Presenter : Dr.

Cebasta
 Background and implication of substance
abuse in children and adolescents.
 Definition
 Epidemiology
 Etiology
 Neurobiology of Adolescent substance use and
addictive behaviors
 Assessment of Adolescent substance use and
problems
 Diagnosis and clinical features
 Implications for prevention and treatment.
 At the beginning 21st century - increasing
substance use and abuse by young people.
 Reluctance - ‘ junkie’ or ‘addict’ to describe
adults with substance abuse problems .
 Peiper et al, found globally, 4th, 5th and 15th
leading contributors to disease burden –
smoking, alcoholism and illegal drug use,
respectively.
 NSDUH, MTF Study, YRBS all show that SU, as
well as accepting attitudes and beliefs toward
use, increases throughout middle and high school.
SUBSTANCE USE DISORDER
1) Substance abuse
2) Substance dependence
SUBSTANCE ABUSE: DSM IV TR
maladaptive pattern of use in a period of 12
months/ one among the following
- Inability to fulfill major obligations
- Use in hazardous situations
- Legal problems
- Continuous use despite social or inter- personal
problems
SUBSTANCE DEPENDANCE : DSM IV TR
substantial degree of involvement with
substance > or = 3 criteria in a 12 month
period
- Tolerance
- Withdrawal symptoms
- Larger amount/ longer period
- Unsuccessful effort to cut down
- Great deal of time spent
- Progressive neglect of social/ recreational
activities
- Continuous use despite clear evidence of
overtly harmful consequences
 AAP (1996) – ‘development of a reversible substance-
specific syndrome due to ingestion of a substance
resulting in a clinically significant maladaptive behavioral
& psychological changes’.
 WHO(1992,1996) ICD 10 defined ‘Dependence’ – cluster of
behavioral, cognitive, physiological phenomena that
develop after repeated substance use, that typically include
- strong desire to take drugs
- difficulties in controlling its use
- persisting use despite harmful consequences
- higher priority to drug use than other activities,
obligations
- increased tolerance
- physical withdrawal state……chronic alcoholism….. Drug
addiction.
 DSM IV TR (1994) – distinguishes between
substance use disorders and substance -induced
disorders ( e.g. intoxication, withdrawal or
delirium).
 Changes from DSM- IV to the DSM- 5 include

i) dependence and abuse diagnoses being

combined into single disorder that is graded in
terms of severity;
ii) elimination of the criterion of SU causing legal
problems;
iii) addition of a craving criterion.
 Large national surveillance surveys have documented
trends in adolescents-
i) electronic cigarette and hookah use – common forms
of nicotine and tobacco use among adolescents.
ii) From 1991 to 2015- prevalence of lifetime, 12
month, 30 day use of marijuana all increased among
adolescents.
iii) B/w 2002 and 2014- both gender similar 12 month
prevalence rates of substance use disorders.
 Approximate Doubling of 30- day alcohol, cigarette,
marijuana use prevalence occurs b/w grade 8 and
10.
 Lifetime prevalence of alcohol abuse or
dependence and drug abuse or dependence
was estimated respectively

