopelessness, appetite and weight and
activity changes, guilt, poor academic
performance, aches and pain and possible suicidal
ideation/attempts - recurrent, impairment requiring professional
interventions - Grief generally resolves with time and
progression through the four stages of
acceptance, working through, adjusting to the
loss, and moving on
65Youth Suicide Rates
- Suicide rates under age 30 increasing largely due
to association with alcohol and drug use. - Among adolescents and young adults suicide is
- 3rd leading cause of death ages 15-24yrs
- 6th leading cause of death ages 5-14yrs
- 50 of teens who commit suicide have a history
of alcohol and drug use
66Youth Risk Factors for Attempted Suicide
- depression
- alcohol or other drug use disorder (including
binge drinking and substance abuse) - interpersonal problems/loss (parents' divorce,
family violence, a breakup with a boyfriend or
girlfriend, stress to perform and achieve, and
school failure) and - aggression or disruptive behaviors, prior attempt
- (Roy, 1992)
67Drug Use Data and Youth Suicide Risk
- Among those with cocaine use disorders, 31
reported previous suicide attempts, (Darke
Kaye, 2004). -
- Prevalence of cocaine use is reported as 20 in
completed suicides in New York City (Marzuk et
al., 1992). - Methamphetamine-dependent individuals are
- reported to have high rates of depression and
suicidal - ideation (Kalechstein et al., 2000 Zweben et
al., 2004). - In one study of suicide completers done in Utah,
the - prevalence of methamphetamine found by
toxicology - screens was 9 in youth and 8 in adults (Callor
et al., - 2005).
68Drug Use Data and Youth Suicide Risk
- Marijuana (MJ)
- Several studies have linked youth MJ use to
depression, suicidal thoughts and schizophrenia - Young people who use MJ weekly have double the
risk of developing depression - Teens age 12-17 who smoke MJ weekly are 3xs more
likely to have suicidal thoughts than non users - MJ use in some teens has been linked to increased
risk for schizophrenia in later years -
- (Office of National Drug Control
Policy/ONDCP, 2005) -
69Anxiety Disorders
- 25 Coexistence with ADHD-inattentive and
combined subtypes (i.e.,obsessive-compulsive
disorder, generalized anxiety disorder) - Higher risk of anxiety disorders among relatives,
however transmission may not be
genetic Pediatrics, Vol 105, Number 5, 2000
May. - Simple phobias and Separation Anxiety Disorder
are very common in young kids - Post-traumatic stress disorder (PTSD) is
particularly problematic post Katrina and Rita
70What is Post Traumatic Stress Disorder (PTSD)?
- Definition
- An anxiety disorder elicited when anyone
experiences, witnesses, or is confronted with an
event or disaster, which entails actual or
threatened death, or injury or a threat to the
physical integrity of themselves or others. - DSMIV-TR, 2000.
71Post Traumatic Stress Disorder (PTSD)
- Symptoms of PTSD
- Intrusive recollections terrifying memories,
nightmares, or flashbacks - Extreme emotional numbing inability to feel
emotions, diminished interest, sense of impending
doom - Extreme attempts to avoid disturbing memories
substance use problematic - Hyperarousal panic attacks, rage, irritability,
violence, poor sleep, concentration, and
attention - DSMIV-TR 2000.
72Predicting Outcome Of Trauma Event Individual
Factors
Individual Factors
Event Factors
Duration
Proximity
Severity
Individual Factors
73Clinical Outcomes of Trauma
- Severe Anxiety (Generalized and/or PTSD, with
obsessive traits) - Severe Depression and/or Grief
- Posttraumatic Stress Disorder (PTSD)
Dissociation fragmented thoughts, amnesia - Addictive Disorder and/or Co-occurring D/Os
- Sub-threshold Trauma-based Syndrome (STS)
experience of clinically disabling feelings and
behaviors, not sufficient to constitute a
diagnosis of PTSD, but may impact functioning.
