Adolescent Psychiatry, V. 29

The Annals of the American Society for Adolescent Psychiatry

Lois T. Flaherty

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134911615
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

A special section on adolescent substance abuse highlights Volume 29 of Adolescent Psychiatry. Contributions range from an examination of brain myelination in relation to onset of addictive disorders (Bartzokis) to the screening instruments used to detect substance use disorders (Rosner) to practical aspects of psychiatric assessment and management of substance abusing adolescents (Havivi). Topical studies focus on the changing patterns of use and health risks of the "designer drug" Ecstasy (Grob); the club drugs gamma-hydroxybutyrate and ketamine (Miotto et al.); and adolescent pathological gambling, a behavioral disorder with strikingly addictive features. Taken together, these illuminating essays converge in an appreciation of adolescent substance abuse and
addiction in all their biopsychosocial complexity.Elsewhere in Volume 29, contributors review neuroimaging studies in an effort to shed light on adolescent psychiatric disorders (Day et al.); reevaluate the construct of borderline personality disorder as it pertains to adolescence (Becker & Grilo; Paris); and present the encouraging results of a pilot project on the psychodynamic psychotherapy of adolescents with panic disorder (Milrod et al.). A case series on the treatment of hospitalized adolescents who deliberately ingest foreign objects (Petti et al.) and a case study of the cross-cultural issues that arose in the therapy of an Asian American adolescent (Shen et al.) enlarge the clinical and cultural scope of the volume.True to the legacy of previous volumes in the series, Volume 29 of Adolescent Psychiatry brings within its purview all the elements of a multidimensional grasp of adolescent development, psychopathology, and treatment. Neuroscientific
findings, empirical clinical studies, case series, and descriptions of clinical approaches all take their place in this illuminating and richly textured collection.

PART I

SPECIAL SECTION ON ADOLESCENT SUBSTANCE USE AND ADDICTION

INTRODUCTION TO SPECIAL SECTION

ADOLESCENT SUBSTANCE USE AND ADDICTION

MACE BECKSON

Thomas, the 15-year-old son of a single mother working in retail sales, has just been suspended for the second time during eighth grade, this time for bullying a classmate. Thomas had been repeating the eighth grade due to academic failure resulting from absenteeism and poor study habits during the previous school year. Thomas has been ditching school and hanging out with his friends, smoking cigarettes and marijuana, and playing cards. Because he can pass for 18 years old, Thomas is also able to use a fake ID to purchase beer for himself and his friends; he not infrequently resorts to shoplifting when he is unable to take money out of his mother's purse. Thomas has been sexually active with several girlfriends since he was 13 years old; he rarely uses condoms. On one occasion, Thomas was detained by the police because of fighting while intoxicated; his mother was called to pick him up at the precinct station. Thomas was diagnosed with attention-deficit disorder during the third grade. However, his mother, who works two jobs to make ends meet, currently does not have health insurance, and consequently Thomas has not been taking his usual Ritalin. Because his mother is usually not home, Thomas is able to avoid doing his homework assignments. When his mother occasionally confronts his antisocial behavior, Thomas typically flies into a rage and storms out of the house.

The case of Thomas is far from unique, in presenting a challenging constellation of biopsychosocial difficulties for the treating adolescent psychiatrist. His continuing use of substances (i.e., tobacco, alcohol, and marijuana) is a major obstacle in achieving a successful therapeutic outcome. It is critical for accurate diagnosis and treatment planning that the adolescent psychiatrist should possess knowledge about substance use, including the current drugs of abuse as well as the complications of substance abuse and dependence, particularly when accompanied by psychiatric comorbidity. Family, school, neurocognitive, medical, and legal issues, among others, will all affect the psychiatric treatment. The adolescent psychiatrist is in a pivotal position to oversee the synthesis of a variety of resources and interventions, in addition to providing psychotherapy or medication.

