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CORK Bibliography: Adolescents and Co-occurring Disorders

123 citations. January 2004 to present

Prepared: January 2008

Alvarado GF; Breslau N. Smoking and young people's mental health. Current Opinion in Psychiatry 18(4): 397-400, 2005. (35 refs.)

Purpose of review: This review addresses the evidence on smoking and young people's mental health, reported during 2004. Recent findings: Research studies have confirmed the previously reported epidemiological associations of smoking with gender, race and social class, as well as suspected risk factors and antecedents. Among youths, the prevalence of smoking varies across subgroups of the population, classified by race/ethnicity and social class Gender differences in smoking vary cross-nationally. Smoking among youths is higher when parents, siblings, or peers smoke. Smoking is also higher in youths with histories of early conduct problems, drinking and illegal drug use, depression, and suicidal behaviors. The protective role of youth involvement in sports and the lesser opportunity to smoke among youths involved in religious practice were also confirmed. Among young people, early conduct problems and associated early onset of daily smoking predict a greater likelihood of becoming nicotine dependent. The interpretation of the high smoking rate among schizophrenic patients as self-medication has been challenged by a recent study that reported that smoking predicted subsequent first hospitalization for schizophrenia. New findings suggest that young persons who experienced their first exposure to nicotine as relaxing are at elevated risk for becoming nicotine dependent. Summary: Longitudinal cohort studies and cross-sectional studies have been published on smoking and young people's mental health. These studies describe smoking correlates and identify predictors of negative outcomes of smoking, as well as predictors of nicotine dependence, smoking initiation, and smoking cessation.

Anderson KG; Chalekian J; Brown SA. Parent and peer influences on alcohol expectancies in comorbid youth. (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 104A-104A, 2004. (0 refs.)

Apodaca TR; Abrantes AM; Strong DR; Ramsey SE; Brown RA. Readiness to change smoking behavior in adolescents with psychiatric disorders. Addictive Behaviors 32(6): 1119-1130, 2007. (45 refs.)

There has been recent increased interest in utilizing motivational interviewing (MI) to increase adolescent readiness to quit smoking, but attempts to impact quit rates have thus far been discouraging. A better understanding of factors associated with adolescent readiness to quit smoking prior to receiving any intervention may provide guidance when tailoring future MI interventions in order to increase their effectiveness with this population. Adolescent smokers (N=191) who had been admitted to a psychiatric hospital and enrolled in a clinical trial evaluating MI completed questionnaires that assessed smoking behavior and variables thought to be related to smoking. Confidence to quit smoking and negative beliefs about smoking were significant predictors of adolescents' baseline readiness to quit smoking. The failure to demonstrate relationships between health consequences and readiness suggest that caution may be warranted in the use of feedback, a common component of MI-based interventions. Such feedback tends to focus on health consequences, which was unrelated to adolescent baseline readiness to change smoking behavior in the current study. Parallels between current results and the Theory of Planned Behavior are discussed in consideration of developing more effective MI-based interventions for adolescent smokers.

Arcelus J; Vostanis P. Psychiatric comorbidity in children and adolescents. Current Opinion in Psychiatry 18(4): 429-434, 2005. (36 refs.)

Purpose of review: This review critically discusses recent research findings on psychiatry comorbidity in children and adolescent persons. Recent findings: Several epidemiological studies have confirmed previous findings in relation to the high rates of psychiatric comorbidity in children and adolescents. In particular, psychiatric comorbidity has been detected in children with substance abuse, and with conduct and oppositional defiant, anxiety and attention deficit-hyperactivity disorders. These studies have also investigated the impact comorbidity has on symptom presentation, outcome and service utilization. Although the presence of concurrent psychiatric disorders in children and adolescents is well established, there has been limited research on the need for different treatment modalities in children suffering from more than one disorder. Summary: It is widely accepted that children and adolescents frequently present with more than one psychiatric diagnosis. The substantial variation in psychiatric comorbidity found in the literature may be due to the different methods of data collection as well as to the classification system used. Whether children and adolescents fulfil diagnostic criteria for a mixed condition (International Classification of Diseases-10) or multiple disorders (Diagnostic and Statistical Manual of Mental Disorders-IV), it is important that the concurrent psychopathology be recognized and treated.

August GJ; Winters KC; Realmuto GM; Fahnhorst T; Botzet A; Lee S. Prospective study of adolescent drug use among community samples of ADHD and non-ADHD participants. Journal of the American Academy of Child and Adolescent Psychiatry 45(7): 824-832, 2006. (45 refs.)

Objective: To describe the late adolescent drug use outcomes from a relatively large, community-identified sample of children with attention-deficit/hyperactivity disorder (ADHD) who have been assessed longitudinally from childhood through late adolescence. Method: Adolescent drug use outcomes were compared between ADHD-only (n = 27), ADHD-externalizing (mostly oppositional defiant disorder) (n = 82), and normal control (n = 91) groups. Results: The ADHD-externalizing group revealed significantly worse drug use outcomes (drug use frequency and substance use disorders) compared to the other two groups, and the ADHD-only group showed outcomes comparable to the community control group. Conclusions: ADHD without a comorbid externalizing disorder is not associated with an increased risk of drug abuse. ADHD with a comorbid externalizing disorder, primarily oppositional defiant disorder, is associated with an elevated risk of drug use, particularly with respect to marijuana and tobacco involvement.

Ballon B; Chaim G. HELP!!! An interactive experiential simulation of youth with concurrent disorders accessing help from "the system''. Addiction Research & Theory 14(6): 603-617, 2006. (8 refs.)

HELP!!! is an interactive, experiential simulation of the health care system that youth with concurrent mental health and addiction issues need to access for help. Using this exercise after a didactic teaching session reinforces the learning, synthesizes the knowledge for application and encourages group discussion and the sharing of participants' knowledge. This exercise was originally developed to create an opportunity for interprofessional learning groups to experience the gaps and barriers youth encounter as they attempt to navigate the system and to act as a catalyst for creative problem solving and system change. By participating, learners experience a simulation of what youth, family members, and various professionals usually encounter in the system. This exercise elicits key issues for discussion and provides a forum for networking and the initiation of collaborative ventures for healthcare providers.

Barkley RA; Fischer M; Smallish L; Fletcher K. Young adult follow-up of hyperactive children: Antisocial activities and drug use. Journal of Child Psychology and Psychiatry and Allied Disciplines 45(2): 195-211, 2004. (46 refs.)

Background: Hyperactive/ADHD children are believed to be a greater risk for adolescent and young adult antisocial activity and drug use/abuse, particularly that subset having comorbid conduct problems/disorder. Method: We report on the lifetime antisocial activities and illegal drug use self-reported at young adult follow-up (mean age 20-21 years; 13+ year follow-up) for a large sample of hyperactive (H; N=147) and community control (CC; N=73) children. Parent reports of childhood hyperactivity and conduct problems at study entry, parent and self-reports of ADHD and conduct disorder at adolescence, and parent reports of ADHD at young adulthood are examined for their contribution to antisocial behavior and drug use at adulthood. Results: More of the H group committed a variety of antisocial acts and had been arrested for doing so (corroborated through official arrest records) than did the CC group. The H group also committed a higher frequency of property theft, disorderly conduct, assault with fists, carrying a concealed weapon, and illegal drug possession, as well as more arrests. These activities reduced to two dimensions corresponding to predatory-overt and drug-related antisocial conduct.

Beitchman JH; Adlaf EM; Atkinson L; Douglas L; Massak A; Kenaszchuk C. Psychiatric and substance use disorders in late adolescence: The role of risk and perceived social support. American Journal on Addictions 14(2): 124-138, 2005. (49 refs.)

This article explores how measures of risk and perceived social support relate to different configurations of adolescent psychopathology using data from a community-based, longitudinal investigation of 284 individuals interviewed in 9982 at age 5 and again at age 19. Discriminant analysis was used to assess differences in risk and social support variables among eight clusters of youth: anxious, anxious drinkers, depressed, depressed drug abusers, antisocial, antisocial drinkers, drug abusers, problem drinkers, and a ninth group representing those participants without a diagnosis. The results indicated that one function, defined by loadings, for (low) family support and (high) early cumulative risk, accounted for the majority of between-group associations. Two groups of drug-abusing youth with multiple adjustment problems were highest on this function, while nondisordered youth and a group of participants with substance abuse alone were lowest. Findings are discussed in terms of the need to consider comorbidity when examining risk factors for later disorder.

Biederman J; Monuteaux MC; Mick E; Spencer T; Wilens TE; Silva JM. Young adult outcome of attention deficit hyperactivity disorder: A controlled 10-year follow-up study. Psychological Medicine 36(2): 167-179, 2006. (58 refs.)

Background. Out-objective was to estimate the lifetime prevalence of psychopathology in a sample of youth with and without attention deficit hyperactivity disorder (ADHD) through young adulthood using contemporaneous diagnostic and analytic techniques. Method. We conducted a case-control, 10-year prospective study of ADHD youth. At baseline, we assessed consecutively referred male, Caucasian children with (n = 140) and without (n = 120) DSM-III-R ADHD, aged 6-18 years, ascertained from psychiatric and pediatric sources to allow for generalizability of results. At the 10-year follow-up, 112 (80%) and 105 (88%) of the ADHD and control children, respectively, were reassessed (mean age 22 years). We created the following categories of psychiatric disorders: Major Psychopathology (mood disorders and psychosis), Anxiety Disorders, Antisocial Disorders (conduct, oppositional-defiant, and antisocial personality disorder), Developmental Disorders (elimination, language, and tics disorder), and Substance Dependence Disorders (alcohol, drug, and nicotine dependence), as measured by blinded structured diagnostic interview. Results. The lifetime prevalence for all categories of psychopathology were significantly greater in ADHD young adults compared to controls, with hazard ratios and 95% confidence intervals of 6(.)1 (3(.)5-10(.)7), 2(.)2 (1(.)5-3(.)2), 5(.)9 (3(.)9-8(.)8), 2(.)5 (1(.)7-3(.)6), and 2(.)0 (1(.)3-3(.)0), respectively, for the categories described above. Conclusions. By their young adult years, ADHD Youth were at high risk for a wide range of adverse psychiatric outcomes including markedly elevated rates of antisocial, addictive, mood and anxiety disorders. These prospective findings provide further evidence for the high morbidity associated with ADHD across the life-cycle and stress the importance of early recognition of this disorder for prevention and intervention strategies.

Brands B; Leslie K; Catz-Biro L; Li S. Heroin use and barriers to treatment in street-involved youth. Addiction Research & Theory 13(5): 477-487, 2005. (39 refs.)

High rates of drug use and risk behaviours have been reported among street involved youth. The present study examined the drug use and risk behaviours in adolescent heroin users, assessed motivation for treatment, and identified barriers to accessing treatment. Forty-nine heroin-using adolescents from four youth community agencies in Toronto were interviewed. Participants reported having used, on average, four different substances in the previous month. Seventy-nine percent had engaged in injection drug use and of these, 58% had shared their injecting equipment. Significant gender differences were found in the prevalence of psychiatric and family problems, the type of drug programs used, and perceived barriers to treatment. Although more than half of the sample had sought treatment for their substance use problems and were knowledgeable about the treatment options available, many believed factors such as lack of housing, finances, and contact with drug-using acquaintances would hamper their rehabilitation. Treatment programs for these youth should include the assessment and treatment of comorbid psychiatric disorders, and the provision of comprehensive services including safe housing, vocational guidance and financial supports.

Bukstein OG; Cornelius J; Trunzo AC; Kelly TM; Wood DS. Clinical predictors of treatment in a population of adolescents with alcohol use disorders. Addictive Behaviors 30(9): 1663-1673, 2005. (35 refs.)

The purpose of this paper is to identify potential predictors of treatment utilization, among both psychiatric and drug and alcohol variables. The subjects were 393 adolescents and young adults, age 12.9 to 18.11 years, who met DSM-IV criteria for a lifetime history of either alcohol abuse or alcohol dependence at baseline assessment. DSM-IV psychiatric and AUD diagnoses were obtained by semi-structure interviews (K-SADS and SC1D). Other alcohol and drug variables were obtained by the Alcohol Consumption Questionnaire and other self-reports. The results of these analyses suggest that there are few potential predictors associated with substance use disorder (SUD) treatment. For mental health (MH) treatment, depression in the form of Major Depressive Disorder was relatively strong associated at baseline and follow-up, while Attention Deficit Hyperactivity Disorder and Conduct Disorder appear to be associated with MH treatment at follow-up. For SUD treatments, there are essentially no variables strongly associated with treatment. The best potential predictors of who enters treatment and how long they stay may not be related to comorbidity or other dimensional variables of clinical severity. Rather, treatment utilization appears to be related to environmental factors, which may include family factors, adolescent and parental motivation, access to treatment, or to the use of appropriate treatment modalities.

Chabrol H; Ducong� E; Casas C; Roura C; Carey KB. Relations between cannabis use and dependence, motives for cannabis use and anxious, depressive and borderline symptomatology. Addictive Behaviors 30(4): 829-840, 2005. (29 refs.)

This study investigated the relations between anxious, depressive and borderline symptomatology, motivations for cannabis use, and cannabis use and dependence among 212 adolescents and young adults, 114 of whom were cannabis users. Motives for cannabis use were assessed using the Marijuana Motives Measure (Simons, J., Correia, C. J., Carey, K. B., & Borsari, B. E. (1998). Validating a Five-Factor Motives Measure: Relations with use, problems and alcohol motives. Journal of Counseling Psychology, 45, 265-273.). In three sets of regression analyses, motives, cannabis use frequency, and cannabis dependence served as criterion variables. First, when motives were regressed on psychopathological measures, borderline symptomatology predicted expansion motives in both boys and girls. Second, when frequency of use was regressed on motives and psychopathological measures, enhancement motives were the only significant predictor among boys and expansion motives were the only significant predictor among girls. Finally, when cannabis dependence was regressed on motives and psychopathological measures, borderline symptomatology was the only significant predictor in boys and expansion motives were the only significant predictor in girls. This study suggests the importance of motives and borderline symptomatology in the understanding of cannabis use and dependence among adolescents and young adults.

Chabrol H; Rodgers R; Duconge E. Relations between dissociative experiences, borderline personality disorder symptoms and cannabis use in adolescents and young adults. Addiction Research & Theory 13(5): 427-437, 2005. (31 refs.)

The aim of the study was to evaluate the relations between cannabis use, dissociative experiences and borderline personality disorder symptoms. A convenient sample of 212 subjects composed of high school students completed questionnaires assessing cannabis use frequency, the symptoms of dependence, the symptoms of dissociation and borderline personality disorder using the Dissociative Experience Scale (DES) completed by a subscale measuring hyper-personalization/hyper-realization experiences and the Borderline Personality Inventory (BPI), respectively; 114 (54%) were cannabis users. Multiple regression analyses showed that the frequency of cannabis use was negatively predicted by the frequency of spontaneous experiences of absorption and imaginative involvement and positively predicted by the frequency of experiences of absorption and hyper-personalization and hyper-realization linked to cannabis use. Cannabis dependence was predicted only by borderline personality symptoms. Positive dissociative experiences appear to be an important element in the understanding of cannabis use in adolescents and young adults.

Chi FW; Sterling S; Weisner C. Adolescents with co-occurring substance use and mental conditions in a private managed care health plan: Prevalence, patient characteristics and treatment initiation and engagement. American Journal on Addictions 15(Supplement 1): 67-79, 2006. (62 refs.)

This study examined the prevalence, patient characteristics, and treatment initiation and engagement of adolescents with co-occurring substance use (SU) and serious mental health (MH) diagnoses in a private, managed care health plan. We identified 2,005 adolescents aged 12-17, who received both SU and MH diagnoses within a 1-year window between 1/1/2000 and 12/31/2002; 57% were girls. Gender variations were found in diagnoses received and point of identification. Being dually diagnosed in specialty departments (rather than Primary Care and Emergency) and receiving both diagnoses within a shorter time period were associated with treatment initiation and engagement.

Chiang SC; Chen SJ; Sun HJ; Chan HY; Chen WJ. Heroin use among youths incarcerated for illicit drug use: Psychosocial environment, substance use history, psychiatric comorbidity, and route of administration. American Journal on Addictions 15(3): 233-241, 2006. (49 refs.)

This study examines differences in psychosocial characteristics, substance use history, and psychiatric comorbidity in relation to heroin use among youths aged 15 to 22 incarcerated in 2003 for illicit drug use in northern Taiwan. Factors associated with heroin use included experiences of child abuse, having friends with illicit drug use, poor school attendance, polydrug use, and early age of drug initiation. Heroin users were found to have more severe clinical manifestation and experiences of conduct and anxiety disorders than non-heroin users; injection users tended to have a longer heroin history. This information may help guide future prevention programs to reduce heroin problems in youth.

Copur M; Turkcan A; Erdogmus M. Substance abuse, conduct disorder and crime: Assessment in a juvenile detention house in Istanbul, Turkey. Psychiatry and Clinical Neurosciences 59(2): 151-154, 2005. (20 refs.)

The purpose of the present study was to determine the rate of substance abuse in the juvenile detention house and to determine the relationship between crime and substance abuse and conduct disorder. Two hundred and thirty cases in the biggest juvenile detention house in Istanbul, Turkey were assessed according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria. Law files and data of crime were examined. A total of 80 out of 230 juvenile detainees (34.8%) were found to have substance abuse excluding nicotine and alcohol. The substances abused in preferential order were cannabis (72.5%), volatile substances (21.3% bally and 3.7% thinner; 25%) and sedative hypnotic drugs and biperidents (2.5%). The rate of conduct disorder was 46.3% in substance abusers and 25.3% in the others (odds ratio: 2.536). The rate of substance abuse was 48.5% in the juveniles who had committed multiple crimes and 14.1% in the others (odds ratio: 5.735). The study shows that conduct disorder was very high in juvenile detainees. Conduct disorder was higher in substance-abusing than in non-abusing juvenile detainees. Substance-abusing juvenile detainees were found to have a higher detention rate than non-abusing juvenile detainees. There was a close relation between conduct disorder and substance abuse and multiple crimes. In the light of these results, diagnosis and treatment for conduct disorder in juvenile detainees are of great importance.