74Disaster Response in Children and Adolescents
- Psychological impact of disaster on children is
greater than on adults with similar exposure - (Davis and Siegel, 2000 LeGreca, 1996 McNally,
1993 Norris et al, 2000) - Research supports correlates between traumatized
parents and their children - Too few definitive studies for conclusion
75Victimization Trauma or Bullying
- Victimization is consistently correlated with
increased co-occurring psychiatric problems,
substance dependence, negative peer pressure and
family influence, HIV risk behavior, and health
problems - Prevalence Rates for lifetime (67), past 90
days (36), and acute/ current (48)
victimization rates are higher than the diagnosis
of PTSD (28) - (Grella et al Stevens, Murphy McKnight 2003)
76Conduct Disorder and Oppositional Defiant
Disorders
- Conduct Disorder (CD)
- a repetitive and persistent pattern of behavior
in which the basic rights of others or major
age-appropriate social norms or rules are
violated - Largest single group of psychiatric disorders (9
boys, 2 girls) - Most likely, an inherited predisposition with
environmental and parenting influences - Poorer outcomes combined with ADHD (delinquency,
substance abuse) - Behavioral therapy and psychotherapy, group or
individual Medication for co-morbid conditions - DSMIV, Fourth Edition, 1994.
77Conduct Disorder and Oppositional Defiant
Disorders
- Oppositional Defiant Disorder (ODD)
- negativistic, defiant, disobedient, and
hostile behaviors toward authority figures - 35 coexistence with ADHD (hyperactive-impulsive
and combined subtypes) - 1 co-morbidity with ADHD in adolescents
- Often children with ODD later develop severe
symptoms consistent with CD - Pediatrics, Vol 105, Number 5, 2000 May.
78Learning Disabilities
- 3 of the population 30-50 Psychiatric
disorders (often autism and hyperkinetic
disorders) - 12-60 (reading disorders/dyslexia) coexist with
ADHD (inattentive and combined types) - More difficult to assessarticulation and
professional skill limitations - IEPs and Special education services required
- Pediatrics, Vol 105, Number 5,
2000 May.
79Complexities of Youth Substance Use
- Is ADD a risk factor for substance use?
- Is stimulant treatment for ADD predisposing to
substance use? - Is psychiatric co-morbidity a risk factor for
substance use? - Are there identified risk and protective factors
for substance use?
80ADD and Substance Use
- Findings from a 4 year prospective study of
adolescents - Conclusions
- ADHD and PSUD rates are both increased with
co-existent Conduct Disorder and Bipolar
Disorder - Untreated ADHD adolescents are more likely to
experiment with drugs and alcohol - Untreated ADHD adults are more likely to become
dependent on drugs and alcohol - Biederman J, et al. APP Focus 2003
81Stimulant Medication and PSUD
- Data collected from 6 studies involving 674
medicated and 360 non-medicated ADHD adolescents
over a 4 year period - Findings
- 1.9 fold decrease in risk of SUD in treated group
- Similar decreased risk of later alcohol and drug
use disorders - Conclusion
- Stimulant medication was protective against SUD,
decreasing the risk of later alcohol and drug
dependence - Wilens T E, et al. Pediatrics 2003 Jan.
82Misuse and DiversionAmong College Students
- Most students not using (93.2) or misusing
(5.4) stimulants for ADHD - 2 of 3 prescribed stimulant for ADHD use them for
medical use only (1.5 vs. 0.7) - Likelihood of students who use stimulants for
ADHD being approached about diverting their
medication - Twice that of college students in general (54
vs. 27) - At least 3 times that for pain medication,
sedatives/anxiety agents, or sleeping medications
(54 vs. 19, 19, 14) - McCabe SE, et al. J Am Coll Health, 2006.
83PSUD ADHD in Adults
- Study examined association between ADHD, PSUD and
co-existing conditions in adults - Conclusions
- ADHD is an independent risk factor for SUD
- ASPD is a risk factor for SUD independent of ADHD
- Mood and Anxiety Disorders are risk factors for
SUD - Biederman J et al. AmJPsych 1995.