1980s - ECA found 13.8% and 6.2%

1990s- NCS found 23.5% and 11.9%
Early 1990s – NLAES found 13.3% and 6.2%
Early 2000s- NESARC found 30.3% and 10.3%
  The most recent MTF study was conducted in 2010
 Key findings of MTF study include:
1. Increase in the overall rate of illicit drug use for all grades
2. Older students in the study showed increase in the use of
marijuana and alcohol
3. 19.6% of students have tried an illicit drug by eighth grade
4. 34.1% by 10th grade
5. 47.4% by 12th grade
6. Marijuana remains by far the most commonly used illicit drug
 One type of illicit drug use – over the past 15 years
is NMPD use.
 Compared with other substances peaked - late
1990s
 NMPD use of amphetamines, Opioids,
tranquilizers - peaked around 2000s.
 In terms of sex, males shown higher rates of
illicit drug use than females with exception higher
NMPD use among female adolescents.
  Extent and pattern of substance abuse among children and adolescent
in India is different from the West
 Substance abuse among girls is uncommon
 Common drugs abused in Indian adolescents are:
1. Alcohol
2. Tobacco
3. Minor tranquillizer
4. Analgesics
5. Cannabis
  A general population survey reported substance use in 0.2-
0.3% of children less than 15 years of age
 Only a few cases of opioid dependence were reported
 A higher prevalence of substance abuse was reported among
school students:
1. Alcohol (4-13%) most common
2. Tobacco (3-6%)
3. Minor tranquillizers (1-4%)
 Initiation to heroin use was before the age of 16 years in 8%
of heroin abusers in the north-eastern part of the country
 A similar age of initiation of heroin abuse has been reported
from other parts of India as well
 A country profile documented by the Ministry of Welfare,
Government of India reported mean age of initiation to
heroin as 14 years
 A high prevalence of tobacco, alcohol and opioid use has been
reported amongst street children
 Inhalants, sedatives, cough syrups and smokeless tobacco is
also common
 Most street children are multiple drug users
 Alcohol use (75%) is most common followed by charas (50%)
and heroin (5-10%)
 Drug use in 91% of street children was reported.
  The Global Youth Tobacco Survey in 2006 showed that in India
1. 3.8% of students smoke
2. 11.9% used smokeless tobacco
 A study of 300 street child laborers in slums of Surat in 1993
showed that 135 (45%) used substances
 Role of nucleus accumbens : stimulate accumbal
dopamine release through pharmacological, as well as
psychological, mechanisms
 Stanwood and colleagues found – D1 and D2 receptor
density increased in nucleus accumbens, striatum,
prefrontal cortex until the age of 40 days, f/b progressive
decline.
 During adolescence, area of the limbic system a/w
primary urges and cravings are functioning at peak
performance.
 Area of control and context to those primary
motivations remain immature.
 Glutamatergic projections from PFC to sub cortical
structures including amygdala, nucleus accumbens –
underdeveloped in adolescence
 Social cues activate limbic circuitry more
strongly in adolescents than adults.
 Presence of peers- increase risk-taking
behavior in adolescents.
 Hormonal changes- THP in adolescents inhibits
high level of GABA( a) receptor, prolongs stress
responses.
 De Bellis and colleagues- adolescents onset
alcohol use disorder, hippocampal volume –
significantly smaller compared with control
subjects.
 Substance abuse disorders – highly familial, 40%
to 60%.
 Neurodevelopmental models postulates that :
 In adolescent substance abusers there is
developmental imbalance between:
 Top down cognitive control systems
 Bottom up incentive-reward systems
  Components of a “top-down” executive system are
1. Pre-frontal cortex (PFC)
2. Anterior cingulate cortex (ACC)
 Cognitive control is the ability to resist temptation in
favor of long-term goal-oriented behavior
 Cognitive control is regulated by top down system
 Top down system improves in a linear fashion from
childhood through adulthood
  A “bottom-up” subcortical system includes:
1. Striatum
2. Midbrain dopaminergic system
 Important in reinforcement learning
 Matures at an earlier stage of development than a
“top-down” system
During adolescence there is imbalance between:
 Immature “top-down” cognitive control processes
and
 Mature and hyperactive “bottom-up” incentive-reward processes
 This allow bottom up system (incentive-reward) system to
supersede cognitive control
 This leads to increased susceptibility to the (incentive-reward)
properties of psychoactive substances
It involves the interface of 3 neurobiologic systems:
1. Control /regulatory system involving the medial and ventral PFCs
2. Reward system involving the ventral striatum and midbrain dopaminergic system
3. Threat/harm-avoidance system involving the amygdala
Increased engagement in substance use during adolescence takes place due to:
1. An inefficient control/regulatory system
2. A strong reward system
3. A weak harm-avoidance system
Stones and colleagues document the predictors of
young adult substance use
 Community domain:
i) Laws and norms favorable to substance use
ii) Availability of substances( e.g., more liquor or
marijuana stores)
iii) Media portrayals of substance use
iv) Extreme economic deprivation
 School domain:
i) Academic failure, as early as mid-elementary
school
ii)Low commitment to school or low expectations
for achievement or finding school is unrewarding
  Adoption study literature gives shows that substance
dependence in adoptees is:
1. Significantly correlated with alcoholism in biological
fathers
2. Uncorrelated or only weakly correlated with alcoholism
in adoptive parents
3. A positive family history of substance use disorder is a
strong predictor for substance use and dependence
  Genetic influences on the development of
adolescent substance abuse may act through:
1. A direct effect on psychophysiological reactions to
substances or their metabolism
2. Indirectly through genetic effects on personality
traits such as behavioral disinhibition which leads to
substance experimentation
 Prenatal exposure to alcohol, cannabis, cocaine is associated
with:

 Cognitive and behavioral self-regulation difficulties in children

(Knopik, Sparrow, Madden et al., 2005)

 Increased risk of adolescent substance use and abuse

(Biederman, Monuteaux, Mick et al., 2006)
  Childhood neglect, physical abuse (PA), sexual abuse (CSA) are
predictive of:
1. Early onset tobacco, alcohol, marijuana and other illicit drug
use
2. Alcohol or other drug problems during adolescence
3. Women are more susceptible
(Widom, Ireland, & Glynn, 1995)
 Family domain:
i)Parents approving attitudes toward drug /
alcohol use
ii)Coming from a substance-abusing parent
iii)Families with high levels of conflicts
iv)Family management problems like poor
supervision and monitoring, lack of clear
behavioral expectations, inconsistent/ harsh
punishment.
 Individual and peer domain:

i)Sensation seekers/ risk takers

ii)Higher levels of childhood aggressive
behavior, antisocial behavior in early
adolescence.
iii)Peers who use substances
  Stage theory proposes that:
1. There is a temporal ordering of substance experimentation
2. Lower order substances which are more commonly used precede
the use of higher order substances
 A licit/legal substance such as alcohol or cigarettes is used first
 It is followed by marijuana which is usually the first illicit substance
 This stage is followed by use of other illicit substances like opioids,
cocaine, stimulants etc.
This theory proposes that:
 Use of marijuana facilitates the entry into other illicit substance use
 This effect can be explained by:
1. Heavy cannabis users have preexisting traits that predispose them
to the use of a variety of different substances
2. Marijuana use is a marker for a tendency to use multiple drugs
3. Marijuana use results in socialization into an illicit drug subculture
which creates favorable attitudes toward the use of other illicit
drugs
 Community and school domain:
Opportunities for pro social involvement such as
i)After-school clubs
ii) Youth organizations
iii) Community events
 Family level- game nights and opportunities to help
with chores
 Resnick and colleagues- found adolescents with
higher sense of attachment/ connection with
families displayed lower rates of substance use.
 Beyers and colleagues- found higher religiosity,
social skills, clear standards were protective
factors.
Neuro cognitive deficits are found in adolescents across the
domains of:
1. Attention
2. Visuo spatial processing
3. Speeded information processing
4. Memory
5. Executive functioning
  During assessment adolescent's confidentiality should be
honored unless:
1. Specific permission and release is obtained or
2. Patient is clinically judged to be a danger to self or others
 Adolescents are usually willing to self-disclose if the rules of
confidentiality are clearly established
 Exceptions to confidentiality should be specified at the
beginning of treatment
 Better tool for identifying substance use –
careful history taking and examination of the
child/ adolescent( Weinberg et al.1998)
 Should use a closed-end semi structured
interview- obtain from guardian
 Presenting complaints
 Developmental history
 Behavior in utero (fetal hyperactivity)
 Neonatal period and infancy( colic,irritable, little
need for sleep,incessant crying, good-natured)
 Toddler years(‘supermarket toddler’)
 2-5 years of age( hyperactive, moody, irritable,
sad, clingy, unable to separate)
 Each school year from kindergarten to present
grade( adaptation, performance, behavior and
concerns)
 Detailed three-generation family history
 Family dynamics
  History of clinical concern is:
1. Extent or severity of substance involvement
2. Specific substances that the patient is abusing or dependent
on
3. Length of time that the pattern has persisted
 For each substance clinicians should inquire about:
1. Age of onset of first use or experimentation
2. Age of progression to regular use
3. Peak use
4. Current use
5. Last use
  Other important information includes:
1. Triggers for craving and use
2. Context of use (e.g with particular peers, or at or before
school)
3. Perceived motivation for using
4. Positive and negative consequences of use
5. Current motivation
6. Goals for treatment
1. Adolescent Drinking Index (ADI)
2. Drug Use Screening Inventory –Revised (DUSI-R)
3. Problem Oriented Screening Instrument for
Teenagers (POSIT)
4. Rutgers Alcohol Problem Index (RAPI)
5.Substance Abuse Subtle Screening Inventory
Adolescent Version(SASSI-A)
6. Teen Addiction Severity Index (T-ASI)
7. CRAAFT- brief screening tool for adolescent
substance abuse.
8. Alcohol use disorders identification test(
AUDIT)
  The efficacy of pharmacotherapies for adolescent drug use
disorders has not been established