PREVALENCE OF SUBSTANCE USE

The 2002 Monitoring the Future survey, conducted by the University of Michigan Institute for Social Research, found that 24.5%, 44.6%, and 53.0% of 8th-, 10th-, and 12th-graders, respectively, had used any illicit drug in their lifetime (Johnston, O'Malley, and Backman, 2002). Among 8th-graders, 21.3% had been drunk, while 44.0% and 61.6% of 10th- and 12th-graders, respectively, had been drunk at least once in their lives. Any use of cigarettes was found in 31.4%, 47.4%, and 57.2% of 8th-, 10th-, and 12th-graders, respectively. The lifetime prevalence rates for marijuana use among 8th-, 10th-, and 12th-graders were 19.2%, 38.7%, and 47.8%. In the previous 30 days, 21.5% of 12th-graders had used marijuana, 26.7% had used cigarettes, and 30.3% had been drunk. Consumption of more than half a pack of cigarettes daily was reported by 9.1% of 12th-graders. This level of daily consumption was reported by 4.4% of 10th-graders and 2.1% of 8th-graders. Daily use of alcohol was reported by 3.5% of 12th-graders; 28.6% of 12th-graders had consumed at least five drinks in a row within the previous two weeks. Among 12th-graders, 16.8% had used amphetamines, 10.5% had used ecstasy, and 7.8% had used cocaine.

The 2001 National Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, examined a nationally representative sample of students in high school grades 9–12 (Grun-baum et al., 2002). Results indicated that 6.6% of 12th-graders smoked more than 10 cigarettes daily, while 71.1% had ever tried cigarettes and 26.9% had been daily users during their lifetime. Among 12th graders, 36.7% had consumed at least five drinks on at least one occasion in the previous 30 days, as had 24.5% of 9th-graders. Among 12th-graders, 26.9% had used marijuana within the preceding 30 days, as had 19.4% of 9th-graders.

The 2002 National Survey on Drug Use and Health, formerly the National Household Survey on Drug Abuse, is conducted by the Substance Abuse and Mental Health Services Administration (2003) and surveys the civilian population of the United States aged 12 years old or older. Among youths aged 12 to 17, 11.6% were current illicit drug users and 28.8% of persons aged 12 to 20 reported drinking alcohol in the previous month. Furthermore, 19.3% were binge drinkers and 6.2% were heavy drinkers. Among youths aged 12 to 17, girls were slightly more likely than boys to smoke (13.6% versus 12.3%).

The most severe substance abusers are likely to be underrepresented in surveys, causing an underestimation of incidence and prevalence. Adolescents involved with drugs are more likely to have quit school, run away from home, become homeless, been incarcerated, or been put into treatment programs (Tarter, 2002).

NORMAL VERSUS ABNORMAL

The diagnosis of substance use disorder (SUD) in teens differs from teen use of substances. While drug use appears to be more a function of social and peer factors, SUD appears more related to biological and psychological processes (Glantz and Pickens, 1992). Normal adolescent development includes stressful challenges: to develop autonomy, establish self-identity, and maintain positive self-esteem, all in the context of dramatic physical maturation. Furthermore, low self-regulation is developmentally normal in adolescence, thereby predisposing adolescents to engage in risky behavior (Tarter, 2002). Adolescents experiment with numerous adult behaviors, such as substance use and sex.

Teens who experiment with substances have, as a group, a better psychosocial prognosis than those who have no such experience (Shedler and Block, 1990). While 54% of 12th-graders have used an illicit drug at some time, less than 10% will develop SUD involving an illicit drug in their lifetime (Anthony and Helzer, 1991). Therefore, substance use history cannot be relied on to predict SUD.

DIAGNOSTIC ISSUES

Research supports validity and utility of DSM-IV alcohol use disorders in adolescents; for instance, degree of alcohol use and psychosocial impairment differ between teens with SUD and those without the diagnosis (Lewinsohn, Rohde, and Seeley, 1996; Langenbucher et al., 2000). Adolescents drink differently than adults do. Commonly, teens consume large quantities of alcohol with peers infrequently (Deas et al., 2000). Among adolescent drinkers, the most commonly met criterion for the diagnosis of alcohol abuse in DSM-IV is that of interpersonal problems. For the diagnosis of alcohol dependence in the DSM-IV, teens most prevalently meet the criteria of tolerance and drinking more or longer than intended (Martin and Winters, 1998).