Cornelius JR; Clark DB; Bukstein OG; Birmaher B; Salloum IM; Brown SA. Acute phase and five-year follow-up study of fluoxetine in adolescents with major depression and a comorbid substance use disorder: A review. Addictive Behaviors 30(9): 1824-1833, 2005. (29 refs.)

This paper reviews the results of an acute phase trial and a five-year follow-up study of fluoxetine in adolescents with major depression and a substance use disorder (SUD). This study included a 12-week open label acute phase study of 13 comorbid adolescents, followed by comprehensive assessments conducted 1, 3, and 5 years after entry into an acute phase fluoxetine trial. The results of the acute phase study and of the 1, 3, and 5-year follow-up assessments have already been published in four papers. The current paper was designed to cover the results of the study across the entire 5-year time spectrum of the study, and to summarize the clinical results across that entire time period. The data from this pilot study suggest that the long-term (5-year) clinical course for the Alcohol Dependence, Cannabis Dependence, and academic functioning of comorbid adolescents following acute phase treatment with SSRIs is generally good. However, the long-term clinical course for the Major Depression of that comorbid adolescent population is surprisingly poor.

Cornelius JR; Clark DB; Bukstein OG; Kelly TM; Salloum aIM; Wood DS. Fluoxetine in adolescents with comorbid major depression and an alcohol use disorder: a 3-year follow-up study. Addictive Behaviors 30(4): 807-814, 2005. (15 refs.)

The goal of this 3-year follow-up evaluation was to determine whether the decreases in drinking and in depressive symptoms that were noted during our acute phase study with fluoxetine in comorbid adolescents persisted at a 3-year follow-up evaluation. At the 3-year follow-up evaluation, the group continued to demonstrate significantly fewer DSM criteria for an AUD and fewer BDI depressive symptoms and also consumed fewer standard drinks than they had demonstrated at the baseline of the acute phase study. However, 7 of the 10 participants demonstrated MDD at the 3-year follow-up assessment, and 4 demonstrated an AUD. The presence of a MDD was significantly correlated with the presence of an AUD at both the 1-year and the 3-year follow-up assessments. Four of the participants restarted SSRI medications during the follow-up period. Half of the subjects graduated from college during the 3-year assessment period, despite their residual depressive symptoms and drinking. We conclude that the long-term therapeutic effects of an acute phase trial of fluoxetine plus psychotherapy slowly decrease but did not disappear when fluoxetine is discontinued shortly after the acute phase trial. The high rate of MDD at follow-up suggests that longer term antidepressant medication treatment may be needed for at least some comorbid adolescents.

Cornelius JR; Maisto SA; Martin CS; Bukstein OG; Salloum IM; Daley DC et al. Major depression associated with earlier alcohol relapse in treated teens with AUD. Addictive Behaviors 29(5): 1035-1038, 2004. (10 refs.)

This study evaluated whether the common comorbid diagnosis of major depressive disorder (MDD) is associated with an earlier relapse to alcohol use among adolescents with an alcohol use disorder (AUD). The study sample consisted of 116 adolescents between the ages of 14 and 18 with an AUD recruited from treatment facilities in the Pittsburgh area, 50 of whom demonstrated a current MDD. An extensive baseline interview was conducted, followed by monthly interviews of alcohol use conducted by telephone for the following year. Those with current comorbid MDD demonstrated a median survival time of only 19 days until the first drink, while those without MDD demonstrated a median survival time of 45 days, which was a significant difference (Kaplan-Meier survival analysis, Breslow Test Statistic = 4.27, df = 1, P = -.039). These results suggest that the comorbid presence of MDD is associated with an earlier relapse to alcohol use among adolescents with an AUD.

Costello EJ. Psychiatric predictors of adolescent and young adult drug use and abuse: What have we learned? (editorial). Drug and Alcohol Dependence 88(Supplement 1): S97-S99, 2007. (14 refs.)

Costello EJ. Psychiatric predictors of adolescent and young adult drug use and abuse. (editorial). Drug and Alcohol Dependence 88(Supplement 1): S1-S3, 2007. (27 refs.)

Couwenbergh C; van den Brink W; Zwart K; Vreugdenhil C; van Wijngaarden-Cremers P; van der Gaag RJ. Comorbid psychopathology in adolescents and young adults treated for substance use disorders. (review). European Child & Adolescent Psychiatry 15(6): 319-328, 2006. (60 refs.)

In a recent review, the prevalence of comorbid psychiatric disorders in non-treated adolescents and young adults with substance use disorders (SUD) in the general population was summarized. This review looks into the prevalence of psychiatric comorbidity in adolescents and young adults treated for SUD. A computerized literature search was conducted resulting in ten eligible studies. The prevalence of comorbid psychiatric disorders varied from 61% to 88%. Externalizing disorders, especially Conduct Disorder (CD), were most consistently linked to SUD in treatment seeking adolescents. Girls are distinguished by their high rate of comorbid internalizing disorders. Comparison with data from community and juvenile justice studies shows an ascending trend of comorbidity rates of externalizing disorders from community to clinical and finally to juvenile justice samples. It seems that young addicts with comorbid disorders are at high risk of ending up in the juvenile justice system.

Crome I; Bloor R. Substance misuse and psychiatric comorbidity in adolescents. Current Opinion in Psychiatry 18(4): 435-439, 2005. (33 refs.)

Purpose of review: Many young people are misusing and becoming dependent on multiple substances (especially nicotine, alcohol, and cannabis), with a complex variety of psychological effects. Recent findings: Analysis of interactions between smoking, drinking, and cannabis use indicates that the relationship between substance use and psychiatric comorbidity is primarily explained by regular smoking. In some studies the use of cannabis on a regular basis was associated with an increased risk of psychiatric illness. This is by no means the case for all studies, so this area of work remains controversial. Children with attention deficit hyperactivity disorder who are substance misusers have a poorer prognosis than those without it so there is concern about treatment with stimulant drugs: this fear appears not to be substantiated by one study. Young people with anxiety disorders are at increased risk of substance use disorders. Clinical trials for adolescent substance abuse treatment have provided support for the benefits of cognitive behavioural interventions. There is an accumulating evidence base for pharmacological treatment for adult substance misusers that can inform treatment for younger patients. It is estimated that, of those adolescents who were likely to be in need of help, only about 9% received. Summary: Since psychiatric disorders beginning in childhood may continue into adult life, there is an opportunity to intervene to prevent or reduce conditions complicated by substance misuse, if services are accessible. The need for longitudinal work is vital to explore the patterns of comorbidity, and implement and evaluate appropriate treatment interventions.

Crome IB. Comorbidity in young people: Perspectives and challenges. Acta Neuropsychiatrica 16(1): 47-53, 2004. (46 refs.)

Trends in prevalence in substance misuse in young people in the UK are described: increased use over the last decade, the tendency to polydrug use, the narrowing of the gender gap. The complex issues relating to the description, definition and classification, and diagnosis of psychiatric comorbidity and substance misuse are outlined. The fact that there is no uniformly accepted definition of what constitutes 'dual diagnosis' or 'psychiatric comorbidity' in young people is highlighted: this variability impacts upon clinical assessment and study design. Despite these considerable drawbacks, a degree of consistency is beginning to emerge in the co-occurrence of some conditions, e.g. disruptive and suicidal behaviours. It is recognized that psychological distress and substance misuse are also associated with multiple social and physical complications. The rapid advances in treatment options are presented. At present the 'best practice' is implementation of what works for adults with addiction and young people with psychiatric disorder. This includes psychosocial interventions such as motivational enhancement techniques and cognitive behavioural treatment, as well as appropriate safe (usually), short-term use of a range of pharmacological agents. Very few comprehensive designated adolescent addiction services exist, while child and adolescent mental health services are under serious pressure. Thus the need for a longitudinal and multidisciplinary approach, with appropriate assessment instruments in young people, is required to further explore diagnostic classification which will classify the degrees and patterns of relationships between disorders. In this way it may be possible to build up a picture of the nature and extent of numerous complex, and sometimes overlapping, problems and needs in children and adolescents in a variety of settings: primary and secondary care, the criminal justice system and educational establishments. This might strengthen the development of innovative treatment services where novel interventions are tested as a priority.

Crone MR; Reijneveld SA. The association of behavioural and emotional problems with tobacco use in adolescence. Addictive Behaviors 32(8): 1692-1698, 2007. (15 refs.)

Smoking is a highly addictive behaviour, often initiated during adolescence. It is suggested that smoking is associated with behavioural and emotional problems. This study aims to assess the impact of psychosocial problems on smoking initiation and vice versa. Method: We obtained data on self-reported psychosocial problems and smoking of adolescents at the age of 13 years and 2 years later. The baseline questionnaire was completed by 1789 students. 68% of the baseline questionnaire could be linked to a questionnaire of the second measurement. Results: 15% smoked at baseline and 29% two years later. Respectively 8% and 9% had a clinical Externalizing problem score or a clinical Internalizing problem score at baseline, 14% had these problems two years later. Externalizing problems at baseline predicted the onset of smoking two years later. Internalizing problems only predicted smoking among girls. This association between psychosocial problems and smoking is most obvious for the onset of regularly smoking and less for the onset of experimenting. Reversibly smoking at baseline is only associated with the onset of externalizing problems two years later. Conclusion: Clinical Externalizing and Internalizing problems make the initiation of regular smoking more likely. The effects on experimental smoking are less obvious.

Cuellar AE; Markowitz S; Libby AM. Mental health and substance abuse treatment and juvenile crime. Journal of Mental Health Policy & Economics 7(2): 59-68, 2004. (61 refs.)

Background and Study Aims: There is a large body of literature examining the determinants of juvenile crime, which highlights economic, family, peer, and educational factors associated with delinquency and recidivism, and the important roles of social service and educational systems. Two factors, substance abuse and mental illness are also potentially important. The observed high correlations between crime, substance abuse and poor mental health suggests that factors which reduce substance abuse and improve mental health may also be effective in reducing criminal activities. The purpose of this paper is to examine the effectiveness of mental health and substance abuse treatment in reducing crimes committed by juveniles. Methods: This paper uses detention data in conjunction with substance abuse and mental health treatment data for youth enrolled in the Colorado state foster care program over a three year period. Duration models arc used to examine the structural determinants of detention. We analyze the impact of treatment in delaying or preventing this group of at-risk youth from engaging in criminal behavior. Violent crimes are analyzed separately. We also include the price of beer in all models to gauge the effectiveness of higher beer prices in reducing crime, holding treatment constant. Results: The analysis finds that individuals who receive treatment have lower probabilities of being detained for any offence. Accounting for the unobserved heterogeneity makes the magnitude of these effects larger. Also consistent with our theory, higher beer prices lower the detention hazard. Conclusion: Results of this study suggest that expansion of health services targeted at these youth may be effective at reducing crime. For violent crime, where the literature shows that substance abuse plays a significant role, stricter alcohol-regulatory policies may also be highly effective.

Da Silveira DX; Grob CS; de Rios MD; Lopez E; Alonso LK; Tacla C et al. Ayahuasca in adolescence: A preliminary psychiatric assessment. Journal of Psychoactive Drugs 37(2): 129-133, 2005. (19 refs.)

Ayahuasca is believed to be harmless for those (including adolescents) drinking it within a religious setting. Nevertheless controlled studies on the mental/ psychiatric status of ritual hallucinogenic ayahuasca concoction consumers are still lacking. In this study, 40 adolescents from a Brazilian ayahuasca sect were compared with 40 controls matched on sex, age, and educational background for psychiatric symptomatology. Screening scales for depression, anxiety, alcohol consumption patterns (abuse), attentional problems, and body dysmorphic disorders were used. It was found that, compared to controls, considerable lower frequencies of positive scoring for anxiety, body dismorphism, and attentional problems were detected among ayahuasca-using adolescents despite overall similar psychopathological profiles displayed by both study groups. Low frequencies of psychiatric symptoms detected among adolescents consuming ayahuasca within a religious context may reflect a protective effect due to their religious affiliation. However further studies on the possible interference of other variables in the outcome are necessary.

D'Amico EJ; Ellickson PL; Collins RL; Martino S; Klein DJ. Processes linking adolescent problems to substance-use problems in late young adulthood. Journal of Studies on Alcohol 66(6): 766-775, 2005. (62 refs.)

Objective: The current study explores three avenues in early young adulthood through which adolescent problems may be linked to later substance use problems: problematic substance use, failure to assume adult roles and responsibilities, and exposure to pro-drug social influences. Method: Participants (N = 1,986; 49% female) filled out surveys at ages 18, 23 and 29. Participants were 67% white, 9% black, 10% Hispanic and 8% Asian. Deviance, poor mental health, substance use, alcohol and other drug (AOD) problems, and school dropout were measured at age 18. AOD problems were also measured at age 23, as were role changes (e.g., marriage) and pro-drug social influences (e.g., friends use drugs). Indicators of substance abuse and dependence were measured at age 29. Demographics and family history of AOD were covariates. Results: Reporting more deviant behavior and heavier drinking at age 18 was associated with a higher likelihood of abuse and dependence at age 29. Alcohol use and pro-drug social influences at age 23 appeared to mediate the effects of adolescent substance use; lack of role assumption did not. The effect of poor mental health at age 18 was not mediated by any set of variables but instead appeared to directly predict dependence at age 29. Conclusions: Findings highlight the importance of early young adult drinking and substance-using peers in continuing patterns of heavy substance use developed during adolescence and also underscore the long-term impact of poor mental health during adolescence on substance use problems in late young adulthood.

Deck D; Vander Ley K. Medicaid eligibility and access to mental health services among adolescents in substance abuse treatment. Psychiatric Services 57(2): 263-265, 2006. (9 refs.)

Objective: The co-occurrence of a mental disorder is common among adolescents who present for substance abuse treatment. This study was conducted to determine whether Medicaid eligibility was associated with greater use of mental health services. Methods: The study used administrative data for 25,813 adolescents in Oregon. Propensity score analysis was used to assess the likelihood that the adolescents would use mental health services, with group differences and mental health need controlled for. Results: Medicaid-eligible youths were nearly five times as likely to receive mental health services in the year they entered substance abuse treatment compared with non-Medicaid-eligible youths. In both groups, there was evidence of racial disparities as well as factors such as foster care that may facilitate access. Conclusions: The fact that Medicaid-eligible youths have greater access to mental health services should be considered in both state policies and research design. States considering ways to better serve adolescents with co-occurring disorders would do well to examine ways to promote Medicaid enrollment or expand eligibility.

Dennis ML; Chan YF; Funk RR. Development and validation of the GAIN Short Screener (GSS) for internalizing, externalizing and substance use disorders and crime/violence problems among adolescents and adults. American Journal on Addictions 15(Supplement 1): 80-91, 2006. (73 refs.)

The Global Appraisal of Individual Needs (GAIN) is a 1-2 hour standardized biopsychosocial that integrates clinical and research assessment for people presenting to substance abuse treatment. The GAIN - Short Screener (GSS) is 3-5 minute screener to quickly identify those who would have a disorder based on the full 60-120 minute GAIN and triage the problem and kind of intervention they are likely to need along four dimensions (internalizing disorders, externalizing disorders, substance disorders, and crime/ violence). Data were collected from 6,177 adolescents and 1,805 adults as part of 77 studies in three dozen locations around the United States that used the GAIN. For both adolescents and adults the 20-item total disorder screener (TDScr) and its four 5-item sub-screeners (internalizing disorders, externalizing disorders, substance disorders, and crime/violence) has good internal consistency (alpha of .96 on total screener), is highly correlated (r = .84 to .94) with the 123-item longer scales in the full GAIN. The GSS also does well in terms of its receiver operator characteristics (90% or more under the curve in all analyses) and has clinical decision-making cut points with excellent sensitivity (90% or more) for identifying people with a disorder and excellent specificity (92% or more) for correctly ruling out people who did not have a disorder. The GSS has good potential as an efficient screener for identifying people with co-occurring disorders across multiple systems and routing them to the right services and more detailed assessments.

Diamond G; Panichelli-Mindel SM; Shera D; Dennis M; Tims F; Ungemack J. Psychiatric syndromes in adolescents with marijuana abuse and dependency in outpatient treatment. Journal of Child & Adolescent Substance Abuse 15(4): 37-54, 2006. (40 refs.)

Objective: The purpose of the current study to assist in understanding the prevalence and clinical correlates of psychiatric distress in adolescents seeking outpatient services for marijuana abuse or dependency. Methods: In a multi-site randomized clinical trial, 600 adolescents and their parents were assessed at intake using the Global Appraisals of Individual Needs. DSM-IV criteria were used to diagnose marijuana use disorders, and a symptom check list was used to measure symptoms on five syndromes: conduct disorder, ADHD, depression, anxiety, and disorders of traumatic distress. Results: Patients endorsed acute levels of conduct disorder (74%), ADHD (77%), depression (37.7%), anxiety (28.8%), and traumatic distress (13.8%), and 72% endorsed acute levels on two or more syndromes. Adolescents with a diagnosis of dependency and females evidenced the greatest severity of mental health distress, and minimal differences were found between racial groups. Patients with acute levels of both internalizing and externalizing syndromes reported problems with substance use, criminal activities, trauma experience, and family environments. Conclusion: Co-occurring psychiatric distress is the norm for adolescents seeking outpatient services for marijuana disorders. Better integration of substance use and mental health services would likely improve the quality of care for these troubled youth.

Diamond GM; Izzard MC; Kedar T; Hudzer A; Mell H. Psychological symptoms and drug use severity among Israeli adolescents presenting for outpatient drug abuse treatment. Journal of Adolescence 28(4): 495-505, 2005. (37 refs.)

The objective of this study was to assess the rates of externalizing and internalizing symptoms, and the relation between psychological symptoms and drug use severity, among 117 Israeli adolescents presenting for outpatient drug abuse treatment. Psychological symptoms were assessed via both adolescent self-report and parent report. Drug use was assessed using both adolescent self-report and urinalysis. Results showed that 58% of the sample evidenced clinical levels of psychological symptoms, with girls evidencing higher rates of externalizing and mixed symptomatology than boys. Parents' report of adolescents' internalizing symptoms predicted severity of drug use. These findings suggest that treatment for this population should be multidimensional, and address not only drug use per se, but also psychological risk factors.

Dierker LC; Ramirez RR; Chavez LM; Canino G. Association between psychiatric disorders and smoking stages among Latino adolescents. Drug and Alcohol Dependence 80(3): 361-368, 2005. (46 refs.)