 No clear evidence exits for:

1. Specific components of therapy that are critical for

successful outcome

2. Therapy particularly efficacious with particular type of

substance abuse
  Randomized clinical trials focused on adolescent substance
abusers are:
1. Rare
2. Typically single site
3. Cannot be generalized to patient populations across diverse
clinical settings
4. Underpowered
  Adolescents with substance abuse:
1. Do not self-refer for treatment
2. Often pressured into treatment by family, school, or court
3. Are defiant
4. Minimize their drug use
 Ethical challenges of clinical research with minors include:
1. Requirement to obtain parental consent for participation
2. Potential for confidentiality breach in obtaining parental consent
  Treatment for adolescent with substance involves recognizing
that these are chronic relapsing conditions
 Patients may need multiple episodes of treatment over time
 Treatment typically involves:
1. Initial attempts to create abstinence or markedly reduce
drug use
2. Addressing the biopsychosocial aspects of substance use
3. Maintenance or relapse prevention•phase
TOBACCO

 Assess the severity of smoking dependance-

Nicotine checklist/ modified Fagerstrom test for
Nicotine dependence.
 Stanton and Grimshaw’s 2013 Cochrane Review
“ Tobacco cessation interventions for young people”
- used complex interventions from multiple health
behavior theories.
 Common modalities – motivational enchancement,
CBT, stage based interventions using
transtheoretical model.
 US Public Health Service 2008 Guideline and AAP
2015 Clinical Practice Policy - 5A model of care
 An early open-label trial using nicotine patch with adolescent smokers
desiring to quit reported no benefit (5% abstinence rate at 6 months)
(Hurt, Croghan, Beede et al., 2000)
 Single underpowered clinical trial failed to find a significant improvement
in abstinence rates at 6 months using the nicotine patch
(Grimshaw & Stanton, 2006)
 Efficacy for pharmacological treatment of adolescent smokers remains to
be established
 Relatively little research has been conducted on the
effectiveness of treatment of opioid abuse in children and
adolescents
 Findings from the limited adolescent-focused research
suggest that methadone is likely to be effective in reducing
long-term use of heroin and other illicit opioids in those
adolescents who have developed severe dependence

(Kellogg, Melia, Khuri et

al., 2006)
 There is little research evaluating pharmacological
treatments for adolescent substance abuse
 Available evidence is based almost entirely on
adult, rather than adolescent samples
 Evaluations of the efficacy of pharmacotherapies
have produced equivocal results regarding their
efficacy in adolescents

(DeLima, Soares, Reisser et

al.,2002)
Motivational Interviewing:
1. Motivational interviewing techniques have been
demonstrated to promote:
 Treatment engagement
 Strong treatment alliance
 Patient generated treatment goals
2. Motivational interviewing principles can be effectively used
in conjunction with another empirically supported treatment
modalities such as individual and/or family-based treatment
  Cognitive-behavioral therapy (CBT) is effective in treating adolescent substance
use disorders
 In CBT following characteristics need to be identified:
1. Reinforcers of substance use
2. Skills deficits
3. Specific cognitive distortions associated with substance use
 CBT should be provided to:
1. Enhance coping strategies to deal effectively with drug cravings and negative
affects
2. Strengthen problem solving and communication skills
3. Identify and avoid high-risk situations
  An important feature of CBT is its emphasis on developing new behaviors
that are:
 Enjoyable
 Incompatible with drug use
Riggs et al. (2005) demonstrated that
 When treatment was free or incentivized, many adolescents voluntarily
entered treatment when referred by counselors, teachers, friends, or
family
 Thus, individual CBT is a viable therapeutic option for youth with SUDs
 This approach encourages healthy changes in behavior
by rewarding adolescents for objective evidence of
abstinence such as negative urinalyses
 It regards substance use as operant behaviors that are
reinforced by the effects of the drugs involved
 Following the operant conditioning model, the
adolescent’s drug use will subside when tangible
incentives are offered for abstinence
 These programs incorporate a self-help approach
centered within the context of reciprocal support
 They are organized around the basic tenets of Alcoholics
Anonymous (AA)
 In this approach individuals support each other’s
sobriety through encouragement of mental and spiritual
health via a lifelong spiritual journey through 12 steps
Multisystemic therapies:
 Treat adolescents within the context of their environment
 Try to modify multiple environmental factors contributing to SUDs
 Multisystemic therapy is an approach that addresses
1. Social and family influences of drug use
2. Associated antisocial behaviors
 Therapists make frequent home visits and are available on a full time basis to
families
 Henngeler et al. (1996) demonstrated that over 98% of youth receiving MST
remained in treatment, compared to very few youth in a control group
 ALCOHOL
 Pharmacologic agents for medication-assisted
addiction treatment:
i) Naltrexone (approved by US FDA)- reduce
relapse of alcohol use.
ii) Receptor specific agents like nalmefene,
acamprostate, baclofen, quetiapine, ondansetron,
topiramate - in combination with topiramate
reduce craving among adults.
 Aversive therapy- among adolescents, disulfiram,
despite its positive impact- limited in practice due
to poor motivation to abstain and avoidance to
experience discomfort.
 Most recent findings from large US multisite trials
with adults suggest that behavioral interventions
should remain the treatment of choice for
  The primary differential diagnosis is establishing whether :
1. Substance abuse or Substance dependence exists for each
substance
2. Extent of relevant comorbid psychiatric and medical
conditions
  Past 6 month prevalence for comorbid psychiatric disorders
with an adolescent substance use disorder is:
1. 76% for any comorbid disorder
2. 68% for any disruptive behavior disorder
3. 32% for any mood disorder
4. 20% for any anxiety disorder
 Comorbidity is the rule rather than the exception among
adolescents with substance use disorders
(Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA)
  The efficacy of pharmacotherapies for adolescent drug use
disorders has not been established

