Child/Youth & COD

2014 4th ANNUAL DC SUMMITChild/Youth & Co-Occurring DisordersObjectivesReview the prevalence of co-occurring substance use and psychiatric disorders in youth.

Review the relationship between substance use and specific co-occurring mental health disorders.

Understand effective treatment approaches and challenges for youth with co-occurring disorders.IntroductionPsychiatric disorders 3/4 by age 24Most adults with SUD started using as adolescents60-85% adolescents with SUD have co-occurring psychiatric disorder(s).

Co-Occurrence of MH & SUDSubstance abuse treatment helps to reduce the frequency of use and the number of abuse/dependence symptoms but has only indirect impact on emotional and behavioral problems (M. Dennis, 2004)

Psychiatric treatment alone for youth with mood disorders and co-occurring SUD does not significantly reduce substance use (Geller et al., 1998)

2012 National Survey on Drug Use and Health (NSDUH) on the co-occurrence of mental illness and mental health problems with substance use and substance use disorders (illicit drug or alcohol dependence or abuse) in the United States. 4Risk Factors:Familial Influence on Substance UseFamilial influencebiological and behavioralA common genetic influence accounts for comorbid substance use during adolescence, specifically problem use of tobacco, alcohol, and cannabis. Approximately 50% of the risk of substance abuse or dependence in adolescence is genetically influenced.

Exposure to parental substance use increases childrens riskSee more at: http://www.psychiatrictimes.com/child-adolescent-psychiatry/familial-influences-adolescent-substance-use#sthash.TC6SK6DD.dpufFamilial Influences on Adolescent Substance Use October 07, 2011 | Child Adolescent Psychiatry, ADHD, Substance Use Disorder, Addiction, Alcohol AbuseBy Amy Yule, MD and Timothy Wilens, MD - See more at: http://www.psychiatrictimes.com/child-adolescent-psychiatry/familial-influences-adolescent-substance-use#sthash.TC6SK6DD.dpuf

Familial Influences on Adolescent Substance Use October 07, 2011 | Child Adolescent Psychiatry, ADHD, Substance Use Disorder, Addiction, Alcohol AbuseBy Amy Yule, MD and Timothy Wilens, MD - See more at: http://www.psychiatrictimes.com/child-adolescent-psychiatry/familial-influences-adolescent-substance-use#sthash.TC6SK6DD.dpuf5A Day in the Life of American Adolescents: Substance Use Facts

This report presents facts about adolescent substance use, their substance use related emergency department visits, and whether they receive substance use treatment. 6Table 1. Illicit drug use in the past month among individuals aged 12 or older: 2013SubstanceAged 12 or olderAged 12 to 17Aged 18 or olderNumber (in thousands)PercentNumber (in thousands)

Percent

Number (in thousands)

Percent

Illicit drug use

24,573

9.42,1978.82,23769.4Marijuana and hashish19,8107.51,7627.118,0487.6Cocaine1,5490.6430.21,5050.6Inhalants4960.21210.53750.2Hallucinogens1,3330.51540.61,1790.5Heroin2890.1130.12770.1Nonmedical use of prescription-type drugs6,4842.55492.25,9352.5Pain relievers4,5211.74251.74,0961.7SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH)In 2013, an estimated 24.6 million Americans aged 12 or older were current (past month) illicit drug users. This represents 9.4 percent of the population aged 12 or older (Table 1).Marijuana was the most commonly used illicit drug, with 19.8 million current users aged 12 or older (7.5 percent). There were 6.5 million nonmedical users of prescription-type drugs (2.5 percent), including 4.5 million nonmedical users of prescription pain relievers (1.7 percent).There were 1.5 million current cocaine users aged 12 or older, or 0.6 percent of the population. An estimated 1.3 million individuals aged 12 or older in 2013 (0.5 percent) used hallucinogens in the past month. An estimated 496,000 individuals aged 12 or older were current inhalant users, which represents 0.2 percent of the population. There were about 289,000 current heroin users aged 12 or older, or 0.1 percent of the population. In 2013, there were 2.2 million adolescents aged 12 to 17 who were current illicit drug users. This represents 8.8 percent of adolescents. In 2013, 7.1 percent of adolescents were current users of marijuana, 2.2 percent were current nonmedical users of prescription-type drugs (including 1.7 percent who were current nonmedical users of pain relievers)0.6 percent were current users of hallucinogens,0.5 percent were current users of inhalants, 0.2 percent were current users of cocaine, and 0.1 percent were current users of heroin. There were 22.4 million adults aged 18 or older who currently used illicit drugs in 2013. This represents 9.4 percent of adults. In 2013,7Substance use disorder (SUD) in the past year among individuals aged 12 or older: 2013