Objective: We examined the prevalence of smoking behaviors and their association with psychiatric disorders within a representative sample of youth from Puerto Rico. Method: A complex sampling design was used and analyses were conducted to account for the unequal selection probability, stratification and Clustering. All analyses were weighted back to the population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and Youth versions of the Diagnostic Interview Schedule for Children, Version 4.0 (DISC-IV). Results: After controlling for other comorbidity, major depression and oppositional defiant disorder were significantly associated with nicotine dependence, rather than with lower levels of use.In contrast, conduct disorder was generally associated with lower levels of use rather than with nicotine dependence. As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. Conclusions: By examining psychiatric correlates of smoking stages within an island-wide sample of adolescents, the present study highlights those disorders that may play a role in the development and/or persistence of smoking behavior in Puerto Rico and further clarifies the appropriate targets for smoking intervention conducted in community settings

Dierker LC; Sledjeski EM; Botello-Harbaum M; Ramirez RR; Chavez LM; Canino G. Association between psychiatric disorders and smoking stages within a representative clinic sample of Puerto Rican adolescents. Comprehensive Psychiatry 48(3): 237-244, 2007. (61 refs.)

Objective: We examined the prevalence of smoking behaviors and their association with specific psychiatric disorders in a representative sample of youth from behavioral health clinics in Puerto Rico. Method: A complex sampling design was used to select the sample, and analyses were conducted to account for the unequal selection probability, stratification, and clustering. All analyses were weighted back to the clinical population from which they were drawn. Psychiatric and substance use disorders were assessed using the parent and youth versions of the Diagnostic Interview Schedule for Children, Version 4.0. Results: More than one third of the sample reported experience with cigarette smoking, and approximately one quarter reported smoking at least once per week (23.4%). As expected, the alcohol and drug use disorders demonstrated some of the strongest associations with individual smoking stages. These were the only disorders that remained significantly associated with nicotine dependence after controlling for comorbidity. Conclusions: Our findings confirm the need for screening of smoking behavior and nicotine dependence in treatment settings and the integration of psychiatric/substance use treatments with smoking cessation.

Dilsaver SC; Akiskal HS; Akiskal KK; Benazzi F. Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality. Journal of Affective Disorders 96(3): 249-258, 2006. (60 refs.)

Objectives: To ascertain rates of panic, obsessive-compulsive (OCD) and social phobic disorders among adolescents with bipolar disorder (BP), unipolar major depressive disorder (MDD) and psychiatric comparison patients, to assess their relationships to suicidality, psychosis, comorbidity patterns and familiality. Methods: The first author (SCD) interviewed 313 Latino adolescents using a structured interview based on the SLID. Family history was ascertained by live interview or interview by proxy. Patients were classified as BP, MDD, or non-affectively ill comparison controls (CC). Data regarding suicidality and psychosis were collected. Regression analysis was used to test associations and control for confounding effects. Positive likelihood ratios were used to measure the dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. Results: Of the total sample, 36.7% were BP, 44.7% MDD and 18.5% CC. In BP vs. MDD the odds of panic disorder were 4.4, of OCD 5.1, and of social phobia 3.3. MDD, in turn, were more likely to have these disorders than CC. BP (but not MDD) with panic disorder and social phobia, were more likely to have suicidal ideation; among the anxiety disorders, only social phobia was associated with having greater odds of suicide attempts. Among BP and MDD, patients with all three anxiety disorders were more likely to be psychotic. Presence of any mood disorder among first-degree relatives substantially increased the odds of having panic disorder and social phobia. The presence of one comorbid anxiety disorder increased the odds of having another. Finally, there were dose-response relationships between number of anxiety disorders and measures of severity of illness and familial loading for affective illness. Limitations: Single interviewer using the SLID; cross sectional exploratory study. Conclusions: BP adolescents have a greater anxiety disorder burden than their MDD counterparts. The results are compatible with the hypothesis that heavy familial-genetic loading for affective illness in juveniles is associated with bipolarity, cumulative anxiety disorder comorbidity, suicidality and psychosis. These observations are in line with pioneering psychopathologic observation in the early 1900s by two French psychiatrists, Gilbert Ballet and Pierre Kahn, who saw common ground between what until then had been considered the distinct categories of the neuroses and cyclothymic (circular) psychoses. This perspective has much in common with current complex genetic models of anxious diatheses in bipolar disorder.

Edwards J; Elkins K; Hinton M; Harrigan SM; Donovan K; Athanasopoulos O et al. Randomized controlled trial of a cannabis-focused intervention for young people with first-episode psychosis. Acta Psychiatrica Scandinavica 114(2): 109-117, 2006. (41 refs.)

Objective: To evaluate a cannabis-focused intervention (cannabis and psychosis therapy: CAP) for patients continuing to use cannabis following initial treatment for first-episode psychosis (FEP). Method: Consecutive admissions to an early psychosis program were screened and consenting individuals using cannabis in the 4 weeks prior to assessment participated. A single-blind randomized controlled trial compared CAP (n = 23) with a clinical control condition (psychoeducation, PE; n = 24). Results: There were no significant differences between the CAP and PE groups on cannabis use at end of treatment and 6 months post-intervention. There were no significant group differences on psychopathology and functional ratings at follow-up. A significant reduction in cannabis use was observed for both groups over time. Conclusion: PE and specific cannabis-focused intervention are associated with similar reductions in cannabis use in an FEP cohort. Simple interventions may therefore be worth considering prior to intensive psychotherapeutic efforts with this population.

Fragola AO. Depression among adolescents and their vulnerability to addictive disorders. Addictive Disorders and their Treatment 5(1): 27-34, 2006. (30 refs.)

This paper examines some aspects of etiopathogenia and addiction clinics in regard to adolescents. Within this context, vulnerability is one of the core issues, and depressive elements are closely associated with this vulnerability. There is a brief review of the confluence of neurobiological, epidemiologic, and psychologic data about addiction, adolescent development, and depression. The adolescent crisis generates affective unbalance, which expresses itself in depressive symptoms, emotional unstableness, lability of self-esteem, and tendency to impulsivity. These disorders act as predisposing factors weighing on the onset and persistence of drug abuse. The paper reviews different explanatory models as well as the concept of self-regulation and the effect of drugs on the limitation of personal freedom.

Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. (Chapter refs.)

This is the third edition of a major reference work in the field of addiction medicine, which was created by the founders of the American Academy of Addiction Psychiatry (AAAP) It is organized into five major sections, with a total of 28 chapters and 51 contributors. This volume provides historical background, diagnostic process and assessment, diagnostic tools, substance specific discussions of the major drug classes, covers the full range of treatment approaches and how these can be adapted to the needs and characteristics of special populations. It also discusses other "behavioral" addictions such as gambling disorders. Section I deals with the foundations of addiction medicine, the neurobiology of substance dependence and the historical and social context of psychoactive substance use disorders. Section II is directed to assessment, both psychological evaluation in adolescents and adults, and laboratory testing. Section III deals with major drug classes: alcohol, nicotine, opiates, marijuana, hallucinogens, and club drugs, cocaine and stimulants, and sedative/hypnotics and benzodiazepines. Section IV considers special populations and special issues: comorbidity, polysubstance abuse; women; the elderly; the workplace; HIV/AIDS; pain; pathological gambling and other "behavioral" disorders. The final section is directed to treatment: individual psychodynamic psychotherapy; cognitive therapy, group therapy; self-help; family-therapy; adolescent treatment; and treatment matching.

Francis K; Katsani G; Sotiropoulou X; Roussos A; Roussos C. Cigarette smoking among Greek adolescents: Behavior, attitudes, risk, and preventive factors. Substance Use & Misuse 42(8): 1323-1336, 2007. (48 refs.)

This study was produced in the context of the first author's thesis at Athens University and was a collaboration between the Department of Clinical Care Medicine, Athens University, and Attiki Child Psychiatric Hospital. It was supported by a project grant from the THORAX Foundation, Greece. Objective: To study the smoking behavior, attitudes, and beliefs of Greek adolescents, as well as the risk and preventive factors for the onset of smoking and to obtain data to serve in the planning of comprehensive antismoking campaigns tailored to the Greek adolescent's specific profile. Sample and Method: A stratified, nationwide, representative, school-based sample of 3827 Greek adolescents was surveyed during the academic year 2001-2002, using a questionnaire on smoking and Achenbach's Youth Self-Report. Results: Cigarette smoking is a serious problem among Greek youth. Family and peers play a primary role in shaping smoking attitudes and habits. Adolescents who smoke regularly have increased rates of psychopathology as indicated by higher scores on the Externalising and Attention Problem scales of Achenbach's Youth Self-Report, compared to adolescents who are non-smokers. The data obtained can indeed guide smoking prevention strategies in Greece.

Frojd S; Marttunen M; Pelkonen M; von der Pahlen B; Kaltiala-Heino R. Perceived financial difficulties and maladjustment outcomes in adolescence. European Journal of Public Health 16(5): 542-548, 2006. (31 refs.)

Background: Studies using traditional SES indicators in strictly adolescent populations have usually failed to find class differences in adolescent mental health. The present study aimed to find out whether there is an association between adolescent perceived financial difficulties of the family and adolescent maladjustment, and to explore the possible sex differences in this association. Methods: School-based survey on 3278 ninth grade students (15-16 years old) in two economically well developed Finnish cities. Results: One-fifth of the adolescents reported that their family had financial difficulties in the previous 12 months. Perceiving financial difficulties was significantly more common among girls than boys. Perceived financial difficulties were associated with known risk factors of poverty and with depression and harmful drinking patterns in both sexes. Adjusting for parental educational levels, parental unemployment and family structure did not change the significant association with maladjustment outcomes. Additional adjustment with comorbidity, however, levelled out the significance of the association of perceived financial difficulties and harmful drinking patterns in boys. Conclusion: While adolescent perception of financial difficulties is probably associated with the objective financial situation of the family it may also be an indicator of the psychological meaning attached to the situation and should thus be considered a possible risk factor for adolescent maladjustment in clinical practice.

Gil AG; Wagner EF; Tubman JG. Associations between early-adolescent substance use and subsequent young-adult substance use disorders and psychiatric disorders among a multiethnic male sample in South Florida. American Journal of Public Health 94(9): 1603-1609, 2004. (44 refs.)

Objectives. We examined the associations among early-adolescent substance use, subsequent young-adult substance use disorders, and psychiatric disorders among a community sample of males. Methods. Early-adolescent data were collected in classroom surveys (1990-1993), and young-adult data were collected in face-to-face interviews (1998-2000). Results. We found strong associations between early-adolescent substance use and young-adult substance use disorders and psychiatric disorders. The magnitudes of these associations varied by racial/ethnic group and were strongest among African Americans and foreign-born Hispanics, who reported the lowest early-adolescent substance use. Conclusions. Early-adolescent substance use is most strongly associated with a later pattern of dysfunction among the racial/ethnic groups that reported the lowest levels of early use. The implications of our findings in the context of primary and secondary prevention are discussed.

Goldberg JF; Ernst CL. Clinical correlates of childhood and adolescent adjustment in adult patients with bipolar disorder. Journal of Nervous and Mental Disease 192(3): 187-192, 2004. (38 refs.)

Impaired psychosocial functioning has been well documented in bipolar disorder, although there is little information linking premorbid adjustment with adult functional outcome. Childhood and adolescent functioning in school, peer relations, and personal interests was evaluated by standardized interviews with 56 adult-onset DSM-IV bipolar I (N = 46), 11 (N = 7), or not otherwise specified (N 3) patients, with collaboration by collateral historians, and assessed relative to current work functioning and overall illness features. Poor childhood or adolescent adjustment was associated with subsequent alcohol or drug abuse or dependence (P < .05), insidious onset of bipolar disorder (P < .02), and increased suicide attempts (p < .02). Poor adjustment in childhood was related to the lifetime development of rapid cycling. Poor premorbid adjustment may be linked with the potential to develop substance abuse comorbidity and an increased risk for suicide attempts and rapid cycling in bipolar patients. The prognostic significance of maladaptive childhood or adolescent behaviors may bear directly on clinical components of outcome in bipolar disorder.

Goldstein RB; Asarnow JR; Jaycox LH; Shoptaw S; Murray PJ. Correlates of "non-problematic" and "problematic" substance use among depressed adolescents in primary care. Journal of Addictive Diseases 26(3): 39-52, 2007. (75 refs.)

Substance use and related problems were assessed in a sample of primary care patients (n = 450) ages 13-21 who screened positive for depression at a clinic visit. Patients were classified as having no substance use (n = 248), non-problematic use (substance use without reported school, work, social, or family problems, n = 90), or use that reportedly caused problems in at least one area (n = 112). In logistic regression models, older age, externalizing symptoms, and not being African American were significantly associated with non-problematic use; older age, male gender, externalizing symptoms, Caucasian/White ethnicity/race, and more friends were associated with problematic use. Odds ratios were similar for patients reporting non-problematic and problematic use, suggesting that, in the presence of depression, any substance use merits evaluation and monitoring to determine treatment needs and to prevent escalation of dysfunction.

Greenbaum PE; Dedrick RF. Changes in use of alcohol, marijuana, and services by adolescents with serious emotional disturbance: A parallel-process growth mixture model. Journal of Emotional and Behavioral Disorders 15(1): 21-32, 2007. (42 refs.)

For the study reported here, the authors used growth mixture modeling to analyze changes in alcohol and marijuana use and the use of drug and alcohol treatment services for a sample of 180 adolescents with serious emotional disturbance (ages 12-14 years at the beginning of the 7-year longitudinal study). Three latent classes of substance users were identified, two of which exhibited significant linear increases in substance use. As expected, adolescents who were heavily involved in substance use at the beginning of the study and who significantly increased their substance use were the most likely to receive the greatest number of alcohol and drug services. Adolescents who had low levels of substance use at the beginning of the study but whose substance use increased significantly during the study received fewer services. The fact that the initially low substance-use class eventually ended up resembling the high substance-use class at the end of the 7-year study underscores the importance of collecting longitudinal data on substance use and employing the rate of change in substance use as an indicator of the need for treatment. Advantages of growth mixture and parallel processing modeling for studying changes in substance use and services are discussed.

Grella CE; Joshi V; Hser YI. Effects of comorbidity on treatment processes and outcomes among adolescents in drug treatment programs. Journal of Child & Adolescent Substance Abuse 13(4): 13-31, 2004. (33 refs.)

This study examined the relationship between treatment processes and posttreatment abstinence using data from the Drug Abuse Treatment Outcomes Studies for Adolescents (N = 810), with a focus on differences between adolescents with and without a comorbid mental disorder. The majority of the sample (62%) was diagnosed with at least one co-occurring mental disorder, most often conduct disorder. Overall, comorbid youth had more service needs and received more services compared with non-comorbid youth, and there were significant differences in service delivery by type of treatment modality. Posttreatment abstinence among the comorbid youth was positively associated with rapport with counselors and participation in 12-step groups while in treatment.

Haarasilta LM; Marttunen MJ; Kaprio JA; Aro HM. Correlates of depression in a representative nationwide sample of adolescents (15-19 years) and young adults (20-24 years). European Journal of Public Health 14(3): 280-285, 2004. (43 refs.)

Background: The authors investigated correlates of depression in a general population sample of adolescents (15-19 years) and young adults (20-24 years). Methods: As part of the Finnish Health Care Survey a random sample of 509 adolescents (281 females, 228 males) and 433 young adults (224 females, 209 males) was interviewed in 1996. DSM-III-R major depressive episode (MDE) was assessed by the University of Michigan Composite International Diagnostic Interview Short Form (UM-CIDI SF). Results: In multivariable regression analysis, current smoking (odds ratio (OR) 5.54; 95% confidence interval (CI) 1.44, 21.3) and chronic illness (OR 3.77; 95% CI: 1.04, 13.7) associated with MDE among adolescents. Among young adults, drunkenness at least twice a month (OR 4.48; 95% CI: 1.44, 14.0) or once a month (OR 2.79; 95% CI: 1.14, 6.83), not being married nor cohabiting (OR 3.50; 95% CI: 1.35, 9.08) and infrequent physical exercise (OR 4.01; 95% CI: 1.18, 14.0) were related to MDE. Female MDE associated with not being married nor cohabiting (OR 3.56; 95% CI: 1.23, 10.1) and living in southern Finland (OR 2.30; 95% CI: 1.06, 5.02). Drunkenness at least twice a month was related to MDE among males (OR 4.54; 95% CI: 1.27, 16.3). Conclusions: Attention should be paid to compromised health and health-related behaviour associating with MDE in youth. Specifically, the association between smoking and major depression in early adolescence should be borne in mind, and drinking habits or frequency of drunkenness should be carefully noted.

Hakko H; Lintunen J; Lappalainen J; Makikyro T; Rasanen P; Timonen M. Nicotine use and dependence and their association to psychiatric disorders in a large sample of adolescent psychiatric inpatients. Addictive Behaviors 31(10): 1873-1880, 2006. (22 refs.)

The purpose of this research was to evaluate the level of nicotine dependence (ND) and to examine its association to psychiatric disorders in a representative clinical sample of adolescent psychiatric inpatients. The modified Fagerstrom Tolerance Questionnaire (mFTQ) was used to assess the level of ND. Psychiatric DSM-IV diagnoses were obtained by using the Schedule for affective disorder and schizophrenia for school-age children (K-SADS-PL). Of the total of 342 inpatients in the study sample, 259 (75.7%) reported to be current smokers. A sum score 6 or higher in the mFTQ, indicating a high level of ND, was found in 37.9% of all smokers. An increased likelihood for high level of ND was associated with substance related disorders (OR 5.1, 95% Cl 2.8-9.3), conduct disorder and oppositional defiant disorders (OR 2.4, 95% CI 1.4-4.4). The usefulness of mFTQ in measuring ND among adolescent inpatients is apparent. Therefore, it can be recommended to be used as a routine screening instrument for ND among adolescents hospitalized due to psychiatric disorders.

Hall W; Degenhardt L. Prevalence and correlates of cannabis use in developed and developing countries. Current Opinion in Psychiatry 20(4): 393-397, 2007. (51 refs.)