84Caring Communities Youth Survey(CCYS) 2002,
2004, 2006
- Report summarizes risk and protective factors
based on survey responses by 6th, 8th, 10th, and
12th graders in Louisiana public schools, to drug
related questions - Four Domains
- Family Factors
- Community Factors
- School Factors
- Peer/Individual Factors
85CCYS Risk Factor Scales
- Community Domain
- Low neighborhood attachment
- Community disorganization
- Transitions and mobility
- Laws and norms favorable toward drug use
- Perceived availability of drugs
- Perceived availability of guns
- Family Domain
- Poor family management
- Family conflict
- Family history of antisocial behavior
- Parental attitudes favorable toward drugs
- Parental attitudes favorable toward antisocial
behavior
- School Domain
- Academic failure
- Low commitment to school
- Peer/Individual Domain
- Rebelliousness
- Early initiation of antisocial behavior
- Early initiation of drug use
- Attitudes favorable toward drug use
- Perceived risks of drug use
- Interaction with antisocial peers
- Friends who use drugs
- Rewards for antisocial behavior
- Depressive symptoms
- Gang involvement
- Intentions to use drugs
86What Substances Do Adolescents Use?
- National Survey on Drug Abuse and Health (NSDUH)
2006 Ages 12-17 - Trends 2002-2006 MJ and Nicotine
(cigarettes)-decline, Alcohol and Cocaine-no
change - Increased prescription pain medicine drug use
(non-medicinal use) - Illicit Prescription Drug use Gateway to Street
Drug use
87What Substances Do Adolescents Use?
- National Survey on Drug Abuse and Health (NSDUH)
2006 Ages 12-17 - Illegal drugs not perceived as more problematic
than prescription drugs - Methamphetamine one time use not perceived as
dangerous - 1/3 of all new drug abuse ages 12-13 yrs but as
early as 10 yrs - Girls more than boys use prescription drugs
(especially pregnant teens, and young adults)
88Access to Drugs
- HOME environment is number one source!
- 50 from family members (medicine
cabinets/friends or taking it from them degree
of availability predictive of degree of use - The Internet .The New Drug Dealer
- (Availability of Addictive opioids (pain meds),
depressants (alcohol, Xanax), stimulants
(Ritalin, Adderall, Methamphetamine)
89Internet Drugs
- Anything Goes scenario
- not requiring prescriptions for purchases.
- online consultations (intended to replace a
face-to-face evaluation from a physician does
not constitute a legitimate doctor-patient
relationship) - (Alcoholism Drug Abuse Weekly, June 26,
2006)
90Internet Drugs
- Benzodiazepines most widely available on Internet
- Xanax and Valium are the most frequently offered
- Breakdown of the classes of drugs available on
the 185 selling sites - Benzodiazepines 155
- Opioids 126
- Stimulants 14
- Barbiturates 2
- broad advertising, computer based, with no
controls to block sales to minors - 20/185 sites required buyers to have a
prescription - 14/20 sites allow buyers to fax prescriptions
- 3/20 sites require a prescription
- 60 now using the online consultation
- National Center on
Addiction and Substance Abuse at - Columbia University,
2004.
91Internet Drugs What should we do?
