Substance Use

Disorders in Children
and Adolescents
 Definition
Two Major Categories (DSM-5)

 Substance-use disorders (SUDs) - SUD is defined by cognitive, behavioral, and physiologic symptoms
due to continued use of a substance despite significant substance use–related problems.

 Substance-induced disorders (SIDs) - SID includes intoxication and withdrawal states, as well as
other substance-induced mental disorders, related to each specific substance.

Classes of Substances

1. alcohol
2. caffeine
3. cannabis
The diagnosis of SID does not
4. hallucinogens require nor preclude the
5. inhalants
6. opioids
diagnosis of SUD.
7. sedatives
8. hypnotics/anxiolytics
9. stimulants
10. tobacco
 History
 Use and abuse of substances have been documented throughout history and date back to ancient
times.

 The liability of certain substances to result in “addiction” was recognized in the late 19th and early 20th
centuries, when laws regulating substances of abuse were introduced.

 The 1914 Harrison Narcotic Act, which forbade the sale of cocaine or opiates except by licensed
physicians or pharmacists, was one of the first laws introduced to regulate substances seen as having a
liability for abuse.

 Prohibition Amendment of 1919 made alcohol an illegal substance but was was overturned in 1933.

 The U.S. Federal Bureau of Narcotics (now the Drug Enforcement Administration) in 1930 was created
to regulate the purchase and use of drugs.
 Epidemiology
 Overall, American adolescents over the past decade have been using fewer substances, although there
are some exceptions.

 Alcohol continues to be the most widely used substance among adolescents.

 Overall alcohol consumption has declined since the 1980s and is currently at the lowest level since the
1970s.

 Tobacco use has also continued to decline over the past decade and is currently at the lowest level
since the 1970s.

 The annual prevalence of using any illicit drug continued to decrease slightly, with the largest decrease
among 10th and 12th grade students.

 Marijuana remains the most widely used illicit drug among adolescents.

 Opioid use is arguably the greatest adolescent and young adult substance use epidemic of the past
decade.
 Epidemiology

 The vast majority of patients entering treatment

for alcohol, alcohol with a secondary drug, or
marijuana use endorsed first use in adolescence
(78.2%, 87.6%, and 92.1%, respectively).

 The prevalence of substance use and SUDs

increases almost linearly from early to late
adolescence.

 There are gender differences, as males report

more substance use than females, and more
frequently meet criteria for dependence on
alcohol and marijuana in late adolescence, while
females are more often nicotine dependent.
 Etiology
The etiology of SUDs lies in those factors that predispose an individual to experiment with substances,
and among experimenters, factors that predict progression to SUD.

Etiology Theories of Adolescent SUDs:

 Genetic and Environmental Influences

 Externalizing Disorders

 Stage Theory and the “Gateway” Theory

 Early Onset of Use

 Family and Peer Effects

 Biologic Mechanisms in the Etiology of Substance Use Disorders

 Substance-Specific Risks
 DIAGNOSIS AND CLINICAL FEATURES
The diagnosis of SUD is made primarily through the clinical interview with the
adolescent, as well as through obtaining collateral information from parents and
teachers.
Important Information to Gather Best Practices

• Extent and severity of substance involvement • Establish rapport to increase

chance of self-disclosure
• The specific substance used
• Use of motivational style –
• The length of time the substance abuse has been going nonjudgmental and collaborative
on approach

• Triggers, context, and motivation for using • Parents or caretakers should be

present in the interview except in
• Positive and negative consequences of use\ discussions around substance
use history
• Motivation and goals for treatment
 SPECIFIC LABORATORY TESTING OF
SUBSTANCES— UPDATED
Detection of substances is a key component of SUD diagnosis and treatment.

 Urinalysis remains the most commonly used method (for the detection of substances).

 The NIDA 5 includes marijuana, cocaine, methamphetamine, heroin, and PCP, which were considered
the most important substances to detect following passage of the Drug-Free Workplace Act of 1988.

 urinalysis for drugs of abuse is less reproducible and may be unreliable when performed using on-site
or point-of-care assays

Substances where Urinalysis is Ineffective

• Alcohol

• Inhalants

• Hallucinogens
 SUBSTANCE-SPECIFIC CLINICAL
FEATURES
 Alcohol - Alcohol is one of the first substances that adolescents usually experiment with, and
alcohol use disorders constitute a major proportion of adolescent SUDs

 Tobacco - The addictive ingredient in tobacco is nicotine, which has been shown to produce
dependence in a substantial proportion of users.