Purpose of review: The aim of this article is to review recent research on the prevalence, antecedents and correlates of cannabis use in young adults in developed and developing countries. Recent findings Cannabis is the most widely used illicit drug globally and its use appears to be increasing in developed and developing countries. In developed countries rebelliousness, antisocial behaviour, poor school performance, and affiliation with drug-using peers are risk factors for early and regular cannabis use. Similar antecedents are now being reported in developing countries. Dependence is an underappreciated risk of cannabis that affects one in six to seven adolescents who use cannabis in developed countries. Adolescent cannabis dependence is correlated with an increased risk of using other illicit drugs, symptoms of depression, and symptoms of psychosis. The plausibility of cannabis playing a contributory causal role has increased for symptoms of psychosis in longitudinal studies but remains contentious. In the case of other illicit drug use and mood disorders common causal explanations remain difficult to exclude. Summary: Early and regular cannabis use in adolescence predicts an increased risk of cannabis dependence which in turn predicts an increased risk of using other illicit drugs, and reporting symptoms of mood and psychotic disorders.

Hanson RF; Self-Brown S; Fricker-Elhai A; Kilpatrick DG; Saunders BE; Resnick H. Relations among parental substance use, violence exposure and mental health: The national survey of adolescents. Addictive Behaviors 31(11): 1988-2001, 2006. (42 refs.)

Objective: To study the relations among parental substance use, violence exposure and psychopathology in a nationally representative sample of adolescents. Method: Random digit dialing methodology was used to obtain a nationally representative sample of 4023 adolescents, ages 12-17. Telephone surveys, conducted in 1995, assessed demographics, parental substance use, violence exposure, and three psychiatric disorders: major depressive disorder (MDE), posttraumatic stress disorder (PTSD), and substance abuse/dependence (SA/D). Results: Obtained prevalence rates included: 8.2% for sexual assault, 22.5% for physical assault, and 39.7% for witnessing violence at home or in the community. Substance use by a family member was reported by 18.4% (n = 721) of adolescents, with 50.6% reporting parental alcohol use and 19.1% (n = 138) reporting parental drug use. Consistent with hypotheses, violence exposure and parental substance use, particularly parental alcohol abuse, were independently associated with outcomes. Additionally, parental substance use emerged as a moderator for MDE, PTSD, and SA/D; however, the moderating relations varied according to the outcome variable investigated. Conclusions: Violence-exposed adolescents reporting parental alcohol or drug use had the highest rates of psychiatric diagnoses.

Harpaz-Rotem I; Rosenheck RA. Changes in outpatient psychiatric diagnosis in privately insured children and adolescents from 1995 to 2000. Child Psychiatry & Human Development 34(4): 329-340, 2004. (17 refs.)

This study examined changes in the diagnostic patterns among children and adolescents treated for mental health problems between the years 1995 and 2000. Using a large database (MarketScan(R)) which compiles claims information from private health insurance plans nationwide, our sample consisted of 100,716 children (under the age of 18) who submitted claims for outpatient mental health services, out of a total of 1,723,681 covered children. Over the five years period, there was a dramatic increase in the proportion of children diagnosed with both Autism and Bipolar disorders. An increase was also observed in Anxiety, ADHD and Depressive disorders. A decrease was observed in diagnostic prevalence of Oppositional, Adjustment and Substance Abuse disorders.

Helstrom A; Bryan A; Hutchison KE; Riggs PD; Blechman EA. Tobacco and alcohol use as an explanation for the association between externalizing behavior and illicit drug use among delinquent adolescents. Prevention Science 5(4): 267-277, 2004. (53 refs.)

The prevalence and persistence of adolescent substance use and abuse is a national health issue, and substance use among adolescents is frequently comorbid with other psychiatric disorders. Most studies in this area utilize samples of middle or high school students or from inpatient settings. Less is known about substance use and psychiatric comorbidity among delinquent adolescents. The present study examined data from two cohorts of juvenile offenders collected over a 2-year period (n=245, n=299). Participants reported frequency of cigarette, alcohol, marijuana, and other substance use. Participants' parents completed a measure of behavior problems. Path analyses suggested that parental reports of externalizing problems were significantly related to self-reported substance use while parental reports of internalizing problems were not. Results also suggested that smoking and alcohol use act as mediators between externalizing problems and marijuana and other drug use. Although there were some mean differences by gender, the pattern of relationships amongst the variables did not differ by gender. Implications of the findings and future directions are discussed.

Horn K; Dino G; Kalsekar I; Massey CJ; Manzo-Tennant K; McGloin T. Exploring the relationship between mental health and smoking cessation: A study of rural youth. Prevention Science 5(2): 113-126, 2004. (62 refs.)

This study examined the association between mental health and smoking cessation among rural youth. Participants were 113 male and 1.45 female adolescents ages 14-19 from rural West Virginia and North Carolina. Participants were enrolled in the American Lung Association's 10-week Not On Tobacco (N-O-T) program or a 15-min single-dose brief intervention. Baseline and postprogram measures were completed on smoking status (i.e., quit, reduction), nicotine dependence, smoking history, and depression and anxiety. Results showed that more N-O-T participants quit and reduced smoking than did brief intervention participants. Intervention group, baseline smoking rate, and the Group x Gender, Group x Anxiety, and Group x Depression interactions were significant predictors of change in smoking behavior from baseline to postprogram. In conclusion, more N-O-T participants demonstrated favorable changes in smoking than did brief intervention participants. Approximately 1/3 of youth exhibited mental health pathology; more females than males. Levels of depression and anxiety improved from baseline to postprogram, overall. Although the extent of the impact of mental health on cessation outcomes was inconclusive, findings suggest that rural youth who smoke may be at risk for pathological depression and anxiety. Future cessation programming with rural youth should consider the inclusion of coping and stress management skills and mental health referral protocols as significant program components.

Houston RJ; Bauer LO; Hesselbrock VA. Effects of borderline personality disorder features and a family history of alcohol or drug dependence on P300 in adolescents. International Journal of Psychophysiology 53(1): 57-70, 2004. (67 refs.)

Decrements in P300 amplitude have been associated with familial risk for alcoholism as well as several other psychiatric disorders characterized by disinhibited behavior. The present study examined the P300 in relation to Borderline Personality Disorder (BPD) features in adolescents with a paternal history of alcohol or drug dependence. One hundred and seventy-five males and females, aged 14-20, were assigned to groups based on BPD features (BPD+ vs. BPD-), family history of substance dependence (negative FH-, alcohol FHA, drug FHD) and gender. BPD features were assessed using the Structured Clinical Interview for the DSM-III-R questionnaire. P300 ERPs were recorded while each subject per-formed the Stroop color-word compatibility test. Repeated measures analyses, which included Conduct Disorder and Depression symptoms as covariates, indicated a significant reduction in P300 amplitude in the BPD+ group. There were no significant effects of FH or gender on P300 amplitude. These results document the presence of neurophysiological abnormalities associated with BPD features in an adolescent sample. This effect appeared to be independent of a family history of alcohol or substance dependence. These findings suggest that BPD symptoms during adolescence are relevant to the examination of the physiological antecedents of those forms of adult psychopathology characterized by behavioral disinhibition, including alcohol and drug dependence.

Ilomaki R; Hakko H; Timonen M; Lappalainen J; Makikyro T; Rasanen P. Temporal relationship between the age of onset of phobic disorders and development of substance dependence in adolescent psychiatric patients. Drug and Alcohol Dependence 75(3): 327-330, 2004. (18 refs.)

Aims: To investigate the age of onset of phobic disorders in relation to later development of substance dependence in a sample of adolescent psychiatric patients. Design, setting and participants: Clinical sample of 238 adolescents (age 12-17) admitted to psychiatric inpatient hospitalization between April 2001 and July 2003. Measurements: Psychiatric diagnoses and onset ages obtained from the schedule for affective disorders and schizophrenia for school aged children-present and lifetime (K-SADS-PL). Findings: Logistic regression analyses revealed that adolescents with phobic disorders had a 4.9-fold risk for comorbid substance dependence compared to those without phobia. The mean onset age was 11.4 and 14.4 years for phobias and comorbid substance dependence, respectively. Boys (13.7 years) had a statistically significantly lower onset age for substance dependence than girls (15.4 years). Over one-half of the adolescents with phobic disorders had developed substance dependence within three years after the onset of phobia. Conclusions: We found that phobias might influence the development of secondary substance dependence within a few years from the onset of phobia already in adolescence.

Kelly TM; Cornelius JR; Clark DB. Psychiatric disorders and attempted suicide among adolescents with substance use disorders. Drug and Alcohol Dependence 73(1): 87-97, 2004. (46 refs.)

Objective: To determine the effects of psychiatric disorders on attempted suicide among adolescents with substance use disorders (SUD). Methods: Age of onset for psychiatric disorders, age of first suicide attempt, and the relationship of psychiatric disorder with attempted suicide were investigated in a sample of 503 adolescents with DSM-IV defined SUD (age range: 12.2-19.0 years). Results: Males who attempted suicide had a significantly earlier onset of alcohol use disorders (AUD) and significantly more mood, AUD, and disruptive behavior disorder symptoms compared to non-attempting males. Females who attempted suicide had a significantly earlier onset and higher counts of mood disorders and SUD symptoms compared to non-attempting females. Hazard analysis revealed that mood disorders represent the highest psychiatric risk for attempted suicide in both the genders. Attention deficit-hyperactivity disorder (ADHD) increased the risk for attempted suicide among males. The interaction of mood disorder and AUD increased the risk for attempted suicide among females. Conclusions: Clinicians should closely monitor SUD adolescents for suicide risk and be aware of gender differences for suicidal behavior based on course and severity of psychiatric disorder in this population.

Keyes CLM. Mental health in adolescence: Is America's youth flourishing? American Journal of Orthopsychiatry 76(3): 395-402, 2006. (36 refs.)

A continuous assessment and a categorical diagnosis of the presence of mental health, described as flourishing, and the absence of mental health, characterized as languishing, are proposed and applied to data from the second wave of the Child Development Supplement (CDS-11) of the Panel Study of Income Dynamics (PSID), in which a comprehensive set of subjective well-being items were administered to a sample of 1,234 youth ages 12-18. Flourishing was the most prevalent diagnosis among youth ages 12-14; moderate mental health was the most prevalent diagnosis among youth ages 15-18. Depressive symptoms decreased as mental health increased. Prevalence of conduct problems (arrested, skipped school, alcohol use, cigarette smoking, and marijuana use) also decreased and measures of psychosocial functioning (global self-concept, self-determination, closeness to others, and school integration) increased as mental health increased. Findings suggest the importance of positive mental health in future research on adolescent development.

King SM; Iacono WG; McGue M. Childhood externalizing and internalizing psychopathology in the prediction of early substance use. Addiction 99(12): 1548 -1559, 2004. (40 refs.)

Aims: To examine the prospective relationships between childhood externalizing and internalizing disorders and substance use in early adolescence. Design:Longitudinal, community-based study of twins (aged 11 at intake; aged 14 at follow-up). Setting and participants:The sample was composed of twins participating in the Minnesota Twin Family Study, an epidemiological sample of twins and their families representative of the state population of Minnesota. A total of 699 twin girls and 665 twin boys participated at both time-points. MeasurementsTwins participated in in-person, life-time diagnostic assessments of the following childhood DSM III-R externalizing and internalizing disorders at age 11: conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder, major depressive disorder and in addition, for girls only, overanxious disorder and separation anxiety disorder. At ages 11 and 14, substance use and abuse were assessed. Findings: Externalizing psychopathology predicted having tried alcohol, nicotine and cannabis by age 14 as well as regular and advanced experience with these substances. Internalizing disorders showed weak effects, with only major depression at age 11 showing a significant relationship with substance use at age 14. Conclusion:The results suggest that externalizing psychopathology is a robust prospective predictor of a variety of early onset substance use behaviors and is systematically related to degree of substance use involvement. The results also suggest that depression may predict initiation of licit substance use in early adolescence.

Knight K; Farabee D, eds. Treating Addicted Offenders: A Continuum of Effective Practices. Kingston NJ: Civic Research Institute, 2004. (Chaper refs.)

This edited volume, with 40 chapters organized into seven sections provides a comprehensive approach to issues of substance use problems among persons in the criminal justice system. Section I focuses upon testing, screening, and referral. Emphasis is placed upon screening for co-occurring psychiatric illness, as well as initiatives to reduce violence. The use of the Practical Adolescent Dual Diagnostic Interview ( PADDI) in a juvenile detection center is described, as is the California Department of Correction's Drug Reduction Strategy Project. Section II focuses upon alternatives to incarceration, with special attention to matching probationers to drug treatment and specific efforts to reduced recidivism, and the role and operation of drug courts. Section III is directed to treatment in correction settings, especially therapeutic communities, looking tot eh experience of several programs, as well initiatives to promote change in the drug/crime lifestyle. Section IV considers the needs and experiences in serving special populations. There are individual chapters directed to treatment of substance-abusing sexual offenders; therapeutic community treatment for women; gender differences; those with psychiatric comorbidities; working with family of delinquent youth; growing inhalant use among juveniles; administrative/clinical issues such as who and how length of treatment is determined; programs to prepare and motivate persons to participate in mandated treatment; corrections-based program, treatment effectiveness with coerced treatment. Section VI deals with aftercare -- promoting a seamless system of care, the role of employment; the use of supervision; and relapse prevention. The concluding section (VII) deals with the application of research to practice, with consideration of the role of Addiction Technology Transfer Centers, professional development for staff, and models for evaluation.

2006, Project Cork

Krakowski M; Czobor P. Gender differences in violent behaviors: Relationship to clinical symptoms and psychosocial factors. American Journal of Psychiatry 161(3): 459-465, 2004. (21 refs.)

Objective: Men are more violent than women in the general population, but this has not been found to be the case among psychiatric inpatients. The reason for this exception is poorly understood. The present study investigated gender differences in violent behaviors among patients with major psychiatric disorders. it examined various clinical symptoms and psychosocial factors to determine their differential impact on violence in men and women. Method: Physical assaults and verbal assaults committed by psychiatric inpatients were recorded prospectively. Patients whose violent incident occurred during their first 2 months of hospitalization were eligible for the study. Patient history of community violence was also obtained. Psychiatric symptoms and ward behaviors were assessed upon entry into the study and after 4 weeks. Results: A similar percentage of women and men had an incident of physical assault in the hospital. Among the patients entered into the study, the women had a much higher level of verbal assaults throughout the evaluation period and a higher level of early physical assaults (i.e., within the first 10 days of the 4-week study period). Positive psychotic symptoms were more likely to result in assaults in women than in men. Physical assaults in the community, on the other hand, were more common in men and were associated with substance abuse, property crime, and a history of school truancy. Conclusions: There are gender differences in the patterns of violent behavior among patients with major psychiatric disorders. Furthermore, psychiatric symptoms an psychosocial risk factors have a different impact on this behavior in men and women. This has important implications for the prediction and differential treatment of violent behavior.

Kratochvil CJ; Kazura A; Deas D; Martin CA; Dosh T; Wilens TE. Pharmacological management of a teen with significant alcohol use and depression. Journal of the American Academy of Child and Adolescent Psychiatry 45(8): 1011-1015, 2006. (14 refs.)

The following case is presented for consideration with attention to pharmacological therapies : A 16-year-old girl in the 10th grade is referred by her parents because of concerns about her significant alcohol use. She started drinking alcohol only sporadically in eighth grade, but escalated her alcohol consumption to almost every Friday and Saturday night throughout ninth grade. For most of this academic year, she has been drinking to intoxication three times per week, despite attempts to limit use, recently experiencing blackouts. The volume of alcohol required to become intoxicated has increased. She admits to several incidents of driving while intoxicated and twice has had, after drinking heavily, sexual intercourse with men she barely knew. On examination, she reported feeling depressed, demoralized, and angry. She described low energy and interest, academic underachievement, and withdrawal from her previous long-standing friends. She has passive suicidality. Various drug therapies are considered along with the strong caution that a comprehensive assessment is critical to identify comorbidities.

Lam TH; Stewart SM; Ho SY; Lai MK; Mak KH; Chau KV et al. Depressive symptoms and smoking among Hong Kong Chinese adolescents. Addiction 100(7): 1003-1011, 2005. (38 refs.)

Aims To examine associations among depressive symptoms, smoking, smoking trajectories and quitting smoking in Hong Kong. Design Prospective longitudinal design, with wave 1 at baseline (T1) and wave 2 (T2) 12 months later. Setting and Participants Form 1 (equivalent to 7th grade in the United States) students, mean age = 12.7 years, n = 1894. Measurements Self-reported smoking status, attempts to quit and depressive symptoms. Findings At both waves, current as well as ex-smokers had higher depressive symptoms than never smokers. T1 smoking predicted T2 depressive symptoms among those with low baseline depressive symptoms. Depressive symptoms at T1 predicted smoking at T2 among non-smokers at T1. Trajectories were defined by separating participants who were never smokers at both waves ('non-smokers'), those who smoked at both waves ('persistent smokers'), those who smoked at one time but were not smoking at either wave ('past smokers), and those who had never smoked at T1 but reported smoking a year later ('new smokers'). Persistent, past and new smokers had higher depressive symptoms at both waves than non-smokers. Smokers who reported not wanting or trying to quit and those who had been unsuccessful at quitting had higher depressive symptoms at T2 than those who successfully quit. Conclusion: Our results suggest that depressive symptoms promote tobacco use in Asian adolescents by making it more likely that an adolescent will begin smoking and less likely that she or he will quit. These findings elucidate risk factors in Hong Kong for two important public health concerns for adolescents: smoking and depression.

Letters P; Stathis S. A mental health and substance abuse service for a youth detention centre. Australasian Psychiatry 12(2): 126-129, 2004. (10 refs.)

Objectives: To describe a new programme, the Mental Health Alcohol Tobacco and Other Drugs Service (MHATODS) at the Brisbane Youth Detention Centre, which aims to provide young people in detention with the same quality of mental health and substance dependency services that would normally be available to them in the community. Conclusions: Young people in detention suffer from considerable mental health and substance abuse problems. MHATODS seeks to address the specific needs of this group of young people. Its innovative structure recognizes the limitations of the prevailing paradigm of separate service delivery for mental health and drug and alcohol treatment, and has created an integrated treatment service for young people in detention.

Lopez B; Turner RJ; Saavedra LM. Anxiety and risk for substance dependence among late adolescents/young adults. Journal of Anxiety Disorders 19(3): 275-294, 2005. (59 refs.)