NSDUH includes a series of questions to assess dependence on or abuse of alcohol or illicit drugs in the past year. These questions are designed to measure dependence and abuse based on criteria specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).2 Individuals with alcohol or illicit drug dependence or abuse are defined as having an SUD.

In 2013, an estimated 21.6 million individuals aged 12 or older had an SUD in the past year (8.2 percent of the population aged 12 or older) (Figure 2). An estimated 1.3 million adolescents aged 12 to 17 had an SUD in 2013 (5.2 percent of adolescents).8Mental health issues in the past year among adolescents aged 12 to 17 and adults aged 18 or older: 2013

Although NSDUH does not contain an overall indicator of mental health among adolescents aged 12 to 17, NSDUH provides estimates of having a past year major depressive episode (MDE) for this age group. MDE is defined using the diagnostic criteria from DSM-IV. Adolescents were defined as having MDE if they had a period of 2weeks or longer in the past 12months when they experienced a depressed mood or loss of interest or pleasure in daily activities, and they had at least four of seven additional symptoms, such as problems with sleep, eating, energy, concentration, and self-worth.6 Adolescents were defined as having MDE with severe impairment if their depression caused severe problems with their ability to do chores at home, do well at work or school, get along with their family, or have a social life.9Co-occurring Substance Use Disorders and Mental Health Issues among Adolescents and Adults

Individuals with both SUD and a mental health issue are defined as having a co-occurring mental health issue and SUD. This section presents estimates of past year co-occurring SUD and MDE among adolescents aged 12 to 17. It also includes estimates of past year co-occurring SUD and mental health issues among adults aged 18 or older.In 2013, 1.4percent of adolescents aged 12 to 17 (359,000 adolescents) in the United States had both SUD and MDE in the past year (Figure5).In 2013, 3.2percent of all adults aged 18 or older (7.7million adults) had both SUD and AMI. In 2013, 1.0percent of all adults aged 18 or older (2.3million adults) had co-occuring SUD and SMI.

104,333 Total Child/Youth Served (DBH) - FY13Primary Substance TypeSubstance TypeCountPercentageAlcohol105%Cocaine/Crack52%Heroin10%Marijuana/Hashish/THC12054%Other84%Other Opiates and Synthetics21%Other Stimulants31%PCP94%No Primary Listed6329%Total221100%Other Opiates and Synthetics - This is where you would code your prescription narcotics, e.g. Oxycontin, Percocet, Vicodin, etc. If the opiate used is heroin or non-prescription methadone, they would be coded under those specific categories. Other Stimulants - Any stimulant medication such as ephedrine or stimulant weight-loss medications. Other category - is there as a catch-all for anything which may emerge in the system not neatly captured by any of the other options. DC has an issue with synthetic marijuana and we are working on a single coding strategy for capturing it. This code table can only be changed by SAMHSA because it feeds up into our state TEDS data and they have not yet added a category for synthetic marijuana12Diagnoses vs. MedicationsCFSA Youth with Co-occurring DisordersPrimary Substance# YouthMarijuana21Other1No Primary Substance Listed1Total FY13 CFSA Youth Matched23PIW Stats 75-85% of children/adolescents treated at PIW have past or current substance use issuesChicken or Egg?Substance-induced Mood DisorderThere is no Cannabis-induced Depressive D/ONot in DSM-IV TRNot in DSM-5Self-medication