Tolerance frequently reflects a normal developmental phenomenon, however; consequently, tolerance does not clearly distinguish adolescents with and without alcohol-related problems (Chung et al., 2001, 2002). In addition, drinking more or longer than intended also has high prevalence, but low specificity: teens may drink more or longer than intended because of inexperience and setting (Caetano, 1999; Chung et al., 2002).

Some adolescents, up to 13.5%, are called “diagnostic orphans,” referring to the fact that they have drinking problems but do not meet full criteria for either abuse or dependence (e.g., they have one or two criteria for dependence; Lewinsohn et al., 1996). At one-year follow-up, the diagnostic orphans resembled DSM-IV alcohol abuse teens in terms of consumption level and follow-up diagnostic status (Pollock and Martin, 1999).

PREVALENCE OF SUBSTANCE USE DISORDERS (SUD) IN ADOLESCENTS

In one community sample, 6.2% of youths met DSM-III criteria for SUD (Kandel et al., 1999). A study of older adolescents reported a lifetime SUD prevalence of 9.8% (Reinherz et al., 1993). In mental health settings, prevalence of SUD has been approximately 50% (Grilo et al., 1995; Reebeye, Moretti, and Lessard, 1995). In youths receiving outpatient substance abuse treatment, lifetime prevalence of SUD by DSM-III-R criteria included 95% for any substance, 68% for alcohol, 42% for marijuana, 9% for amphetamines, 4% for hallucinogens, and 2% for opiates (Westermeyer et al., 1994). In a juvenile justice setting, 81% of adolescents studies met DSM-III-R criteria for SUD (Milin et al., 1991).

PSYCHIATRIC COMORBIDITY

In a study of adolescent inpatients in a substance abuse treatment facility, 82% had Axis I disorders and 75% had more than one disorder. Mood disorders (61%), conduct disorder (54%), and anxiety disorders (43%) were most common (Bukstein, Glancy, and Kaminer, 1992). The onset of mood disorders may precede or follow onset of SUD (Bukstein et al., 1992; Hovens, Cantwell, and Kiriakos, 1994). Depressed adolescents have been observed as more likely to progress to SUD at an earlier age than a control group of adolescents (Grilo et al., 1995).

Social phobia usually precedes alcohol abuse; panic disorder usually follows onset of alcohol abuse (Kushner, Sher, and Beitman, 1990). A history of posttraumatic stress disorder predicts adolescent SUD (Van Hasselt et al., 1992). Bulimia nervosa is associated with adolescent SUD (Bulik et al., 1992). Conduct disorder has up to 80% comorbidity with SUD (Milin et al., 1991). For a subgroup of adolescents, drug use clusters with delinquency, early sexual behavior, and pregnancy (Huizinga, Loeber, and Thornberry, 1993). Significant co-occurrence has been observed between SUD and Cluster B personality disorders (Grilo et al., 1995).

RISK FACTORS

Greater adolescent substance use is associated with low socioeconomic status and high crime (Brook et al., 1990). SUD is associated with parental substance abuse, parent beliefs/attitudes toward substance use, parental tolerance of adolescent substance use, lack of closeness and attachment between parent and child or parent and adolescent, and lack of parental involvement, supervision, or discipline (Kandel, Kessler, and Margulies, 1978; Baumrind, 1983).

Development of SUD is associated with early childhood disruptive behavior, aggression, risk-taking, and poor school performance (Brook, Linkoff, and Whiteman, 1977; Jessor and Jessor, 1977; Kandel et al., 1978). Among preadolescents, deviant behavior and indicators of family dysfunction are risk factors for alcohol use (Webb, Baer, and McKelvey, 1995). Peer substance use and attitudes about substance use are associated with development of SUD in adolescents striving to determine their identities (Kandel et al., 1978). Transition from trial to occasional use includes friends’ smoking and approval, cigarettes offered by friends, smoking intentions, school grade, and alcohol and marijuana use of cigarettes (Moolchan, Ernst, and Henningfield, 2000). Only parental smoking and family conflicts, however, were significant predictors of transition from occasional to regular use of cigarettes (Moolchan et al., 2000). Correlations between individual and peer drug use may primarily be due to adolescent drug users’ selecting drug-using friends (Bauman and Ennett, 1994).