This study examined the relation between comorbid and pure (non-comorbid) anxiety disorders and both substance dependence and substance use problems in a community sample of 1747 young adults ages 18-23 years. Results indicate that collectively anxiety disorders, both pure and comorbid with other psychiatric diagnoses, are predictive of substance dependence. When temporal order was controlled, anxiety disorders generally preceded the onset of substance dependence. However in analyses in which PTSD was excluded, anxiety disorders were no longer predictive of substance dependence, suggesting that the increased risk associated with anxiety disorders is largely if not wholly attributable to PTSD. Finally, comorbid and pure anxiety disorders were found to be predictive of the number of alcohol and drug use problems.

Lubman DI; Hides L; Jorm AF. Beliefs of young people and their parents about the harmfulness of alcohol, cannabis and tobacco for mental disorders. Medical Journal of Australia 187(5): 266-269, 2007. (18 refs.)

Objective: To ascertain the beliefs of young people and their parents about the role of alcohol, tobacco and marijuana in the prevention and treatment of mental disorders. Design, setting and participants: Between May and August 2006, a national computer-assisted telephone survey was conducted on a representative sample of Australian youths aged 12-25 years. 3746 young people and 2005 of their parents were presented with a case vignette portraying psychosis, depression, depression with alcohol misuse, or social phobia in a young person. Main outcome measures: Participants' beliefs regarding the role of substance use in preventing or dealing with mental disorders in young people. Results: Over 85% of participants agreed that alcohol, tobacco and marijuana were harmful for the young people in the vignettes, and over 80% of youths agreed that not using marijuana or drinking alcohol in excess would reduce the risk of developing a similar problem. Conclusion: Young people and their parents are fully aware of the negative impact of substance use on mental disorders. Translating this knowledge into behavioural change will be a major challenge for future public health campaigns.

Macgowan MJ; Wagner E. Iatrogenic effects of group treatment on adolescents with conduct and substance use problems: A review of the literature and a presentation of a model. IN: Hilarski C, ed. Addiction, Assessment, and Treatment with Adolescents, Adults, and Families. New York: Haworth Social Work Practice Press, 2005. pp. 79-90. (33 refs.)

Group therapy is the most popular approach in the treatment of adolescent substance use problems. Recently, concerns have mounted about possible iatrogenic effects of group therapy based on studies on adolescents with conduct disorder. This paper reviews three possible contributors to response to group treatment among adolescents, and proposes a model of the relations among these variables, specifically in regard to how they independently and interactively contribute to outcomes among youth with conduct disorder and substance use problems.

Mark TL; Song X; Vandivort R; Duffy S; Butler J; Coffey R et al. Characterizing substance abuse programs that treat adolescents. Journal of Substance Abuse Treatment 31(1): 59-65, 2006. (19 refs.)

Few systematic studies have examined the characteristics of substance abuse treatment programs serving adolescents. An expert panel recently identified nine key elements of effective adolescent substance abuse treatment. We measured the percentage of treatment programs in the United States with at least 10 adolescent clients on a given day that reported these elements using data from the 2003 National Survey of Substance Abuse Treatment Services. This first look into the characteristics of facilities serving significant numbers of adolescents indicates that many facilities may be lacking in components considered important. The most significant measured potential areas for improvement occurred in the areas of including mental health as well as medical issues in comprehensive assessments and developing curricula to meet the developmental and cultural needs of clients. On a more encouraging note, many facilities were conducting discharge planning and providing aftercare, although the specifics of these services were not determined.

McCarthy DM; Tomlinson KL; Anderson KG; Marlatt GA; Brown SA. Relapse in alcohol- and drug-disordered adolescents with comorbid psychopathology: Changes in psychiatric symptoms. Psychology of Addictive Behaviors 19(1): 28-34, 2005. (46 refs.)

This study examined reciprocal relationships between posttreatment substance use and psychiatric symptoms in adolescents with both a substance use disorder and an Axis 1 mental health disorder. Participants (13-18 years old) were recruited from inpatient treatment centers and interviewed during treatment and monthly for 6 months. Participants who relapsed (N = 103; 48% female) reported the incidence and severity of psychiatric symptoms experienced before and after their 1st posttreatment substance use. The number of symptoms and depression symptoms experienced were related to use of stimulants and other drugs during relapse. There was evidence for both self-medication (symptom reduction) and rebound (symptom exacerbation) effects of substance use on symptom severity. These results demonstrate that, for adolescents with both substance use and mental health disorders, psychiatric symptoms are 1 factor influencing posttreatment substance use.

McLellan AT; Meyers K. Contemporary addiction treatment: A review of systems problems for adults and adolescents. Biological Psychiatry 56(10): 764-770, 2004. (49 refs.)

There is national concern regarding the problems of alcohol and drug abuse and the adequacy and quality of the national addiction treatment system, particularly for adolescents. This article reviews the published literature evaluating the ability of health, education, and specialty treatment systems to identify and treat affected adolescents and adults. A separate section reviews the status of the national treatment system for adults through findings from a nationally representative survey of 175 specialty treatment programs. The findings are unambiguous and disturbing, Although substance abuse is prevalent in most schools, primary care practices, mental health clinics, and criminal justice agencies, there is insufficient training, organization, or reimbursement to screen, assess, and refer those with dependence or abuse disorders to appropriate services. There are too few programs available to treat those substance-dependent patients who are screened and significant barriers for patients attempting to enter those programs. Finally, the organizational, administrative, and personnel infrastructures of many treatment programs are fragile and unstable, making them unable to implement evidence-based care. These problems are serious in the adult system and even worse in the adolescent system. The article concludes with suggestions for improving systems integration to improve the quantity and quality of available care.

Measelle JR; Slice E; Hogansen JM. Developmental trajectories of co-occurring depressive, eating, antisocial and substance abuse problems in female adolescents. Journal of Abnormal Psychology 115(3): 524-538, 2006. (98 refs.)

Growth trajectories of co-occurring symptomatology were examined in a community sample of 493 female adolescents who were followed annually from early to late adolescence. On average, depression, eating disorder, and substance abuse symptoms increased over time, whereas antisocial behavior decreased. Increases in each symptom domain were associated with relative increases in all other domains. Initial depressive and antisocial behavior symptoms predicted future increases in the other; substance abuse and antisocial behavior symptoms also showed prospective reciprocal relations. Initial depression predicted increases in eating disorder and substance abuse symptoms. Initial eating disorder symptoms predicted increases in substance abuse problems. Finally, the results suggest that the developmental covariation between depressive and eating disorder symptoms and between antisocial behavior and substance abuse symptoms was accounted for by distinct but related 2nd-order growth parameters.

Mills KL; Teesson M; Darke S; Ross J; Lynskey M. Young people with heroin dependence: Findings from the Australian Treatment Outcome Study (ATOS). Journal of Substance Abuse Treatment 27(1): 67-73, 2004. (49 refs.)

This paper examines the patterns and correlates of heroin use in a cohort of 210 young Australians aged between 18 and 24, who were participants in the Australian Treatment Outcome Study, a longitudinal study of treatment outcomes for heroin dependence. Of major importance were the high rates of psychiatric comorbidity found among this group (37% lifetime Post Traumatic Stress Disorder, 23% current Major Depression, 75% Anti-Social Personality Disorder, and 51% Borderline Personality Disorder). Seventeen percent had attempted suicide in the preceding year. Although both the young (aged 18-24 years) heroin users and their older counterparts (aged 25-56 years) initiated drug use at the same age, young heroin users progressed to heroin use, regular heroin use, and treatment for heroin use, twice as quickly as older heroin users. These findings suggest that there is a limited window of opportunity in which early interventions may be applied before young heroin users progress to problematic use.

Moolchan ET; Frazier M; Franken FH; Ernst M. Adolescents in smoking cessation treatment: Relationship between externalizing symptoms, smoking history and outcome. Psychiatry Research 152(2/3): 281-285, 2007. (25 refs.)

Previous research has indicated a potential bi-directional link between youth substance use and externalizing psychiatric comorbidities. We hypothesized that the degree of externalizing symptoms predicts the likelihood of successful smoking cessation (prolonged abstinence) among adolescent smokers participating in a cessation trial. We also explored the association of extemalizing symptoms with age at smoking initiation. Ninety one adolescents (mean +/- S.D.; age 15.1 +/- 1.4 years, cigarettes per day 18.4 +/- 8.1, Fagerstrom Test for Nicotine Dependence 7.1 +/- 1.3) were included. The Child Behavior Checklist/4-18 and Youth Self-Report assessed the degree of externalizing symptoms. Regression analysis indicated that lower CBCL externalizing scores significantly predicted the likelihood of prolonged abstinence. Pearson's correlation analysis indicated a significant association of lower externalizing scores with later onset of smoking initiation. Our findings highlight the importance of addressing externalizing behaviors in adolescent smoking cessation programs.

Najavits LM; Gallop RJ; Weiss RD. Seeking Safety therapy for adolescent girls with PTSD and substance use disorder: A randomized controlled trial. Journal of Behavioral Health Services & Research 33(4): 453-463, 2006. (39 refs.)

This randomized, controlled trial evaluated a manualized psychotherapy, Seeking Safety (SS), for posttraumatic stress disorder (PTSD) and substance use disorder (SUD) in adolescent females. To our knowledge, no prior study has evaluated any psychotherapy designed for this population. SS was compared to treatment as usual (TAU) for 33 outpatients, at intake, end-of-treatment, and 3 months follow-up. SS evidenced significantly better outcomes than TAU in a variety of domains at posttreatment, including substance use and associated problems, some trauma-related symptoms, cognitions related to SUD and PTSD, and several areas of pathology not targeted in the treatment (e.g., anorexia, somatization). Effect sizes were generally in the moderate to high range. Some gains were sustained at follow-up. SS appears a promising treatment for this population, but needs further study and perhaps additional clinical modification.

Niemela SM; Sourander A; Poikolainen K; Elonheimo H; Helenius H; Sillanmaki L et al. Adaptive functioning, psychopathology and service use among 18-year-old boys with drunkenness-related alcohol use. Alcohol and Alcoholism 41(2): 143-150, 2006. (37 refs.)

Aims: To study the associations between drunkenness frequency and adaptive functioning, psychopathology and service use among 18-year-old Finnish boys in a nation-wide population-based study. Methods: Information about drunkenness frequency within the previous six months was collected from the Finnish boys born in 1981 (n = 2306) at the boys' obligatory military call-up in 1999. Self-report questionnaires were used to study demographic factors, adaptive functioning, risk behaviour, life events, and mental health service use. Psychopathology and adaptive functioning was assessed with the Young Adult Self-Report (YASR) questionnaire. Results: Of the boys, 85% reported drunkenness within the previous 6 months. Most of the subjects were occasionally drunk: 39% reported drunkenness less than a month, and 35% less than once a week, while 10% reported being frequently drunk once a week or more often. Occasional drunkenness was associated with better adaptive functioning and psychosocial well-being in general. Refraining from drunkenness was associated with suicidal ideation and internalizing problems in the YASR scale. Frequent drunkenness associated with daily smoking, illicit drug use, and externalizing problems in the YASR scale, especially delinquent behaviour. In the multivariate analysis, number of friends, having a regular relationship and cigarette smoking had a linear association with frequency of drunkenness, while drunkenness-related alcohol use was less common among those with poor friendship quality. Among the participants, entering substance use treatment was rare (0.2%). Frequent drunkenness was found to be common among mental health service users. Conclusions: Among late- adolescent boys, occasional drunkenness is a normative alcohol use pattern and associates with social competence and good psychosocial functioning. Late-adolescent boys refraining from drunkenness in addition to those with frequent drunkenness may be in a need of mental health assessment. As entering substance use treatment is infrequent, establishing integrated services with multi-professional co-operation for late-adolescent males with frequent drunkenness is emphasized.

Nolen-Hoeksema S; Stice E; Wade E; Bohon C. Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology 116(1): 198-207, 2007. (60 refs.)

The authors examined the reciprocal relations between rumination and symptoms of depression, bulimia, and substance abuse with longitudinal data from 496 female adolescents. Rumination predicted future increases in bulimic and substance abuse symptoms, as well as onset of major depression, binge eating, and substance abuse. Depressive and bulimic, but not substance abuse, symptoms predicted increases in rumination. Rumination did not predict increases in externalizing symptoms, providing evidence for the specificity of effects of rumination, although externalizing symptoms predicted future increases in rumination. Results suggest rumination may contribute to the etiology of depressive, bulimic, and substance abuse pathology and that the former two disturbances may foster increased rumination. Results imply that it might be beneficial for prevention programs to target this cognitive vulnerability.

Obot IS; Anthony JC. Mental health problems in adolescent children of alcohol dependent parents: Epidemiologic research with a nationally representative sample. Journal of Child & Adolescent Substance Abuse 13(4): 83-96, 2004. (37 refs.)

In this study, with an epidemiologic sample of national scope, we seek confirmatory evidence about specific mental health problems of adolescent children living with actively alcohol dependent parents (AD+ children) as compared to control children whose parents are not alcohol dependent (AD- children). Treatment sample research leads us to expect the most prominent AD+/AD- differences with respect to externalizing symptoms. Data for this study were from the 1995 and 1996 National Household Survey on Drug Abuse (NHSDA), with the sample and field research staff 'blinded' to the study's hypothesis. Within the NHSDA national sample, a total of 1,720 parent-child pairs living in the same household were assessed. Youths were asked to complete an adapted version of Achenbach's Youth Self-Report. Independently, the parent was asked about his or her alcohol problems using an adapted version of the Diagnostic Interview Schedule. Analysis of variance (ANOVA) showed the AD+ children (n = 79) to have higher delinquency (p < .001) and aggressive behavior scores (p < .05) as compared to AD- children (n = 1,650). Multivariate analysis of covariance (MAN COVA), with five sociodemographic characteristics as covariates, confirmed the presence of independent delinquency excesses (but not independent aggressive behavior excesses) among children living with a parent with alcohol problems (F = 9.23, df = 1, 1659, p < .01). The evidence of this study favors the hypothesis that adolescent children living with an alcohol dependent parent have more delinquency problems than other adolescents. We did not find similar patterns of association for the internalizing symptoms, nor for aggression, once delinquency was held constant.

Office of Applied Studies. The DASIS Report. Adolescents with Co-Occurring Psychiatric Disorders: 2003. Issue December 23, 2005. Rockville MD: Substance Abuse and Mental Health Services Administration, 2005. (5 refs.)

This short report based on information from the Treatment Episide Data Set (TEDS) presents information on the prescence of co-occurring disorders among adolescents who entered substance abuse treatment. Information is provided on the rates of co-occurring by racial and ethnic groups, by source of referral, by the primary substance of abuse, by the setting in which treatment is provided, and by educational levels. Among the findings is that co-occurring disorders are more common among females than males (38% versus 28%); three-quarters of adolescents with co-occurring disorders were White compared to half of other admissions; and that the criminal justice system was the most common source of referral for all adolescent admissions (48%), but less common among those with co-occurring disorders (57%).

Ohannessian CM; Hesselbrock VM; Kramer J; Kuperman S; Bucholz KK; Schuckit MA et al. The relationship between parental alcoholism and adolescent psychopathology: A systematic examination of parental comorbid psychopathology. Journal of Abnormal Child Psychology 32(5): 519-533, 2004. (54 refs.)

The relationship between parental alcohol dependence (with and without comorbid psychopathology) and adolescent psychopathology was examined in a sample of 665 13-17 year-old adolescents and their parents. Results indicated that adolescents who had parents diagnosed with alcohol dependence only did not significantly differ from adolescents who had parents with no psychopathology in regard to any of the measures of psychological symptomatology (substance use, conduct disorder, and depression) or clinical diagnoses (alcohol dependence, marijuana dependence, conduct disorder, or depression) assessed. In contrast, adolescents who had parents diagnosed with alcohol dependence and either comorbid drug dependence or depression were more likely to exhibit higher levels of psychological symptomatology. In addition, adolescents who had parents diagnosed with alcohol dependence, depression, and drug dependence were most likely to exhibit psychological problems. These findings underscore the importance of considering parental comorbid psychopathology when examining the relationship between parental alcoholism and offspring adjustment.

Ohannessian CM; Hesselbrook VM; Kramer J; Kuperman S; Bucholz KK; Schuckit MA et al. The relationship between parental psychopathology and adolescent psychopathology: An examination of gender patterns. Journal of Emotional and Behavioral Disorders 13(2): 67-76, 2005. (47 refs.)

The primary goal of this study was to examine the relationship between parental psychopathology (specifically, alcohol dependence and depression) and adolescent psychopathology, by the gender of the adolescent and the gender of the parent. The sample included 426 13- to 17-year-old adolescents and their parents. All participants were administered the SemiStructured Assessment for the Genetics of Alcoholism to obtain clinical psychiatric diagnoses. Paternal psychopathology (depression and alcohol dependence) significantly predicted adolescent alcohol dependence, whereas maternal psychopathology did not. Maternal alcohol dependence did not predict any of the adolescent psychiatric diagnoses. In contrast, both paternal depression and maternal depression significantly predicted adolescent conduct disorder and depression. In addition, maternal depression significantly predicted adolescent anxiety. No significant interactions between parental psychopathology and adolescent gender were observed. Nevertheless, results from this study underscore the importance of considering the gender of the parent when examining the relationship between parental psychopathology and psychopathology in the offspring.

Pardini D; White HR; Stouthamer-Loeber M. Early adolescent psychopathology as a predictor of alcohol use disorders by young adulthood. Drug and Alcohol Dependence 88(Supplement 1): S38-S49, 2007. (73 refs.)

Few prospective studies have examined the relation between early adolescent conduct disorder (CD) symptoms and the development of alcohol use disorders (AUD) by young adulthood. The relative contribution of other forms of adolescent psychopathology (i.e., attention-deficit hyperactivity disorder, depression, anxiety/withdrawal) to the development of AUD also remains poorly understood. There is some suggestion that the co-occurrence of conduct disorder symptoms with other forms of psychopathology may interact synergistically in predicting later alcohol use problems. The current study explores these issues using data on 506 boys from the oldest sample of the Pittsburgh Youth Study (PYS). Consistent with prior research, early conduct disorder symptoms emerged as a consistent predictor of increased AUD symptoms and an alcohol dependence diagnosis by young adulthood. In contrast, adolescent boys with high levels of anxiety/withdrawal had lower levels of AUD symptoms and were less likely to develop alcohol dependence by young adulthood. Increased depression in early adolescence was associated with higher AUD symptoms and alcohol abuse and dependence diagnoses by young adulthood, but only for boys with high levels of conduct disorder symptoms. No evidence was found for a relation between attention-deficit hyperactivity disorder symptoms and AUD symptoms or diagnoses after controlling for co-occurring psychopathology.