 Marijuana - Marijuana use disorders accounts for the largest proportion of adolescent SUDs
(4) and recent changes in state-by-state marijuana policies have multiple implications for
adolescents

 Opiates - Heroin use and abuse of prescription opiates has risen during the past two
decades.

 Cocaine - Physical effects of cocaine use include constricted blood vessels, dilated pupils,
increased temperature, heart rate, and blood pressure.

 Amphetamines - Methamphetamine is known by a variety of street names including ice,

speed, crystal, glass, and crank.
 SUBSTANCE-SPECIFIC CLINICAL
FEATURES
 MDMA - Past year use of MDMA, or ecstasy, surged in the early 2000s to its highest
prevalence, subsiding by 2004. Over the past decade MDMA past year prevalence peaked
again in 2010, subsequently declining to 0.9%, 2.3%, and 3.6% of 8th, 10th, and 12th grade
students in 2014.

 GHB - Approximately 2% of US high school seniors reported using gamma hydroxy butyrate
(GHB) within the past year (8). GHB is known by such street names such as “grievous bodily
harm,” “G,” or “liquid ecstasy.

 Inhalants - Approximately 5% of US high school students reports having tried inhalants at

least once in the past year (3); however, rates of inhalant abuse or dependence are much
lower, as only 0.1% of adolescents report abuse or dependence upon inhalants.

 Steroids - Approximately 0.6% to 2.0% of male US high school students report having used
anabolic steroids within the past year, which is down by approximately half among younger
adolescents over the past decade.
 COURSE AND PROGNOSIS
The course and prognosis of SUDs is varied. Earlier onset, more severe substance use, and comorbid
conditions predict a more severe course and outcome. In general, substance disorder implies a chronic,
relapsing condition.

 Treatment - Treatment for adolescent SUDs involves recognizing that these are chronic relapsing
conditions. Patients may need multiple episodes of treatment over time.

 Specific Therapeutic Approaches

• Motivational Interviewing

• Cognitive-Behavioral Therapy

• Family and Multisystemic Therapies

• Community Reinforcement and Behavioral Approaches

 COURSE AND PROGNOSIS
 Specific Therapeutic Approaches

 Contingency Management

 Pharmacotherapies

 Integrated Mental Health and Addiction Treatment Principles

 Family and Multisystemic Therapies
 Multisystemic Therapy (MST). MST targets key factors that are associated with serious antisocial
behavior in children and adolescents with substance use disorders, such as attitudes, family, peer
pressure, school and neighborhood culture.

 Brief Strategic Family Therapy (BSFT). BSFT targets family interactions that are thought to maintain or
exacerbate adolescent substance use disorder and other co-occurring problem behaviors such as
conduct problems, oppositional behavior, delinquency, associating with antisocial peers, aggressive and
violent behavior, and risky sexual behaviors.

 Multidimensional Family Therapy (MDFT). MDFT, a comprehensive intervention for adolescents, focuses
on multiple and interacting risk factors for substance use disorders and related comorbid conditions.
This therapy addresses adolescents’ interpersonal and relationship issues, parental behaviors, and the
family environment. Families receive assistance with navigating school and social service systems, as well
as the juvenile justice system if needed. Treatment includes individual and family sessions.
 Behavioral Therapies

Behavioral treatment (alone or in combination with medications) is a

cornerstone to successful long-term outcomes for many individuals with
drug use disorders or other mental illnesses. Several strategies have shown
promise for treating specific comorbid conditions.

• Dialectical Behavior Therapy (DBT)

• Assertive Community Treatment (ACT)
• Therapeutic Communities (TCs)
• Exposure Therapy
• Integrated Group Therapy (IGT)
• Seeking Safety (SS)
• Mobile Medical Application
 The Connection Between Substance Use
Disorders and Mental Illness
Many individuals who develop substance use disorders (SUD) are also
diagnosed with mental disorders, and vice versa.

Three main pathways can contribute to the comorbidity between

substance use disorders and mental illnesses:

● Common risk factors can contribute to both mental illness and substance use and
addiction.

● Mental illness may contribute to substance use and addiction.