ADHDPrevalence approx. 3-5%but those receiving medications for ADHD is 1-20%Male:Female is 4:1Medication treatment for ADHD is one of the most studied areas in C&A psychiatryOver- vs. under-medicationOvermedication is a problem in some instances, while undermedication is still a concern.Sx for ADHD must be maladaptive and inconsistent with developmental level (esp important to recognize with pre-school, school-age)Course of ADHDRule of 1/3s:1/3 show significant improvement over time1/3 have a few symptoms into adulthood (inattention)1/3 continue to have significant problems into adulthoodUntreated:Increased risk of MVAs, drop outs, family discord, and substance use (15% comorbidity)Stimulant MedicationsAbsolute Contraindications:Cardiovascular disorders, hypertensionHyperthyroidismGlaucomaActive PsychosisCo-administration with MAO-IsRelative contraindications:Seizures (no evidence of decreasing sz thresold)Drug Abuse

Sympathomimetics can induce mydriasis (dilation).No evidence that stimulants decrease szr threshold.These are controlled substances so need to be mindful of drug use by child and family members.Major Depressive DisorderAt least 2 wks pervasive change in mood manifested by either:Depressed or irritable mood and/orLoss of interest/pleasureOther sx:Same criteria as for adult MDD but presents differentlyLack of joy Withdrawal IrritabilityBoredom Failing grades Act outAggression

Treatment OptionsMild-moderate depression: psychotherapyCognitive Behavior Therapy (CBT)Moderate-severe: pharmacotherapy + psychotherapyPharmacotherapy may not be sufficient alone due to strong psychosocial influences

CBT vs. SES21PharmacotherapySSRIs are the predominant medications used for both depressive disorders and anxiety disorders

Older antidepressants (TCAs) have not shown much benefit and have more side effectsWell discuss these together22FDA Black Box Warning24 placebo-controlled trials, >4400 patients:Placebo 2%; on antidepressants 4%Double risk of suicidal thinking/behaviorNo completed suicidesCould be linked to behavioral activation or akathisiaImpulsiveAgitatedUK banned use of all SSRIs except fluoxetine for C/A Pediatric trials 4% vs 2% placebo- increased ideations but not attempts and no actual suicides. Data suggests that decrease in Rx may be associated with increase in suicides.

23Anxiety DisordersProbably the 2nd most common group of disorders; however, do not get recognized so people often do not present for txPrevalence rates from 6-20% for one disorderChildren/youth may not recognize fear as unreasonableVery common to have somatic c/o, crying, irritability, outbursts

Prev based on several large epidemiological studies. Prev decreases with strict adherence to criteria.Avg age of onset varies, but panic disorder often emerges later in in mid-teens. Irritability/outbursts may mimic ODD behavior but they are expression of fear or effort to avoid anx-provoking stimulus.

24Anxiety DisordersObsessive Compulsive Disorder*DSM-5: Obsessive-Compulsive and Related DisordersPost Traumatic Stress Disorder*DSM-5: Trauma and Stress-Related DisordersSeparation Anxiety DisorderSchool refusalGeneralized Anxiety DisorderPanic DisorderSocial PhobiaSelective mutismSpecific Phobia

Anxiety Disorders Treatment GuidelinesBegin with psychotherapy for mild cases:CBT- exposure/response preventionFamily and Parent-Child

Consider psychotherapy + medication for:Acute symptom reduction for moderately-severely anxious childBZDs vs. buspironeCo-morbid disorder that requires treatmentPartial response to psychotherapyPotential for improved outcome with combination

Could be done indiv. or in groups, with and without parentsCBT includes: psychoeducation, somatic mgmt skills, cogntv restructring, exposure, relapse prev.Coping Cat-manualized CBT for 7-14yo for Separation Anxiety, GAD, and social phobia. Some efficacy.

Psychodynamic- Anxiety as a signal of internal distress/conflict. Extensiv clin expernc but few clinical trials.

Parent-Child and Family- Parents and families play important role in developmt and maintenc of childhood anx. Parental anx, parenting styles, insecure attchments, and parent-child interaxns are Risk Factors that may not be addrssd in indiv tx26Bipolar DisorderCommonly has onset in adolescenceGen population lifetime prevalence for Bipolar I is 0.4%-1.6%For C/A ranges from 1%-13%Overall affects both sexes equally, early-onset pre-dominantly male (esp. onset