 No clear evidence exits for:

1. Specific components of therapy that are critical for

successful outcome

2. Therapy particularly efficacious with particular type of

substance abuse
 Social learning theorists propose that
substance use -learning from the social
environment.
 Most prevention interventions are based on
social learning models.
 Social learning interventions
educational approaches,
family-based interventions,
community-based projects.
 Project Towards No Drug Abuse (TND) is designed to help high risk
students (14 to 19 years old) resist substance use and abuse
 It is based on an underlying framework that young people at risk for
substance abuse will not use substances if they:
 Are aware of misconceptions and myths about drug use
 Have adequate coping skills and self-control
 Know about negative consequences of substance use
 Are aware of cessation strategies for all forms of substance use
 Have good decision-making skills
( BASICS) is a program for college students who drink alcohol
heavily and are at risk for alcohol-related problems like:
 Poor class attendance
 Missed assignments
 Accidents
 Sexual assault
 Violent behavior
 It is not designed for students who are alcohol dependent
 The goal of BASICS is to motivate students to reduce their
alcohol use in order to decrease the negative consequences
of drinking
  Family based substance abuse prevention programs for
adolescents are:
1. Family Matters
2. Creating Lasting Family Connections
3. Brief Strategic Family Therapy
  Community Trials Intervention to Reduce High-Risk
Drinking (RHRD) is a universal intervention
 RHRD aims to alter community-wide alcohol use
patterns such as:
1. Drinking and driving
2. Underage drinking
3. Binge drinking and related problems
  The RHRD program uses five prevention components:
1) Reducing alcohol access by helping communities use zoning and
municipal regulations to control the density of bars, liquor stores, etc.
2) Responsible beverage service by training alcohol beverage servers and
assisting retailers develop policies and procedures to reduce drunkenness
3) Reduce drinking and driving through increased law enforcement
4) Reduce underage alcohol access by training alcohol retailers to avoid
selling to minors and increased enforcement of laws regarding alcohol
sales to minors
5) Provide communities with tools to form the coalitions needed to
implement and support the interventions
 Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V.
M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008
Blackwell Publishing Limited. ISBN: 978-1-405-14549-7
 Neurobiology of Adolescent Substance Use and Addictive Behaviors:
Prevention and Treatment Implications:Christopher J. Hammond, MD1,2,
Linda C. Mayes, MD1, and Marc N. Potenza, MD, PhD; Adolesc Med State Art
Rev. 2014 April ; 25(1): 15–32.
 Evidence-Based Interventions for Preventing Substance Use Disorders in
Adolescents; Kenneth W. Griffin, Gilbert J. Botvin, Ph.D; Child Adolesc
Psychiatr Clin N Am. 2010 July ; 19(3): 505–526.
doi:10.1016/j.chc.2010.03.005