● Substance use and addiction can contribute to the development of mental illness.
 COMMON COMORBID DISORDERS PHARMACOTHERAPY FOR ADOLESCENTS WITH A
SUBSTANCE USE DISORDER
Comorbid Disorder
Attentiondeficit hyperactivity
disorder
Bipolar disorder
Effective Treatment for
Adolescents without SUD
First line: pharmacotherapy (generally;
psychostimulants) Medication options with
low abuse potential: pemoline, bupropion,
atomoxetine
First line: pharmacotherapy Mood
stabilizers (lithium, valproic acid,
carbamazepine)
Impact of Treatment on Adolescents with
SUD
One controlled trial of pemoline (Riggs et al., 2004 (106); N
= 69) suggests: Efficacy for ADHD despite nonabstinence
• Good safety profile in 12-wk trial; potential for
hepatotoxicity, relative contraindication for pemoline
• No decrease (or increase) in drug use in the absence of
specific behavioral intervention for SUD
• Potential for hepatoxicity relative contraindication for
pemoline given other current options
• Clonidine relatively contraindicated
One randomized controlled trial of lithium in adolescents
with SUD and comorbid bipolar (Geller et al., 1998 (107); N
= 25) suggests:
• Efficacy and reasonable safety for bipolar disorder
despite nonabstinence
• Not adequate as an effective treatment for SUD in the
absence of specific behavioral treatment for SUD
 COMMON COMORBID DISORDERS PHARMACOTHERAPY FOR ADOLESCENTS WITH A
SUBSTANCE USE DISORDER
Comorbid Disorder Effective Treatment for
Adolescents without SUD
• First line: combined pharmacotherapy and
psychotherapy
• Pharmacotherapy: SSRIs (> support,
fluoxetine) in adolescents without SUD
• Psychotherapy: cognitive-behavioral
Depression
therapy (CBT) and interpersonal
psychotherapy, combined with medication
for severe depression fluoxetine + CBT >
efficacy than either alone (TADS study
March/TADS team 2004, JAMA) (108)
Anxiety disorder (often
Anxiety disorder (often comorbid with
comorbid with depressive
depressive disorders)
disorders)
Impact of Treatment on Adolescents with
SUD
One randomized controlled trial of fluoxetine in
adolescents with SUD and comorbid MDD + CBT for SUD
(Riggs et al. (109); N = 126) suggests:
• Efficacy for depression despite nonabstinence (16-wk trial)
• Good safety profile
• High rate of depression remission in both fluoxetine and
placebotreated subjects suggests that CBT also + impact
on depression despite focus on drug abuse, not depression
• High rate of depression remission in both fluoxetine and
placebotreated subjects suggests that CBT also + impact
on depression despite focus on drug abuse, not depression
• Remitters drug use decreased significantly; nonremitters
had no change in drug use
• Remitters drug use decreased significantly; nonremitters
had no change in drug use
Anxiety disorder (often comorbid with depressive
disorders)
• Fluoxetine efficacy and safety in reducing symptoms of
anxiety in depressed, substance-dependent adolescents
with significant anxiety symptoms and/or anxiety disorders
(GAD, SAD, PTSD)
• No difference in depression and drug use outcomes
comparing those with and without anxiety disorders
 Implications for Integrated Mental
Health/Substance Treatment
 Each of these studies utilized a standardized and comprehensive semi-structured diagnostic interview
to determine substance and other psychiatric diagnoses at baseline.

 Based on psychiatric diagnosis (e.g., MDD/CDRS-R; ADHD/ADHD-RS) psychometrically valid and

clinically informative measures of psychiatric symptom severity were administered at baseline and
repeated at least monthly throughout treatment to monitor changes in psychiatric symptom severity in
response to treatment.

 Changes in substance use was assessed at baseline and throughout treatment using standard TLFB
procedures based on self-reports. Urine drug screens were also obtained at baseline and weekly during
treatment as a biologic measure of substance use.

 The medications used in the aforementioned trials (i.e., fluoxetine, OROS-MPH, atomoxetine)
demonstrated relatively good safety profiles, despite nonabstinence in most participants, in the context
of concurrent participation in substance treatment and regular safety monitoring.
 CONCLUSION

Adolescent substance use present in a myriad

number of ways in clinical settings. Often the use of
substances may complicate the assessment or
treatment of another psychiatric conditions and the
primary clinical task is to establish whether a use
disorder exists
 References

Martin, A., Volkmar, F., & Bloch, M. (Eds.). (2017). Lewis’s Child and Adolescent Psychiatry: A
Comprehensive Textbook (5th ed.) [E-book]. LWW.

Common Comorbidities with Substance Use Disorders Research Report. Bethesda (MD):
National Institutes on Drug Abuse (US); 2020 Apr. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK571451/