Pirkle EC; Richter L. Personality, attitudinal and behavioral risk profiles of young female binge drinkers and smokers. Journal of Adolescent Health 38(1): 44-54, 2006. (49 refs.)

Purpose: Analyses were conducted to identify personality, attitudinal and behavioral correlates of binge drinking and smoking among adolescent girls and young women, a population whose substance use attitudes and behaviors have received only limited attention in the literature. Methods: A nationally representative sample of girls and young women (n = 929) from three age cohorts completed a telephone interview assessing various personality, attitudinal, and behavioral characteristics. Respondents were categorized into four groups based on self-reported binge drinking and smoking (binge drinker/nonsmoker, smoker/non-binge drinker, binge drinker/smoker, or nonbinge drinker/nonsmoker) and were assessed on a number of variables, including self-monitoring, depressive symptoms, coping style, religiosity/spirituality, popularity, dieting behavior, and smoking- and alcohol-related expectations. Univariate and multiple regression analyses were conducted to identify characteristics that best describe each of these types of substance users. Results: Risk profiles varied across the groups. Girls and young women who binge drank but did not smoke were more likely to be high self-monitors, to engage in disordered dieting, and to believe drinking provided an excuse to act with less inhibition. Those who smoked but did not binge drink were more likely to report depressive symptoms. Those who binge drank and smoked were more likely to be popular and to report depressive symptoms. Certain forms of avoidant coping and low religiosity were associated with all three types of substance use. Conclusion: Understanding the risk profiles of girls and young women who engage in specific forms of substance use can facilitate the identification of those at risk and the development of more targeted and effective prevention programs and interventions.

Poulin C; Hand D; Boudreau B; Santor D. Gender differences in the association between substance use and elevated depressive symptoms in a general adolescent population. Addiction 100(4): 525-535, 2005. (58 refs.)

Aims: This study explores gender differences in the association between substance use and elevated depressive symptoms in the general adolescent population. Design: Cross-sectional self-reported anonymous survey, the 2002/2003 Student Drug Use Survey in the Atlantic Provinces. The sample design was a single-stage cluster sample of randomly selected classes stratified by grade and region. Setting The four Atlantic provinces of Canada. Participants A total of 12 771 students in junior and senior high schools of the public school systems, representing a response rate of about 97%. The average age of participants was 15.2 years. Measurements: The measure of elevated depressive symptoms was a 12-item version of the CES-D with three categories of depression risk validated in a companion study. Findings: The prevalence of very elevated depressive symptoms was 8.6% in females and 2.6% in males. Alcohol use and cigarette smoking were found to be independent predictors of elevated depressive symptoms in females, but not males; cannabis use was found to be an independent predictor of elevated depressive symptoms in both males and females. Age was found to have a curvilinear relationship with elevated depressive symptoms in females but not in males. The adolescent's academic performance and province of residence were found to be independent risk factors of elevated depressive symptoms among both males and females. About 10.3% of adolescents considered to be potential candidates for needing help reported having received help because they felt depressed. Conclusions: The association between depression risk and age, alcohol use, cigarette smoking and cannabis use in the general adolescent population is not straightforward and may differ according to gender. There is unmet need for help for depression among adolescents.

Ramo DE; Anderson KG; Tate SR; Brown SA. Characteristics of relapse to substance use in comorbid adolescents. Addictive Behaviors 30(9): 1811-1823, 2005. (23 refs.)

This study examined the factors associated with the relapse process for substance use disordered (SUD) youth with comorbid psychiatric disorders. Temporal and situational characteristics as well as psychiatric symptoms, self-efficacy, and developmentally relevant experiences preceding first relapse after treatment were evaluated as part of a youth focused addiction relapse model. Method: Adolescents (N=81) with a DSM-III-R substance use disorder (SUD) and another Axis 1 psychiatric disorder were recruited from inpatient substance abuse and psychiatric treatment. Face-to-face interviews were conducted while youth were in treatment and monthly telephone interviews were conducted in the six months following treatment to ascertain length of time to first substance use episode and characteristics of the episode. Results: Youth who relapsed within the first month were more likely to report use of drugs other than alcohol or marijuana in their first use, while use among late relapsers was more often preceded by direct social pressure to use. Those relapsing in the first 3 days after treatment were less likely to view substance use as a problem and less likely to report passive emotional states (e.g., boredom) prior to use. Psychiatric symptoms were associated with relapse in conflict/life stress, negative emotional states and active emotional states. Self-efficacy was related to relapse among youth with conflict/life stress, and when youth were experiencing a desire to use in the two weeks prior to relapsing. Conclusions: Findings highlight some of the factors that are most important in understanding the process of relapse in comorbid adolescents. Research and treatment implications are discussed.

Rhee SH; Hewitt JK; Young SE; Corley RP; Crowley TJ; Neale MC et al. Comorbidity between alcohol dependence and illicit drug dependence in adolescents with antisocial behavior and matched controls. Drug and Alcohol Dependence 84(1): 85-92, 2006. (41 refs.)

Background: Knowledge regarding the causes of comorbidity among substance use disorders can have significant impact on future research examining the etiology of these disorders. Unfortunately, the conclusions of past studies examining the comorbidity among substance use disorders are conflicting; some studies emphasize familial influences common to multiple substances, while others emphasize substance-specific influences. Discrepancies in results may reflect different analytical approaches or differences in the samples. Here, we examine the causes of comorbidity between alcohol dependence and illicit drug dependence in adolescents. Methods: We ascertained a clinical sample of adolescents treated for antisocial behavior and substance use disorders and their siblings and a matched control sample. A model fitting approach was used to test 13 alternative hypotheses for the causes of comorbidity. Results: The best supported hypothesis for the comorbidity between alcohol dependence and illicit drug dependence was a model hypothesizing that comorbid disorders are alternate forms of a single underlying liability. The next best fitting models were two of the correlated liabilities models (correlated risk factors and reciprocal causation). Discussion: The results suggest that the best hypotheses explaining the comorbidity between alcohol and illicit drug dependence in adolescents are that alcohol dependence and illicit drug dependence are manifestations of a single general liability to develop substance dependence or that there are separate liabilities that are highly correlated.

Riggs PD; Hall SK; Mikulich-Gilbertson SK; Lohman M; Kayser A. A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 43(4): 420-429, 2004. (27 refs.)

Objective: In adolescents with substance use disorder (SUD), comorbid attention-deficit/hyperactivity disorder (ADHD) is associated with greater severity of substance abuse, conduct problems, and worse treatment outcomes. Although many controlled trials have established the efficacy of psychostimulants, including pemoline, for ADHD in children and adolescents, none have been conducted in adolescents with SUD. This randomized, placebo-controlled trial, conducted between 1996 and 2000, evaluated the safety and efficacy of pemoline on substance abuse and conduct problems. Method: Sixty-nine adolescents (aged 13-19) with conduct disorder (CD), SUD, and ADHD were recruited from the community and randomly assigned to a 12-week clinical trial of pemoline (n = 35) or placebo (n = 34), titrated over 4 weeks to a single morning dose of 75 to 112.5 mg as tolerated. Results: Pemoline had greater efficacy than placebo for ADHD as determined by significantly more Clinician's Global Impression-Improvement (CGI-I) ratings of 1 (very much improved) or 2 (much improved) at the study endpoint (n = 69; p < .05). There was also greater reduction in ADHD severity on the parent-rated Conners Hyperactivity-Impulsivity scale in pemoline-treated study completers compared to placebo-treated completers (pemoline, n = 17; placebo, n = 16; p < .01), but no difference between groups in the intent-to-treat analysis (n = 68; p < .13). Substance use did not decline in either group, and there was no difference between groups in baseline to study endpoint change in substance use or CD symptoms. Overall, pemoline was well tolerated, demonstrating a good safety profile and no elevation in liver enzyme levels. Conclusions: Pemoline was efficacious for ADHD but did not have an impact on CD or substance abuse in the absence of specific treatment for SUD.

Roberts RE; Roberts CR; Xing Y. Comorbidity of substance use disorders and other psychiatric disorders among adolescents: Evidence from an epidemiologic survey. Drug and Alcohol Dependence 88(Supplement 1): S4-S13, 2007. (59 refs.)

This paper extends our knowledge of comorbidity of substance use disorders (SUDS) and other psychiatric disorders by examining comorbidity of specific types of SUDS and risk of comorbidity separately for abuse and dependence. The research question is whether there is specificity of risk for comorbidity for different SUDS and whether greater comorbidity is associated with dependence. Data are presented from a probability sample of 4175 youths aged 11-17 assessed with the NIMH DISC-IV and self-administered questionnaires. SUDS outcomes are alcohol, marijuana and other substances in past year. Mean number of other comorbid disorders ranged from 1.9 for marijuana abuse to 2.2 for other substance abuse and 1.9 for marijuana dependence to 2.8 for other substance dependence. None of the abuse SUDS does not increase risk of anxiety disorders, but dependence does. Both abuse and dependence increased risk of comorbid mood disorders. Similar results were observed for disruptive disorders. Patterns of comorbidity varied by substance, by abuse versus dependence, and by category of other psychiatric disorders. In general, there was greater association of comorbidity with other disorders for dependence versus abuse. Marijuana is somewhat less associated with other disorders than alcohol or other substances. The strongest association is for comorbid disruptive disorders, regardless of SUDS category. Having SUDS and comorbid other psychiatric disorders was associated with substantial functional impairment. Females with SUDS tended to have higher rates of comorbid disorders, as did older youths. There were no differences observed among ethnic groups. When comorbidity of SUDS with other disorders was examined, controlling for other non-SUDS disorders for each specific disorder examined, the greater odds for dependence versus abuse essentially disappeared for all disorders except disruptive disorders, suggesting larger number of comorbid non-SUDS in part account for the observed effects for dependence.

Robertson AA; Dill PL; Husain J; Undesser C. Prevalence of mental illness and substance abuse disorders among incarcerated juvenile offenders in Mississippi. Child Psychiatry & Human Development 235(1): 55-74, 2004. (37 refs.)

The prevalence of psychiatric disorders among incarcerated juveniles in Mississippi was examined. A total of 482 adolescents completed a diagnostic questionnaire and a subset (N=317) was assessed with face-to-face semistructured interview. Most of the study participants met criteria for one mental disorder, 71-85% depending on assessment method, one-third have co-occurring mental health and substance abuse disorders. Gender and placement site differences in rates of some psychiatric disorders were also noted. Routine mental health screening should be performed on all juveniles placed in secure detention facilities to identify those who need treatment services.

Roncero C; Collazos F; Valero S; Casas M. Cannabis consumption and development of psychosis: State of the art. (review). Actas Esponolas de Psiquiatria 35(3): 182-189, 2007. (30 refs.)

Cannabis is the most widely used illegal drug in Spain. Currently, its use is on the rise as risk perception is decreasing, primarily among young people. It is well known that cannabis negatively influences course and prognosis in schizophrenic patients. However, the relationship between cannabis use and development of a psychotic or schizophrenic disorder remains controversial. The study of this topic has been approached using longitudinal cohort studies, which study cannabis use and psychotic or schizophrenic disorders. In addition to the classic Swedish conscript study published by Andreasson et al. 1987, during the past years, six more longitudinal cohort studies have been published. The data demonstrate that there are both temporal and dose-response relationships, and that early initiation of cannabis use is highly correlated with the development of psychotic symptoms. Cannabis consumption can increase the risk of developing schizophrenia in a vulnerable population twofold, to the extent that some studies suggest a causal relationship. The current knowledge base makes it necessary to warn the population about the relationship between cannabis use and the development of psychosis.

Rowe CL; Liddle HA; Greenbaum PE; Henderson CE. Impact of psychiatric comorbidity on treatment of adolescent drug abusers. Journal of Substance Abuse Treatment 26(2): 129-140, 2004. (91 refs.)

Comorbidity of substance abuse disorders (SUD) and psychiatric disorders is one of the most important areas of investigation in contemporary drug abuse treatment research. This study examined the impact of psychiatric comorbidity on the treatment of 182 adolescent drug abusers in a randomized clinical trial comparing family and individual cognitive-behavioral therapy. Three distinct groups of adolescent substance abusers were compared: (1) Exclusive Substance Abusers (SUD only); (2) Externalizers (SUD + externalizing disorder); and (3) Mixed Substance Abusers (SUD + externalizing and internalizing disorder). The purpose of this study was to determine whether adolescents in these comorbid groups differed in clinical presentation and treatment response. More severe comorbidity was associated with greater family dysfunction and being female and younger at intake. An examination of substance use trajectories over time indicated that the Mixed group initially responded to treatment but returned to intake levels of substance use by 1 year post-discharge.

Rumpold G; Klingseis M; Dornauer K; Kopp M; Doering S; Hofer S et al. Psychotropic substance abuse among adolescents: A structural equation model on risk and protective factors. Substance Use & Misuse 41(8): 1155-1169, 2006. (23 refs.)

The use of psychotropic substances in adolescents represents a serious public health problem. In this study a representative sample of 485 Austrian students between 14 and 18 years of age were investigated with a semistructured interview about substance-related issues and completed the general health questionnaire. The following rates of regular psychotropic substance use were found: cigarettes 41.4%, alcohol 44.5%, cannabis 10.1%, and other illicit substances 3%. Logistic regression analyses and structural equation modeling revealed the following major risk factors for substance use: peer pressure, negative family atmosphere, school difficulties, and psychopathology. Knowledge about substance use acted as a protective factor. Prevention of adolescent substance use and misuse should aim at these different targets. Information about coping with peer pressure may be a particularly promising route of intervention.

Scott M; Parthasarathy S; Kohn C; Hinman A; Sterling S; Weisner C. Adolescents with substance diagnoses in an HMO: Factors associated with medical provider referrals to substance abuse and mental health treatment. Mental Health Services Research 6(1): 47-60, 2004. (28 refs.)

This study examines the factors related to referrals of adolescents with substance use disorders to substance abuse or mental health treatment by their medical providers. Administrative and chart review data from the membership of a large private health maintenance organization (HMO) were collected from a probability sample of 400 adolescents, ages 13-18, who were diagnosed with a substance use disorder in 1999. Logistic regression analyses examined referral to substance abuse treatment and referral to mental health treatment in the aggregate and stratified by gender. Documented use of both alcohol and another illicit drug, and legal problems increased likelihood of referral to substance abuse and mental health treatment, whereas diagnoses of alcohol and marijuana use disorders decreased likelihood of referral to substance abuse treatment. Mental health diagnoses played a limited role in both types of referrals, although specific psychosocial problems were associated with increased likelihood of referrals. Treatment history and location of first mention of problem were significant predictors of referral. There were no gender differences in referral rates to either substance abuse or mental health treatment; however predictors of referral differed by gender.

Slesnick N; Prestopnik J. Dual and multiple diagnosis among substance using runaway youth. American Journal of Drug and Alcohol Abuse 31(1): 179-201, 2005. (94 refs.)

Although research on runaway and homeless youth is increasing, relatively little is known about the diagnostic profile of runaway adolescents. The current study examined patterns of psychiatric dual and multiple diagnosis among a sample (N=226) of treatment-engaged substance-abusing youth (ages 13 to 17) who were residing at a runaway shelter. As part of a larger treatment outcome study, the youths' psychiatric status was assessed using the DSM-IV based computerized diagnostic interview schedule for children [CDISC]. The majority of the youth in our sample met criteria for dual or multiple diagnosis (60%) with many having more than one substance-use diagnosis (56%). The severity of mental-health and substance-use problems in this sample of substance-abusing runaways suggests the need for continued development of comprehensive services. The range and intensity of diagnoses seen indicates a need for greater focus on treatment development and strategies to address their multiple areas of risk.

Solorio MR; Milburn NG; Andersen RM; Trifskin S; Rodriguez MA. Emotional distress and mental health service use among urban homeless adolescents. Journal of Behavioral Health Services & Research 33(4): 381-393, 2006. (22 refs.)

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N=688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.

Staller JA. Diagnostic profiles in outpatient child psychiatry. American Journal of Orthopsychiatry 76(1): 98-102, 2006. (7 refs.)

Outpatient child psychiatrists appear to be treating a broadening array of complex, highly comorbid, and difficult-to-treat youths. In this study, designed to evaluate the current demographic and diagnostic profile of outpatient child psychiatric patients 1,292 outpatient records from 8 treatment settings were reviewed. Patient age, race, gender, and diagnoses were recorded and analyzed. Externalizing disorders (ADHD and/or behavior disorders) were diagnosed most frequently, followed by internalizing (depressive and anxiety) disorders. Comorbidity was evident in nearly half of all patients, regardless of age. Substance abuse was infrequently reported as a comorbid condition. Externalizing and internalizing pathology frequently co-occurred. Findings reinforce the need for clinician vigilance and thorough assessment of outpatient children and adolescents.

Stathis S; Martin G. A transdisciplinary approach to adolescent forensic mental health. Australian and New Zealand Journal of Psychiatry 38(9): 746-752, 2004. (57 refs.)

Examined new strategies which may be implemented to address the significant mental health and substance abuse problems of young people within the juvenile justice system. A wide-ranging literature review of mental health problems within the juvenile justice population is given, illustrating the high prevalence of mental health problems within this cohort of young people. Reference is made to the differing demographics and agendas of the American justice system compared to that found in Australia. It is suggested that new initiatives stemming from quality Australian studies are required in order to facilitate reform within adolescent forensic mental health. Psychiatrists need to be at the forefront of innovative policy delivery within the juvenile justice system. A transdisciplinary approach is required to meet the changing needs of young people within the juvenile justice system. Such a system of care recognizes that these young people and their families have multiple needs that cross traditional boundaries and a collaborative approach across agencies is essential at both the policy and practical level. Psychiatrists have an important role to play in the development of these services. A systemic process to address such needs is offered.

Stathis SL; Letters P; Doolan I; Whittingham D. Developing an integrated substance use and mental health service in the specialised setting of a youth detention centre. Drug and Alcohol Review 25(2): 149-155, 2006. (53 refs.)

