Transcript Slide 1

The true measure of a nation’s standing is
how well it attends to its children – their
health and safety, their material security,
their education and socialization, and
their sense of being loved, valued, and
included in the families and societies into
which they are born.
Unicef (2007) Child Well-Being in Rich
Countries. Innocenti Research Centre
http://www.unicef.ca/portal/Secure/Communi
ty/502/WCM/PRESS/IRC7/RC7.pdf
dexamphetamine
cathinone
Trends in youth deaths
900
800
700
600
500
males
females
400
300
200
100
0
1961
1971
1981
1991
2001
870 adolescents, 510 from SUD treatment and 360 community, followed up for 8 years
Clark et al 2008.
themes
► chemistry
► mortality
► Aetiology
► Neurobiology
► Terminology
► Intervention
Genetic and environmental factors
► Family
studies (Marmorstein et al 2008) increased
risk CD in offspring of parents with substance
dependence
► More antisocial behaviour and substance use in
biological children compared to adopted children
of smokers (genetic pathway) ‘disinhibited
behavior, including substance use, disruptive
behavior disorders, delinquency, antisocial
attitudes, aggressive orientation, and preference
for risk taking.’
► Keyes
et al 2008
‘factor’ refers to disinhibition – scores for impulsive, delinquent,
aggressive personality, antisocial attitudes and substance use.
genetics
► Adopted
away studies (Cadoret et al 1995)
► ‘behavioral disinhibition’ (Iacono et al 1999)
► Colorado longitudinal twin study (Button et al
2007) ‘The common genetic influence on all three
phenotypes lends further support to the
hypothesis of a single latent variable, such as
behavioral disinhibition, with a strong genetic
component, underlying a wide range of problem
behaviors in adolescence’
Risks for substance abuse
► ADHD/
‘risk-taking’, conduct problems,
school difficulties, affective symptoms
► individual/neurodevelopmental
► Not two biological parents, discord, lack
of confiding, abuse, local authority care
► Family, (attachment / trauma)
► geography, ‘hanging out’, substance
using peers, disorganised
neighbourhoods
► ‘deviant peers’
Drug use
50
40
30
no CP
20
CP
10
0
no peer use
peer use
Outcome ADHD
►
males






58% reading problems
40% persistent ADHD symptoms [only 4% ADHD]
24% alcohol use disorder
32% any substance use disorder
25% ASPD
12% Autism Spectrum
► Rasmussen
Gillberg (2000) Natural outcome of ADHD with
DCD at age 22 years: JAACAP 39:1424-1431.
► Barkley et al (2006) Young adult outcome of hyperactive
children: adaptive functioning in major life activities JAACAP
45:192-202.
► Mannuzza et al (2003) Persistence of ADHD into adulthood:
what have we learned from the prospective follow-up studies?
J Att Dis. 7(2):93-100.
Effect of culture
► “in
circumstances marked by high levels of
social control, a large percentage of the
sample – irrespective of their genetic
diversity – exhibits the same phenotype; in
settings marked by low social control,
people’s choices and behaviors are more apt
to reflect their genotype.”
►Shanahan
& Hofer cited in Button T. et al (2009)
In summary
►
►
►
►
►
increased risk of conduct disorder, ADHD, major
depressive and anxiety disorders in the children of parents
with alcohol problems compared to the children of parents
without alcohol problems
‘a common diathesis’: this increases risk for
‘psychopathologies that interfere with social functioning’
but also for substance misuse and a range of risky
behaviours including alcohol use disorders [46].
abnormalities in the myelinisation associated with
maturation of frontal cortical networks
a potential ‘parsimonious…organising concept’, perhaps
best characterised as ‘psychological dysregulation’ or
‘neurobehavioural disinhibition’.
► Clark
et al (2002, 2008) cited in Newbury-Birch et al (2009)
outcome
►
Females