- Improved Parental monitoring of and education
about internet use - Curriculum development on subject with updates
- Clarification of federal law prohibiting online
sale or purchase of controlled prescription drugs
without an original copy of a prescription issued
by a physician with DEA - Warnings of illegal use and blockage of sites
that fail to require a legitimate prescriptions - Public service announcements on the dangers of
online purchasing (could appear during Internet
searches for prescription drugs.) - a national nonprofit clearinghouse designed to
identify and shut the operations of illegal
Internet pharmacies
92Intervention Strategies
93Prevention
- Identify at risk kids based on risk factors
typically associated with adverse behaviors. - Advocate for inclusion of identified protective
factors in settings you control
94CCYS Risk Factor Scales
- Community Domain
- Low neighborhood attachment
- Community disorganization
- Transitions and mobility
- Laws and norms favorable toward drug use
- Perceived availability of drugs
- Perceived availability of guns
- Family Domain
- Poor family management
- Family conflict
- Family history of antisocial behavior
- Parental attitudes favorable toward drugs
- Parental attitudes favorable toward antisocial
behavior
- School Domain
- Academic failure
- Low commitment to school
- Peer/Individual Domain
- Rebelliousness
- Early initiation of antisocial behavior
- Early initiation of drug use
- Attitudes favorable toward drug use
- Perceived risks of drug use
- Interaction with antisocial peers
- Friends who use drugs
- Rewards for antisocial behavior
- Depressive symptoms
- Gang involvement
- Intentions to use drugs
95What can We Do? CCYS Protective Factor Scales
- School Domain
- Opportunities for prosocial involvement at school
- Rewards for prosocial involvement at school
- Peer/Individual Domain
- Religiosity
- Social skills
- Belief in the moral order
- Interaction with prosocial peers
- Prosocial involvement
- Perceived rewards for prosocial involvement
- Community Domain
- Opportunities for prosocial involvement in the
community - Rewards for prosocial involvement in the
community - Family Domain
- Family attachment
- Opportunities for prosocial involvement in the
family - Rewards for prosocial involvement in the family
96Treatments
- Aggressive diagnosis of substance abuse problems
as well as mental health problems (diagnosing
with expectation, during acute intoxication and
visits for treatment of psychiatric distress,) - Appropriate combinations of medication
management, behavioral interventions and
psychotherapy.
97Medication Guidelines
- Medication may be prescribed for psychiatric
symptoms and - disorders, including, but not limited to
- Bedwetting - if it persists regularly after age 5
and causes serious problems in low self-esteem
and social interaction. - Anxiety (school refusal, phobias, separation or
social fears, generalized anxiety, or
posttraumatic stress disorders)-if it keeps the
youngster from normal daily activities.
98Medication Guidelines
- Attention deficit hyperactivity disorder (ADHD)
-if it interferes with school work and ability to
get family and friends - Obsessive-compulsive disorder (OCD) - if
excessive time is lost to rituals and it
interfere with a youngster's daily functioning.
99Medication Guidelines
- Depression - if it results in a decline in school
work and changes in sleeping and eating habits. - Bipolar (manic-depressive) disorder if the
behavior interferes with school performance or
social functioning or is life threatening
100Medication Guidelines (cond)
- Eating disorder if behavior is life
threatening, either self-starvation (anorexia
nervosa) or binge eating and vomiting (bulimia),
or a combination of the two. - Psychosis typically requires medication
interventions symptoms include irrational
beliefs, paranoia, hallucinations (seeing things
or hearing sounds that don't exist) social
withdrawal, clinging, strange behavior, extreme
stubbornness, persistent rituals, and
deterioration of personal habits. May be seen in
developmental disorders, severe depression,
schizoaffective disorder, schizophrenia, and some
forms of substance abuse. - Autism - (or other pervasive developmental
disorder such as Asperger's Syndrome) when
behaviors are harmful typically to self
characterized by severe deficits in social
interactions, language, and/or thinking or
ability to learn, and usually diagnosed in early
childhood. - Severe aggression typically requires medication
to prevent harm to self or others - Sleep problems if depravation interferes with
daytime functioning or nighttime behaviors are
dangerous symptoms can include insomnia, night
terrors, sleep walking, fear of separation,
anxiety.
101Behavioral Therapy
- Consists of interventions designed to modify
physical and social environments - Requires training of parents and teachers
- Involves rewards for desired behaviors (positive
reinforcement) removal of access to positive
reinforcement (time-out) Withdrawal of rewards
or privileges contingent on performance (response
cost) combining positive reinforcement and
response cost (token economy) - Pediatrics Vol 108, 2001 October.
102Healthcare Professional Maintenance and
Sustainability
- Academic
- CEUs/Continuing Education Units (child and
adolescent specific) - Journal Subscriptions (Brown University Child
and Adolescent Pharmacology) - Multidisciplinary Teams/Consultations, Engage
professional partners avoid the vacuum! - Engage Family (expand definition)
- Explore non-traditional approaches/interventions
- Personal
- Do Fearless and Moral Inventory of Strengths and
Limitationsrespect both! - Avoid Burnout 3Bs -- Balance, Boundaries,
Beliefs
103Questions and Comments