This article describes the frequency of co-morbid substance use and mental health problems of young people within the youth justice system and demonstrates that mental health and drug and alcohol services can be integrated and work effectively. The establishment of an integrated Mental Health Alcohol Tobacco and Other Drugs Service (MHATODS) to juveniles in detention represents a shift away from the traditional paradigm of separate services frequently found throughout Australia. The development of referral procedures and adolescent-focused treatment programmes that are tailored to the specific needs of this disadvantaged population are discussed. A wide-ranging literature review illustrates the consequences of the high prevalence of co-morbid substance use and mental health problems in juveniles within the youth justice system. A retrospective and descriptive account is given of the expansion of the MHATODS, including the recruitment of an Indigenous health worker, the incorporation of an automatic referral process for young people with substance use problems and the development of a brief four-session drug and alcohol counselling programme and a group relapse prevention programme. The proportion of Indigenous clients referred to MHATODS is now equitable to referrals of non-Indigenous youth. The introduction of an automatic voluntary referral process resulted in an increase in referrals for drug and alcohol assessment and counselling from 17% to 64% of total referrals. Of those young people commencing the drug and alcohol programme, 32% completed all sessions. While young people reportedly enjoyed the group programme, feedback from participants indicated that they felt vulnerable in a group setting. MHATODS recognises the limitations of the prevailing paradigm of separate service delivery for mental health and drug and alcohol treatment, and has developed an integrated treatment service for juveniles in detention. The service has expanded its referral base for substance use problems by employing an Indigenous health worker, and initiating an automatic referral process for young people admitted into detention who have a history of significant substance use. Early evidence indicates increased utilisation of drug and alcohol services by young people in detention.

Stefanis NC; Delespaul P; Henquet C; Bakoula C; Stefanis CN; Van Os J. Early adolescent cannabis exposure and positive and negative dimensions of psychosis. Addiction 99(10): 1333-1341, 2004. (38 refs.)

Aims: To investigate the effect of exposure to cannabis early in adolescence on subclinical positive and negative symptoms of psychosis. Design: Cross-sectional survey in the context of an ongoing cohort study. Setting: Government-supported general population cohort study. Participants: A total of 3,500 representative 19-year olds in Greece. Measurements: Subjects filled in the 40-item Community Assessment of Psychic Experiences, measuring subclinical positive (paranoia, hallucinations, grandiosity, first-rank symptoms) and negative psychosis dimensions and depression. Drug use was also reported on. Findings Use of cannabis was associated positively with both positive and negative dimensions of psychosis, independent of each other, and of depression. An association between cannabis and depression disappeared after adjustment for the negative psychosis dimensions. First use of cannabis below age 16 years was associated with a much stronger effect than first use after age 15 years, independent of life-time frequency of use. The association between cannabis and psychosis was not influenced by the distress associated with the experiences, indicating that self-medication may be an unlikely explanation for the entire association between cannabis and psychosis. Conclusions: These results add credence to the hypothesis that cannabis contributes to the population level of expression of psychosis. In particular, exposure early in adolescence may increase the risk for the subclinical positive and negative dimensions of psychosis, but not for depression.

Steuber TL; Danner F. Adolescent smoking and depression: Which comes first? (rapid communication}. Addictive Behaviors 31(1): 133-136, 2006. (7 refs.)

Despite the well-known health risks of smoking, adolescents continue to smoke at alarming rates. Smoking is also known to be associated with depression, but the direction of this relation is unclear. This study used data from the National Longitudinal Study of Adolescent Health (Add Health) to evaluate the direction of the relation between cigarette smoking and depression among adolescents. A total of 14,634 adolescents (7132 males and 7502 females) completed in-home surveys in 1995 and 1996 and were split into four smoking status groups. Adolescents who were Starters, Quitters, and Maintainers were found to be 1.5, 1.4, and 2.0 times more likely, respectively, than Nevers to be depressed at Time 2. In addition, females showed a striking pattern of increases in depression around the onset of smoking and decreases around the time of quitting. While these findings do not prove that smoking leads to depression, they are consistent with such a prediction.

Strong DR; Kahler CW; Abrantes AM; MacPherson L; Myers MG; Ramsey SE et al. Nicotine dependence symptoms among adolescents with psychiatric disorders: Using a Rasch model to evaluate symptom expression across time. Nicotine & Tobacco Research 9(5): 557-569, 2007. (62 refs.)

Little is known about the longitudinal course of symptoms of nicotine dependence among adolescents following interventions designed to affect smoking behavior, particularly among high-risk samples. We used an item-response modeling strategy to examine how well nicotine dependence symptoms cohere to a latent construct, the stability of the construct over time, and the sensitivity of the nicotine dependence symptoms to changes in smoking patterns among adolescents with comorbid psychopathology. Assessments occurred prior to cessation treatment delivered within a randomized clinical trial and again at 6 and 12 months after treatment. We used a Rasch item-response modeling approach to examine nicotine dependence as measured by a structured Adolescent Nicotine Dependence Interview (ANDI) and by the Modified Fagerstrom Tolerance Questionnaire (mFTQ). These analyses provided support for a unidimensional latent measurement model that can be used to organize symptoms of nicotine dependence obtained from ANDI and mFTQ measures. The derived measure showed good construct validity with significant relationships to smoking levels and salivary cotinine levels. The typical symptom patterns and the relative severity of nicotine dependence symptoms remained stable over multiple assessments. Changes in smoking levels were related longitudinally to changes in nicotine dependence, and changes in nicotine dependence were related to changes in motivation to quit and readiness to change smoking behavior. Several behavioral symptoms were sensitive to change in smoking rate over time, whereas core symptoms of physiological dependence did not evidence significant changes. Results suggest that DSM-IV and mFTQ measures of nicotine dependence provide complementary information when assessing nicotine dependence levels among adolescents with psychiatric disorders.

Strong DR; Kahler CW; Ramsey SE; Abrantes A; Brown RA. Nicotine withdrawal among adolescents with acute psychopathology: An item response analysis. Nicotine & Tobacco Research 6(3): 547-557, 2004. (51 refs.)

The present study explored the relationship between psychopathology and the experience of nicotine withdrawal among 191 adolescent smokers deprived of nicotine during a psychiatric hospitalization. Using methods based in item response theory, we demonstrated the ability of symptoms of nicotine withdrawal to cohere in measuring the withdrawal syndrome. After controlling for nicotine dependence, we found that several disorders showed significant but modest univariate relationships with individual withdrawal symptoms. After controlling for comorbidity with other disorders, we found that depressive and conduct disorders maintained significant but modest relationships with increased withdrawal severity. Item analyses across groups suggested that girls, individuals with a depressive disorder, and individuals with a conduct disorder tended to report higher levels of nicotine withdrawal but did not appear to inflate their scores because of disorder- or gender-specific reporting bias. Although levels of acute distress were related to withdrawal severity, the six-item withdrawal index showed good discriminant validity in this sample by demonstrating stronger correlations with craving and level of dependence than could be accounted for by levels of distress alone.

Sung MJ; Erkanli A; Angold A; Costello EJ. Effects of age at first substance use and psychiatric comorbidity on the development of substance use disorders. Drug and Alcohol Dependence 75(3): 287-299, 2004. (59 refs.)

In this paper, we examine the effects of age at first substance use, and history of psychiatric disorders, on the development of substance use disorder (SUD) by age 16. We use a prospective, longitudinal design to disaggregate the effects of age at first use and time since first use on the development of adolescent SUD. Second, we test the hypothesis that adolescent SUD is an unlikely progression from early substance use unless children also show other early conduct problems. A population sample of 1420 children from the Great Smoky Mountains Study (GSMS) was assessed annually between ages 9 and 16. Logistic regression models were applied within the hierarchical Bayesian framework, where the covariate effects were described by time-varying parameters having a first-order auto-regressive prior distribution. Posterior analyses based on a Gibbs sampling approach revealed that, controlling for years of exposure, the risk of transition to SUD increased with age at onset for onsets before age 13, but began to fall for onset at 14. Among users, use alone, without early conduct problems, led to a 11% prevalence of SUD by age 16. Past conduct disorder (CD) had a strong additive effect at ages 13-15, but at age 16, when substance use and abuse became more normative, the excess risk from prior CD decreased. Boys, but not girls, with a history of depression were at increased risk of SUD. Anxiety increased the risk of SUD in girls at age 16, but not before that. Results only partially support the study hypothesis; early use was a major predictor of adolescent SUD even in the absence of CD.

Tao FB; Xu ML; Kim SD; Sun Y; Su PY; Huang K. Physical activity might not be the protective factor for health risk behaviours and psychopathological symptoms in adolescents. Journal of Paediatrics and Child Health 43(11): 762-767, 2007. (24 refs.)

Aim: This study aims to examine the effect of physical activity (PA) intensity on tobacco or alcohol abuse, suicide behaviours and psychopathological symptoms in junior and senior high school students in China. Methods: A total of 5453 students from nine middle schools participated in a self-administered anonymous survey to report their frequency of moderate and vigorous physical activity at a normal learning week. Tobacco or alcohol use in the past 30 days, suicide behaviours during the past 12 months were asked. The Symptoms Checklist 90 was used to assess general mental problem and nine special psychopathological symptoms. The Rosenberg's Self-esteem Scale and School Life Satisfaction Rating Questionnaire for Adolescent were selected to rate the respondents' self-esteem and school life satisfaction. Results: Percentage of high-, low-moderate- and very-low-intensity physical activity was 22.0%, 37.0% and 41.0%, respectively. By using multivariable multinomial logistic regression, it was indicated that low-moderate-intensity physical activity was a protective factor of depression (odds ratio (OR) was 0.61, 95% confidence interval (CI) was 0.40-0.91) and psychotic symptoms (OR 0.54, 95% CI 0.31-0.93), while high-intensity physical activity was a risk factor of binge drinking (OR: 1.81, 95% CI: 1.29-2.54), suicide ideation (OR: 1.26, 95% CI: 1.04-1.54), general psychological disorders (OR: 1.43, 95% CI: 1.11-1.84), and hostile symptoms (OR: 1.46, 95% CI: 1.03-2.07). Conclusion: Different intensity physical activity in adolescents had different association with risk health behaviours and psychopathological symptoms. The reasons are worth further researching.

Tarter RE. Psychological evaluation of substance use disorder in adolescents and adults. IN: Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. pp. 37-62. (93 refs.)

Psychological evaluation is directed at characterizing cognitive, emotional and behavioral processes. The evaluation of substance use disorders focuses on multiple domains. Instruments are described which have practical utility, have been evaluated and which are applicable to diverse populations. The chapter is organized into three sections. Section I discusses the scope and requirements of a psychological assessment. Section II describes the methods for conducting an assessment. the relevant domains are cognitive strengths and weakness, emotion, health status, psychiatric comorbidity, personality, family adjustment, social adjustment in respects to functioning, peers, social skills, school/vocational adjustment, and recreation. Section III presents a decision-tree format that links the results of psychometric evaluation to specific modes of treatment.

Teplin LA; Elkington KS; McClelland GM; Abram KM; Mericle AA; Washburn JJ. Major mental disorders, substance use disorders, comorbidity, and HIV-AIDS risk behaviors in juvenile detainees. Psychiatric Services 56(7): 823-828, 2005. (32 refs.)

Objectives: This study determined the prevalence of 20 HIV-AIDS risk behaviors of four groups of juvenile detainees: those with major mental disorders alone, those with substance use disorders alone, those, with comorbid mental and substance use disorders, and those without any, major-mental or substance use disorder. Methods: Interviewers administered the AIDS Risk Behavior Assessment to 800 randomly selected juvenile detainees aged ten to 18 years who were initially arrested between 1997 and 1998. Diagnoses were determined with the Diagnostic Interview Schedule for Children, Version 2.3. Results: The sample included 340 females and 460 males. As with the other groups of detainees, youths with major mental disorders had a high prevalence of most HIV-AIDS risk behaviors, much higher than the rates found among youths in the general population. Comorbid substance use disorders substantially increased risk; 96 percent of youths in this group had been sexually active, 62 percent had had multiple partners within the past three months, and 59 percent had had unprotected vaginal sex in the past month. Among youths with a substance use disorder, either alone or with a comorbid major mental disorder, more than 63 percent bad engaged in five or more sexual risk behaviors. Conclusions: Delinquents with substance use disorders, either with or without comorbid major mental disorders, are at particular risk of HIV-AIDS. The juvenile justice and public health systems must provide HIV-AIDS interventions is well as mental health and substance abuse treatment. Greater coordination between community services and correctional facilities can reduce the prevalence of HIV-AIDS risk behaviors of juvenile delinquents and stem the spread of HIV infection among young people.

Thatcher DL; Cornelius JR; Clark DB. Adolescent alcohol use disorders predict adult borderline personality. Addictive Behaviors 30(9): 1709-1724, 2005. (50 refs.)

Background: This study investigated adolescent alcohol use disorders (AUDs) and other characteristics as predictors of adult borderline personality disorder (BPD) symptoms. Methods: Adolescents with AUDs (n=355) were recruited from clinical treatment sources and adolescents without AUDs (n=169) were recruited from the community. During an adolescent assessment (age 16 +/- 1.3), childhood physical and/or sexual abuse history, AUDs and associated psychiatric disorders were measured via semi-structured interviews. Symptoms of BPD were measured in a young adult follow-up assessment (age 22 +/- 2.4). Latent class analysis was utilized to classify individuals into four categories based upon BPD symptom profiles. Results: Multinomial regression models indicated that adolescent AUDs and other psychiatric disorders mediated the relationship between child physical and/or sexual abuse and adult BPD latent class. Conclusions: Results were consistent with a developmental conceptualization of BPD, with AUDs and other adolescent psychopathology antecedents representing developmentally relevant forms of dysregulation, and in their more severe forms culminating in borderline symptomatology.

Tomlinson KL; Brown SA; Abrantes A. Psychiatric comorbidity and substance use treatment outcomes of adolescents. Psychology of Addictive Behaviors 18(2): 160-169, 2004. (58 refs.)

Treatment outcomes of 126 adolescents (13-18 years old) with comorbid substance use disorders (SUDs) and Axis I psychiatric disorders (mood, anxiety, conduct, and attention-deficit/hyperactivity disorders) were compared to 81 SUD adolescents with no additional Axis I disorder. Participants completed structured interviews and symptom measures while participating in an adolescent treatment program and at 6 months following treatment. Results indicated that comorbid youth received more treatment during the outcome period; despite this, more comorbid SUD-Axis I disordered adolescents used substances following treatment than SUD-only youth, even after controlling for socioeconomic status and ethnicity. Among comorbid youth, internalizing disordered adolescents were less likely to use substances during the follow-up period, and externalizing disordered youth returned to substance use most rapidly after discharge from treatment.

Trupin EW; Turner AP; Stewart D; Wood P. Transition planning and recidivism among mentally ill juvenile offenders. Behavioral Sciences and the Law 22(4): 599-610, 2004. (38 refs.)

Objectives: To determine the extent to which transition planning and community service would predict lower levels of recidivism among mentally ill juvenile offenders. Design: Review of legal, medical and social service records including examination of 3-month period following community release. Participants: juvenile offenders incarcerated for 6 months or more (N = 44) transitioning to community. Measures: Child and Adolescent Functional Assessment Scale (CAFAS), sum of different documented pre- and post-release discharge planning contacts, documented community service contacts. Outcomes: Re-offense during the first year post-release. Results: Documented community service contacts in the 3 months following discharge were rare for mental health (20.5%), substance abuse (38.6%), financial assistance (29.9%), and school placement (34.1%). The average number of different pre-release and post-release discharge planning contacts was also low, M(SD) = 1.86(1.68) and M(SD) = 2.34(1.71) respectively. Post-release discharge planning and the receipt of financial assistance and mental health services were all associated with lower levels of reoffending. Conclusions: Community transition planning, including the coordination and provision of community services, is an essential component of community reintegration for juvenile offenders and is associated with lower rates of recidivism during the first year post-discharge.

Turner WC; Muck RD; Muck RJ; Stephens RL; Sukumar B. Co-occurring disorders in the adolescent mental health and substance abuse treatment systems. Journal of Psychoactive Drugs 36(4): 455-462, 2004. (44 refs.)

This article explores the rates of co-occurring disorders in two large federally-funded programs that target youth. In the mental health treatment system, the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) supports the Comprehensive Community Mental Health Services for Children and Their Families Program. SAMHSA's Center for Substance Abuse Treatment (CSAT) supports a number of grant programs providing substance abuse treatment for adolescents. The data from these programs underscores the need for the use of systematic, validated, biopsychosocial assessment instruments for all youth entering either the substance abuse or mental health treatment systems. The current evidence base for models of co-occurring treatment for youth is discussed and recommendations made for future activity related to adolescent co-occurring treatment.

Upadhyaya HP; Brady KT; Wang W. Bupropion SR in adolescents with comorbid ADHD and nicotine dependence: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry 43(2): 199-205, 2004. (35 refs.)

OBJECTIVE: Bupropion SR has been shown to be effective for the treatment of nicotine dependence in adults. This open-label pilot study was designed to examine the feasibility and preliminary tolerability of bupropion SR in adolescents with nicotine dependence. METHOD: Sixteen adolescents aged 12 to 19 years were enrolled in the study. Eleven of the 16 participants also had comorbid attention-deficit/hyperactivity disorder (ADHD). Participants were titrated over 1 week to bupropion SR 150 mg b.i.d. and maintained at this dosage for 6 weeks. Participants also received two brief smoking cessation counseling sessions. RESULTS: Nine participants received at least 4 weeks of medication. There was a significant decrease in the average number of cigarettes smoked (p <.00) and carbon monoxide levels (p =.04) over the course of treatment. Intent-to-treat analysis showed that 31.25% of the adolescents were completely abstinent (5/16) after 4 weeks of taking bupropion SR. Participants' weight did not change significantly during the study (p =.55). There was a no significant change in ADHD symptoms during the study (p =.1). CONCLUSIONS: Bupropion SR along with brief counseling may be safe and potentially efficacious for adolescents with nicotine dependence with and without ADHD. Smoking cessation trials in adolescents need to focus on strategies to increase retention for optimal effect.