Gender Effects

Adolescent males use substances and develop SUD at higher rates than female adolescents (Reinherz et al., 1993). Boys typically present with comorbid externalizing disorders such as conduct disorder, while girls typically present with comorbid internalizing disorders such as depression and PTSD (Clark et al., 1995).

Genetic Influences

While there is evidence for genetic influences on adolescent substance use, the magnitude of influences is modest, and genetics probably plays a role only when environments allow for their expression (Hooper, Crowley, and Hewitt, 2003). Genetic risk may predispose to sensitivity to the effects of an adverse rearing environment (Hooper et al., 2003). By age 16, adolescent boys of substance-abusing fathers can be differentiated from boys with normal parents: the sons of alcoholic fathers have stronger motivation and greater substance involvement (Kirisci and Tarter, 2001). In one study, SUD in the father independently predicted daily smoking in the child at age 16 (Reynolds and Kirisci, 2001).

Cognitive Function

Problems of executive cognitive function (ECF) have been associated with risk for SUD. Giancola et al. (1996) found that high-risk children had problems with planning, attention, abstract reasoning, foresight, judgment, self-monitoring, and motor control. ECF deficits may reflect dysfunction or dysmaturity of the prefrontal cortex (Aytaclar et al., 1999). Tarter (2002) has pointed out that deficient decision-making capacity predisposes to poor behavioral choices resulting in risky behaviors. Risky behavior is predicted by such cognitive deficits as incapacity to identify options, appreciate consequences, estimate probable consequences, and synthesize the information available (Beyth-Marom and Fischoff, 1997). Impulsivity and suboptimal decision making, as well as motivation to learn about adult experiences, increases vulnerability to SUD (Chambers et al., 2003).

Affective and Behavioral Dysregulation

Youth at high risk for SUD are noted for affective and behavioral dysregulation. Affective dysregulation manifests as susceptibility to emotional arousal, irritability, negative affect, difficult temperament, and anxiety symptoms (Pandina et al., 1992; Clark and Sayette, 1993; Tarter et al., 1995; Blackson, Tarter, and Mezzich, 1996; Colder and Chassin, 1997; Mezzich et al., 2001). Behavioral dysregulation manifests as impulsivity, aggressivity, and sensation seeking (Kirillova et al., 2001; Moss et al., 1992; Martin et al., 1994; Wills, Windle, and Cleary, 1998; Mezzich et al., 2001). The score achieved on a dysregulation inventory at age 10–12 predicted substance use severity at age 12–14 (Mezzich et al., 2001).

BRAIN DEVELOPMENT

Adolescence is a period of heightened biological vulnerability to the addictive properties of substances (Chambers et al., 2003). Plasticity of the brain, particularly the prefrontal cortex, continues during adolescence through an integrated process of overproduction and elimination of synapses, evolution of neurotransmitter systems, and progressive myelination (Laviola et al., 1999). Impulsivity and novelty seeking increase in adolescence and decrease with age (Arnett, 1992; Spear, 2000). Primary motivation circuitry involves the prefrontal cortex and ventral striatum; the hippocampus and amygdala provide relevant contextual memory and affective information (Panksepp, 1998; Bechara, 2001). The prefrontal cortex is involved in the representation, execution, and inhibition of motivational drives by influencing patterns of neural ensemble firing in the nucleus accumbens, so that downstream motor centers can act on specific motivational information (Chambers et al., 2003).

Sensory, affective, and contextual memory information, leading to the generation of representations of motivated drives in the prefrontal cortex, is subsequently gated by dopamine release in the striatum (Finch, 1996; O'Donnell et al., 1999). Addictive drugs and other reward-related stimuli increase dopamine in the nucleus accumbens (Panksepp, 1998). Novelty seeking has been associated with 5-HT deficit (Zuckerman, 1996). Maturational differences in promotivational dopamine systems and inhibitory 5-HT systems may contribute to adolescent novelty seeking and impulsivity (Chambers et al., 2003). Greater motivational drives for novel experiences, coupled with an immature inhibitor...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• CONTENTS
• Editor's Introduction
• PART 1. SPECIAL SECTION ON ADOLESCENT SUBSTANCE USE AND ADDICTION
• PART II. DEVELOPMENT, PSYCHOPATHOLOGY, AND PSYCHOTHERAPY
• Author Index
• Subject Index