75% depression/anxiety disorder
75% conduct disorder
50% substance dependence
5% eating disorder
►
Beiderman et al 2006 Psychopathology in females with
ADHD: a controlled five year prospective study Biological
Psychiatry 60:1098-1105
 30% Borderline PD
►
►
Anckarsater, Gillberg C. et al. The impact of ADHD and
autism spectrum disorders on temperament, character, and
personality development. AJP 163(7):1239-44, 2006
More stds and teenage pregnancy
►
Barkley et al 2006
Family s.e.c.
Unresponsive
mother/
parental
conflict
Child abuse
Parental
substance
misuse
(smoking)
Conduct
disorder
symptoms 10
year
Weak/ strong final predictors
deviant peer associations
age 15
•“…adolescent peer affiliations reflect
the endpoint of a complex social
process in which the individual's peer
choices are likely to be shaped by his
or her social environment, family and
parental factors, and preexisting
temperamental or behavioural
characteristics…”
Fergusson DM & Horwood L. (1999) Prospective
childhood predictors of deviant peer affiliations in
adolescence. JCPP 44:581-92
Terminological debates
► addiction,
which refers to the loss of control over
the intense urges to take the drug even at the
expense of adverse consequences
► The term “dependence” has traditionally been
used to describe “physical dependence,” which
refers to the adaptations that result in withdrawal
symptoms when drugs, such as alcohol and
heroin, are discontinued. Physical dependence is
also observed with certain psychoactive
medications, such as antidepressants and betablockers.
► OBrien
et al 2008 Am. J. Psychiat
Altered white
matter in
adolescent binge
drinkers.
McQueeny et al
2009
Principles:
Person-centred care
► People
who misuse drugs should be given
the same care, respect and privacy as any
other person.
► Ensure that there are clear plans to
facilitate effective transfer of people who
misuse drugs between services, to reduce
loss of contact
► Use biological testing as part of a
comprehensive assessment of drug use
Time to First Heavy Drinking Day by Naltrexone and Combined Behavioral Intervention (CBI)
Interaction
Anton, R. F. et al. JAMA 2006;295:2003-2017.
Copyright restrictions may apply.
A new class of untouchables
► ‘A
new class of untouchables is emerging in our
inner cities, on the social fringes of suburbia, and
in some rural areas; young people who are
functionally illiterate, disconnected from school,
depressed, prone to drug abuse and early criminal
activity, and eventually, parents of unplanned or
unwanted babies. These are the children at high
risk of never becoming responsible adults.’
 Dryfoos J.G. (1990) Adolescents at risk: prevalence and
prevention. Oxford University Press: New York. Quoted in Liddle
HA., Dakof G., Parker K., Diamond G., Barrett K., Tejeda M. (2001)
Multidimensional family therapy for adolescent drug abuse: results
of a randomized clinical trial. The American Journal of Drug and
Alcohol Abuse 27:651-688.
Long term effect intervention
► 14-year
follow-up MST v individual therapy for
adolescent offenders
► All arrests 81 v 50%, Drug arrests 33 v 13%
► ‘improved family support and decreased deviant
peer involvement may have
allowed…(participants) to succeed in …
developmental tasks (e.g. normal romantic
relationships)…’
► Schaeffer
et al (2005) Long-term follow-up of a RCT of MST
with serious and violent juvenile offenders. J. Consulting and
Clinical Psychology 73(3):445-453
10
9
8
7
6
FC
DC
MST
MST/CM
5
4
3
2
1
0
pre-
post-
12 mo f-up
10
9
8
7
6
FC
DC
MST
Littell J (2005) Cochrane Review - No evidenceMST/CM
that
5
4
3
MST superior to usual services
2
1
Sundell et al (2008) J. Fam. Psychology – no
differences from usual services
0
pre-
post-
12 mo f-up
Medical intervention
► The
percentage of patients receiving CBI
only who had a good global clinical outcome
(60.6%) was intermediate between those
receiving placebo and medical management
(58.2%) and those receiving placebo
medical management and CBI (71.3%).
Overall, the differences among these 3
groups were not significant (P = .07).
Figure 2. Effect Size Estimates and Hazard Ratios for Primary Outcomes Effect size estimates
for percent days abstinent are reported as Cohen d values.
Anton, R. F. et al. JAMA 2006;295:2003-2017
Copyright restrictions may apply.
Medical intervention
►N
= 1400 ‘alcoholics’
► All improved, best outcomes:
 medical management plus naltrexone
 Medical management plus CBI
► at
end treatment: MM with placebo = CBI
► At 12 mo.: CBI>MMP=MM naltrexone
► Anton
RF. Et al Combined pharmacotherapies and
behavioral interventions for alcohol dependence:
the COMBINE study: a randomized controlled
trial. JAMA. 295(17):2003-17, 2006
NICE PHG – targeted prevention
►
“In young people with aggressive and behavioural
disorders one two year multicomponent family based
programme, Coping Power (targeted at 9-11 year olds),
was effective in reducing use of alcohol, tobacco, and
cannabis and this was associated with a reduction in
problem behaviours. In contrast, a single component
approach, LST, had no effect on substance use
behaviours.”
►A
review of community-based interventions to reduce substance
misuse among vulnerable and disadvantaged young people
► Lochman & Wells (2004) the Coping Power Program for preadolescent
boys and their parents: 1 year follow-up. J Cons Clin Psychol 72:571578
Other interventions
► ‘aftercare’
by phone reduced relapse
compared to no aftercare
►Kaminer
2008
Outcomes according to NTA
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“The proportion of young people who complete an
intervention according to the goals set out in their care
plans is 57%...
interventions tend to be more successful when they involve
the young person’s parents and siblings, grandparents or
foster carers…
In reaching out to more young people with drug and
alcohol misuse problems, specialist services have
established much closer links with other children’s services
NTA Young Peoples report 2009
In summary
Psychoactive drugs have a degree of shared chemical
structure
► All work through the same subcortical reward mechanisms
► Disproportionately impact vulnerable children, all of whom
have mental disorders
► Vulnerability is substantially genetically determined
► Affected children and young people require a full
assessment and multimodal treatment
► Treatment is partially effective and needs to be longer
term.
►
Parental illicit drug use
* 0
Childhood sexual abuse
* 0
Female gender
* 0
Novelty seeking/conduct * *
problems
Cannabis use 16-25
*
Affiliation 16-25
*
Alcohol use 16-25
*
cigarettes
*
1 year lagged measure
illicit drug use
*
Age x cannabis use
*
Child
predictors
Adolescent/
young adult
predictors
Fergusson et al (2008) The
developmental antecedents
of illicit drug use. Drug Alc
Dep 96:165-77
Parental illicit drug use
* 0
Childhood sexual abuse
* 0
Female gender
* 0
Novelty seeking/conduct * *
problems
Cannabis use 16-25
*
Affiliation 16-25
*
Alcohol use 16-25
*
cigarettes
*
1 year lagged measure
illicit drug use
*
Age x cannabis use
*
Child
predictors
Adolescent/
young adult
predictors
Fergusson et al (2008) The
developmental antecedents of
illicit drug use. Drug Alc Dep
96:165-77
“…cannabis use
mediated the
effects of
childhood factors
on later illicit drug
abuse…”
m/f motivations for drug use
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Relax
intoxicated
Keep going
Enhance activity
Keep going
Enjoy company
Decrease boredom
Increase confidence
Stay awake
Feel elated/euphoric
Sleep
After effects
Lose inhibitions
Enhance sex
Improve effects
Work
Lose weight
Boys et al 2001