Upadhyaya HP; Rose K; Wang W; O'Rourke K; Sullivan B; Deas D et al. Attention-deficit/hyperactivity disorder, medication treatment, and substance use patterns among adolescents and young adults. Journal of Child & Adolescent Psychopharmacology 15(5): 799-809, 2005. (53 refs.)

Objective: The aim of this study was to examine the relationship between current active attention-deficit/hyperactivity disorder (ADHD) symptoms, medication treatment, and substance use patterns among college students. Method: Three hundred and thirty-four students at a local college were surveyed for current ADHD symptoms and psychopharmacological treatment. The survey was conducted in conjunction with an annual national survey that probes students about their substance use patterns and attitudes. Results: Participants with ADHD as ascertained by medication treatment of ADHD had greater past-year tobacco and marijuana use. Among those with ADHD, participants with active ADHD symptoms were more likely to have past-year tobacco and other drug (besides tobacco, alcohol, and marijuana) use as compared to those without active ADHD symptoms. In addition, participants with active ADHD symptoms were more likely to have past-month "other" drug use as compared to those without active ADHD symptoms. Among those prescribed medications for ADHD, 25% reported ever using their medication to "'get high" and almost 29% reported ever giving or selling their medication to someone else. Conclusions: Results of our preliminary study indicated that ADHD symptom control may be important to protect against increased risk of substance use (particularly tobacco and drugs other than alcohol and marijuana) among college-age students with ADHD. Further studies of misuse/diversion of prescription stimulant medication among college students are needed.

Vaughn MG; Ollie MT; McMillen JC; Scott L; Munson M. Substance use and abuse among older youth in foster care. Addictive Behaviors 32(9): 1929-1935, 2007. (5 refs.)

The purpose of this study was to explore prevalence and predictors of current and lifetime substance use, substance abuse disorder, and polysubstance use among older youth in foster care. Interviews were conducted with 406 17-year old youth (90% of those eligible) in one state's foster care system between December 2001 and June 2003. Forty-five percent of foster care youth reported using alcohol or illicit drugs within the last six months; 49% had tried drugs sometime during their lifetime and 35% met criteria for a substance use disorder. Having a diagnosis of Conduct Disorder and/or living in an independent living situation significantly increased the likelihood of current and lifetime substance use and disorder. A diagnosis of Post Traumatic Stress Disorder also predicted increased likelihood of polysubstance use and substance abuse disorder. In conclusion, older youth in the foster care system report similar levels of lifetime alcohol and illicit substance use when compared to the general adolescent population. However, rates of substance use disorder are high. Particularly at risk for both high rates of use and disorder are youth in independent living situations and youth with a diagnosis of Conduct Disorder or Post Traumatic Stress Disorder.

Verdurmen J; Monshouwer K; Van Dorsselaer S; Ter Bogt T; Vollebergh W. Alcohol use and mental health in adolescents: Interactions with age and gender - Findings from the Dutch 2001 Health Behaviour in School-Aged Children Survey. Journal of Studies on Alcohol 66(5): 605-609, 2005. (29 refs.)

Objective: This study examines the association between alcohol use and mental health in adolescence, specifically the interaction with age and gender. Method: Data were derived from the 2001 Health Behaviour in School-Aged Children (HBSC) survey-a repeated cross-sectional study with a total of 5,730 students aged 12-16 years, carried out as part of the World Health Organization cross-national HBSC Project. A two-stage random sampling procedure was used. Written questionnaires were administered in classroom settings. These contained questions about alcohol and other drug use as well as sociodemographic and behavioral variables. In addition, the Youth Self-Report was used to assess mental health. Results: Weekly alcohol use among adolescents is related to less withdrawn behavior and more delinquent, aggressive behavior. Significant interactions between weekly alcohol use and age were found on both externalizing and internalizing problems, indicating a stronger association between weekly alcohol use and problems among younger adolescents. No interactions with gender were found. Conclusions: Particularly at a young age, the weekly use of alcohol is associated with mental health problems. Regular alcohol use should alert parents and professionals that these adolescents might experience problems in other areas.

Wade D; Harrigan S; McGorry PD; Burgess PM; Whelan G. Impact of severity of substance use disorder on symptomatic and functional outcome in young individuals with first-episode psychosis. Journal of Clinical Psychiatry 68(5): 767-774, 2007. (28 refs.)

Objective: To investigate whether severity of substance use disorder is independently associated with 15-month symptomatic or functional outcome in young individuals with first-episode Psychosis. Method: Ninety-two individuals aged 15 to 30 years with first-episode psychosis participated in a 15-month prospective follow-up study. DSM-IV criteria were used to diagnose psychotic disorders, and DSM-III-R criteria were used to diagnose substance use disorder (abuse or dependence). Measures of outcome included severity of positive and negative symptoms, quality of life, and level of social functioning. Data were collected between March and July 2001 at a specialist first-episode psychosis service and between January and December 1997 at 2 generic mental health services. Results: Multiple linear regression showed that heavy substance use disorder was significantly associated with more severe positive symptoms at 15 months after controlling for the effects of gender, duration of untreated psychosis, and medication adherence (vs. no Substance use disorder, p =.006; vs. mild substance use disorder, p =.023). Heavy substance use disorder was also significantly associated with poorer social functioning at 15 months after controlling for the effects of gender, duration of untreated psychosis, medication adherence, and positive symptoms (vs. no substance use disorder, p =.025; vs. mild substance use disorder, p =.047). Heavy substance use disorder was not associated with negative symptoms or quality of life after controlling for the effects of potential confounding variables. Conclusion: Heavy but not mild substance use disorder appears to be independently associated with poorer symptomatic and functional outcome in young patients with first-episode psychosis.

Wasserman GA; McReynolds LS; Ko SJ; Katz LM; Cauffman E; Haxton W; Lucas CP. Screening for emergent risk and service needs among incarcerated youth: Comparing MAYSI-2 and voice DISC-IV. Journal of the American Academy of Child and Adolescent Psychiatry 43(5): 629-639, 2004. (30 refs.)

Objective: To examine associations between the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2) and Diagnostic Interview Schedule for Children-Present State Voice Version (DISC-IV) and the extent to which they overlap in identifying youths with mental health concerns. Method: Among 325 New Jersey and South Carolina correctional youths, associations were examined using receiver operating characteristic analyses and logistic regression (binomial and multinomial). Results: MAYSI-2 subscales generally mapped best onto homotypic DISC-IV disorders; however, many subscales mapped almost as well onto heterotypic disorders. Alcohol/Drug Use and Suicide Ideation, respectively, identified youths reporting substance disorder and recent attempt; other subscales did not identify parallel DISC-IV disorders as well. Conclusions: MAYSI-2 identifies some DISC-IV disorders better than others. Lack of overlap may result from MAYSI-2's combining diagnostic constructs into single subscales. Substantial percentages of disordered youths were not identified by corresponding subscales. In systems with multiple avenues of referral, the MAYSI-2 is a useful intake screen, but its utility as the sole means for identifying diagnoses for treatment purposes is limited. The authors differentiate between screening for emergent risk and service needs, recommending best practices for a comprehensive approach to mental health assessment among justice youth.

Whitbeck LB; Johnson KD; Hoyt DR; Cauce AM. Mental disorder and comorbidity among runaway and homeless adolescents. Journal of Adolescent Health 35(2): 132-140, 2004. (33 refs.)

Purpose: To investigate prevalence of mental disorder and comorbidity among homeless and runaway adolescents in small to medium sized cities in four Midwestern states. Methods: The study presents lifetime, 12-month prevalence, and comorbidity rates for five mental disorders (conduct disorder, major depressive episode, posttraumatic stress disorder, alcohol abuse, and drug abuse) based on UM-CIDI and DISC-R structured interviews from the baseline interviews of a longitudinal diagnostic study of 428 (187 males; 241 females) homeless and runaway adolescents aged 16-19 years (mean age = 17.4 years, SD = 1.05). The data were collected by full-time street interviewers on the streets and in shelters in eight Midwestern cities of various populations. Separate logistic regression models were used to investigate factors associated with meeting criteria for any disorder and two or more disorders. Results: Lifetime prevalence rates were compared with rates for same-aged respondents from the National Comorbidity Survey (NCS). Homeless and runaway adolescents were six times more likely than same-aged NCS respondents to meet criteria for two or more disorders and were from two to 17 times more likely to meet criteria for individual disorders than. Conclusions: Homeless and runaway adolescents in small and mid-sized Midwestern cities report significant levels of mental disorder and comorbidity that are comparable and often exceed that reported in studies of larger magnet cities.

Whitbeck LB; Johnson KD; Hoyt DR; Walls ML. Prevalence and comorbidity of mental disorders among American Indian children in the Northern Midwest. Journal of Adolescent Health 39(3): 427-434, 2006. (42 refs.)

Purpose: To investigate the prevalence of mental disorder and comorbidity among American Indian children aged 10-12 years from four U.S. reservations and five Canadian reserves in the Northern Midwest. Method: Specially, trained Native interviewers administered the Diagnostic Interview for Children-Revised for 11 diagnostic categories to 736 tribally enrolled children (mean age 11 years) and their female caretakers. Results: Prevalence rates are reported by child self-report, female caretaker reports, and combined caretaker-child reports. Twenty-three percent (combined caretaker-child reports) of the children met criteria for one of the 11 disorders and 9% met criteria for two or more of the disorders. Externalizing disorders were more prevalent than internalizing disorders or substance abuse disorders. The strongest predictor of child mental disorder was a depressed female caretaker. Conclusions: Nearly one-fourth of Native children met criteria for at least one mental disorder. The presence of early mental disorder is an important risk factor for substance use and mental health problems in later life. We need systematic research to identify risk and protective factors for early mental health problems and to identify barriers to services utilization so that we can develop empirically informed, culturally specific prevention programs that address these needs.

Williams RJ; Zolner T; Bertrand LD; Davis RM. Mental health status of infrequent adolescent substance users. Journal of Child & Adolescent Substance Abuse 14(2): 41-60, 2004. (54 refs.)

Frequent substance use has a strong association with poor mental health. The relationship between infrequent substance use and mental health is less clear. The present study investigated this relationship in a large group (n = 2118) of 12-19-year-olds from Alberta, Canada. Results indicated that adolescents who used tobacco or alcohol once a month or less tended to have equivalent mental health status to abstainers. Using cannabis 3-5 times/year or less had no adverse mental health associations. However, poorer mental health was associated with single time use of hallucinogens or other drugs. In general, substance usage tended to have more negative mental health associations for younger compared to older adolescents.

Wilson JJ; Levin FR. Attention-deficit/hyperactivity disorder and early-onset substance use disorders. Journal of Child & Adolescent Psychopharmacology 15(5): 751-763, 2005. (94 refs.)

In recent years, there has been an increased recognition of the common comorbidity of attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) among adolescents and adults. ADHD can be an important factor in the pathogenesis and maintenance of SUD; moreover, retrospective studies suggest that treating ADHD during childhood may prevent the development of SUD. In addition, treatment of ADHD among adults, and possibly adolescents, with SUD can reduce their risk of relapse. Theoretical mechanisms that may explain the relationship between ADHD and SUD are explored in this paper. Current research and recommended clinical practices related to the diagnosis and treatment of ADHD with SUD in adolescents are discussed as well. More research is needed to definitively assess the effectiveness and safety of medications in this population of youths with ADHD and SUD.

Windle M. Suicidal behaviors and alcohol use among adolescents: A developmental psychopathology perspective. Alcoholism: Clinical and Experimental Research 28(5 Supplement 1): 29S-37S, 2004. (44 refs.)

A developmental psychopathology conceptual model was provided to represent the major categories of risk and protective factors, including alcohol use and binge drinking, that predict suicidal behaviors that range from suicidal thoughts to completed suicides. The conceptual model emphasized the importance of identifying age-specific sets of risk and protective factors to facilitate the development of effective interventions. As an empirical illustration, a multivariate mediation path model was specified and evaluated with a sample of teens. Findings indicated that several distal variables (e.g., difficult temperament, coping motives for drinking, lower family support, higher percentage of friends using alcohol) significantly predicted mediators (e.g., depression, stressful events, binge drinking) that, in turn, predicted suicidal behaviors. Binge drinking significantly predicted suicide attempts over and above the influence of depression and stressful events.

Wu LT; Schlenger WE; Ringwalt CL. Use of nitrite inhalants ("poppers") among American youth. Journal of Adolescent Health 37(1): 52-60, 2005. (40 refs.)

Purpose: We examined the patterns and correlates of nitrite inhalant use among adolescents aged 12 to 17 years. Methods: Study data were drawn from the 2000 and 2001 National Household Surveys on Drug Abuse. Logistic regression was used to identify the characteristics associated with nitrite inhalant use. Results: Among adolescents aged 12 to 17 years, 1.5% reported any lifetime use of nitrite inhalants. The prevalence of lifetime nitrite inhalant use increased to 12% and 14% among adolescents who were dependent on alcohol and any drug in the past year, respectively. Many nitrite inhalant users used at least three other types of inhalants (68%) and also met the criteria for alcohol (33%) and drug (35%) abuse or dependence. Increased odds of nitrite inhalant use were associated with residing in nonmetropolitan areas, recent utilization of mental health services, delinquent behaviors, past year alcohol and drug abuse and dependence, and multi-drug use. Conclusions: Adolescents who had used nitrite inhalants at least once in their lifetime tend to engage in delinquent activities and report co-occurring multiple drug abuse and mental health problems in the past year.

Yen CF; Chong MY. Comorbid psychiatric disorders, sex, and methamphetamine use in adolescents: A case-control study. Comprehensive Psychiatry 47(3): 215-220, 2006. (45 refs.)

The purpose of this case-control study was to elucidate the relative proportions of amphetamine use disorder (AUD) and amphetamine-induced disorder (AID) in a group of adolescents with the use of methamphetamine (MAMP) and to examine the risks for psychiatric comorbidity and sex for MAMP use. Psychiatryric comorbidity in the preceding year was determined for 200 adolescent MAMP users and 400 drug-free control subjects by diagnostic interview using the Kiddie epidemiologic version of the Schedule for Affective Disorders and Schizophrenia. The proportions of AUD and AID were calculated, and the association between psychiatric comorbidity, sex, and MAMP use was assessed. The results revealed that among the MAMP users, 65 subjects (32.5%) had AUD, whereas 19 (9.5%) had AID. Early use of MAMP use was seen in AUD, whereas high-frequency MAMP use was associated with the Occurrence of AID. Alcohol, nicotine, and betel nut use disorders were more prevalent in MAMP users for both sexes. By applying conditional logistic regression analysis, it was demonstrated that MAMP use was associated with conduct disorder in males, whereas in females, it was associated with conduct disorder and adjustment disorder. The results indicated that age of first use and subsequent frequency of MAMP use appeared to be associated with the development of amphetamine-related disorders. Sex differences in the association between psychiatric comorbidity and MAMP use were demonstrated. These factors have to be taken into consideration when intervening for adolescent MAMP use.

Yen CF; Su YC. The associations of early-onset methamphetamine use with psychiatric morbidity among Taiwanese adolescents. Substance Use & Misuse 41(1): 35-44, 2006. (23 refs.)

The purpose of this study was to examine the associations of early-onset methamphetamine (MAMP) use in early adolescence with psychiatric morbidity in adolescents with MAMP use by gender. A total of 299 adolescents with MAMP use in Taiwan were recruited from two juvenile detention centers in Kaohsiung and Taipei from September 1998 to March 2002. Using the Kiddie epidemiological version of the Schedule for Affective Disorders and Schizophrenia (K-SADS-E), each adolescent was interviewed by a child psychiatrist to determine what psychiatric conditions, including substance use disorders (SUDs) and other psychiatric comorbidities might be associated with the early-onset (15 years old or below) MAMP use according to gender In females, early-onset MAMP use was significantly associated with the diagnoses of depressive disorder conduct disorder and amphetamine use disorder In males, however early-onset MAMP use was only significantly associated with amphetamine use disorder Gender differences exist in the association between early-onset MAMP use and psychiatric morbidity. The association between early-onset MAMP use and psychiatric morbidity may have important implications for public health policy and treatment for adolescents with MAMP use.

Yu JW; Buka SL; Fitzmaurice GM; McCormick MC. Treatment outcomes for substance abuse among adolescents with learning disorders. Journal of Behavioral Health Services & Research 33(3): 275-286, 2006. (34 refs.)

This paper assesses whether chemically dependent adolescents with comorbid learning disorders (LDs) derived less effective treatment results when compared to chemically dependent adolescents without LD and examines the moderating effects of prior treatments, treatment length, and treatment completion. Two hundred one adolescents were recruited between 1992 and 1993 from Massachusetts residential treatment centers and subsequently followed up 6 months after enrollment. Compared to chemically dependent teenagers without LD, those with LD were twice as likely to re-use substances at least once by follow-up. LD teenagers were more likely to attend Alcoholics/Narcotics Anonymous if they had prior admissions to treatment programs and longer treatment length. LD teenagers who completed treatment also experienced a greater decrease in current depression compared to LD teenagers not completing the treatment. This study is the first to consider outcomes of substance abuse treatment for adolescents with LD and contributes to the growing literature on comorbidity and substance abuse treatment.

Zimmermann US; Blomeyer D; Laucht M; Mann KF. How gene-stress-behavior interactions can promote adolescent alcohol use: The roles of predrinking allostatic load and childhood behavior disorders. (review). Pharmacology, Biochemistry and Behavior 86(2): 246-262, 2007. (209 refs.)

A variety of environmental and genetic factors modulating the risk for alcoholism have been described, which predominantly act by interacting with each other. For example, the family, peers and society determine the level of exposure to stress and alcohol, while genes modulate how sensitive an individual responds to both. The resulting behaviors feed back to the social environment, modulating and in the worst case increasing further stress exposure. We here review neurobiological evidence how such a process of mutual interaction can involve and affect drinking. In at-risk adolescents it may have been in force for many years before they have their first alcoholic drink, increasing their risk for addiction by generating allostatic load. As an example, psychiatric disorders involving attention deficit, hyperactivity, or disruptive behaviors first evolve during childhood and are influenced by all the above factors. They are also strongly associated with harmful adolescent drinking and later alcohol use disorders. One important implication of this concept is that issues such as family adversity, adolescent psychiatric disorders, or adolescent drinking might not only be associated with, but causally related to, the risk for later addiction. They are targets for preventive interventions, which should start as early as possible in subjects at-risk.