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CORK Bibliography: Adolescents and Psychopathology (Dual Diagnosis)

89 citations. January 2003 to present

Prepared: December 2005

Abrantes AM; Brown SA; Tomlinson KL. Psychiatric comorbidity among inpatient substance abusing adolescents. Journal of Child & Adolescent Substance Abuse 13(2): 83-101, 2003. (39 refs.)

We studied the association between type, severity and sequencing of psychopathology and these same dimensions of substance involvement among inpatient substance-abusing adolescents with comorbid psychiatric disorders. Adolescents (N = 140, 54% female; 15.9 years) meeting DSM-III-R criteria for a substance use disorder and at least one other Axis I psychiatric disorder were interviewed while inpatients in an adolescent psychiatric facility. Findings point to associations between externalizing disorders and a history of regular use of cigarettes, alcohol, and stimulants among comorbid adolescents. When sequencing of psychopathology was examined, different substance use patterns were observed. Severity of depressive disorders was associated with more substance withdrawal symptoms; externalizing symptomatology was related to more substance dependence symptoms, and ADHD severity was associated with more alcohol dependence symptoms. Findings may have important clinical implications such as the need to assess comorbidity early and to develop treatment plans based on type of comorbid psychiatric disorder.

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.)

Anderson RL; Huffine C. Child & adolescent psychiatry: Use of community-based services by rural adolescents with mental health and substance use disorders. Psychiatric Services 54(10): 1339-1341, 2003. (14 refs.)

This column deals with the conundrum of dual diagnosis among adolescents. The problems described are all the more daunting because of the problems of finding services in a rural setting. Her paper, which represents an overview of mental health, substance abuse, and public health, fits well with the column's theme of collaboration and building systems of care.

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.

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.

Bolognini M; Plancherel B; Laget J; Stephan P; Halfon O. Adolescents' self-mutilation: Relationship with dependent behaviour. Swiss Journal of Psychology 62(4): 241-249, 2003. (44 refs.)

The aim of this study, which was carried out in the French-speaking part of Switzerland, was to examine the relationship between suicide attempts and self-mutilation by adolescents and young adults. The population, aged 14-25 years (N= 308), included a clinical sample of dependent subjects (drug abuse and eating disorders) compared to a control sample. On the basis of the Mini Neuropsychiatric Interview (Sheehan et al., 1998), DSM-IV criteria were used for the inclusion of the clinical population. The results concerning the occurrence of suicide attempts as well as on self-mutilation confirm most of the hypotheses postulated: suicidal attempts and self-mutilation were more common in the clinical group compared to the control group, and there was a correlation between suicide attempts and self-mutilation. However, there was only a partial overlap, attesting that suicide and self-harm might correspond to two different types of behaviour.

Boys A; Farrell M; Taylor C; Marsden J; Goodman R; Brugha T et al. Psychiatric morbidity and substance use in young people aged 13-15 years: results from the Child and Adolescent Survey of Mental Health. British Journal of Psychiatry 182: 509-517, 2003. (31 refs.)

Background: Psychoactive substance use is strongly associated with psychiatric morbidity in both adults and adolescents. Aims To determine which of alcohol, nicotine and cannabis is most closely linked to psychiatric disorders in early adolescence. Method Data from 2624 adolescents aged 13-15 years were drawn from a national mental health survey of children. The relationship between psychiatric morbidity and smoking, drinking and cannabis use was examined by logistic regression analyses. Results: Having a psychiatric disorder was associated with an increased risk of substance use. Greater involvement with any one substance increased the risk of other substance use. Analyses of the interactions between smoking, drinking and cannabis use indicated that the relationship between substance use and psychiatric morbidity was primarily explained by regular smoking and (to a lesser extent) regular cannabis use. Conclusions: In this sample, links between substance use and psychiatric disorders were primarily accounted for by smoking. The strong relationship is likely to be due to a combination of underlying individual constitutional factors and drug-specific effects resulting from consumption over the period of adolescent development and growth.

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.

Brody GH; Ge XJ; Kim SY; Murry VM; Simons RL; Gibbons FX et al. Neighborhood disadvantage moderates associations of parenting and older sibling problem attitudes and behavior with conduct disorders in African American children. Journal of Consulting and Clinical Psychology 71(2): 211-222, 2003. (87 refs.)

Data from 296 sibling pairs (mean ages 10 and 13 years), their primary caregivers, and census records were used to test the hypothesis that African American children's likelihood of developing conduct problems associated with harsh parenting, a lack of nurturant-involved parenting, and exposure to an older sibling's deviance-prone attitudes and behavior would be amplified among families residing in disadvantaged neighborhoods. A latent construct representing harsh-inconsistent parenting and low levels of nurturant-involved parenting was positively associated with younger siblings' conduct disorder symptoms, as were older siblings' problematic attitudes and behavior. These associations were strongest among families residing in the most disadvantaged neighborhoods. Future research and prevention programs should focus on the specific neighborhood processes associated with increased vulnerability for behavior problems.

Brook DW; Brook JS; Rosen Z; De la Rosa M; Montoya ID; Whiteman M. Early risk factors for violence in Colombian adolescents. American Journal of Psychiatry 160(8): 1470-1478, 2003. (79 refs.)

This study sought to identify personality, familial, peer, and ecological variables associated with violence in Colombian adolescents. A survey of adolescents was conducted in 1995-1996. A standard self-report measure was adapted that ensured linguistic and cultural relevance. 2,837 adolescents ages 12-17 years from various self-reported ethnic groups were randomly selected from the community in three Colombian cities: Bogota, Medellin, and Barranquilla. Eighty percent of eligible adolescents agreed to participate. Data were collected concerning the adolescent's personality attributes, family characteristics, peer characteristics, and ecological/cultural factors, including the availability illicit drugs and the prevalence of violence in the community. The dependent variable was the adolescent's self-reported frequency of violent behavior. Violence directed at the adolescent and the adolescent's own substance use were both more highly correlated with the adolescent's violent behavior than were other risk factors. Significant risk factors of less importance included tolerance of deviance, peer drug and alcohol use, peer deviance, and exposure to violence on television. Results from this study supported a model in which violent behavior was correlated independently with a number of risk factors from several domains. The findings point to the use of specific intervention procedures for adolescents to prevent their own subsequent acts of violent behavior.

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.

Clark DB; De Bellis MD; Lynch KG; Cornelius JR; Martin CS. Physical and sexual abuse, depression and alcohol use disorders in adolescents: Onsets and outcomes. Drug and Alcohol Dependence 69(1): 51-60, 2003. (66 refs.)

Adolescents with alcohol use disorders (AUDs) often have major depressive disorder (MDD). While physical abuse and sexual abuse (PS Abuse) have been observed to be common in adolescents with AUDs, the influence of PS Abuse on comorbid MDD and AUD has not been determined. The effect of pre-existing PS Abuse on the young adulthood outcomes of adolescents with AUDs has also not been adequately explored. This study examined the relationships among PS Abuse, MDD, and AUD in adolescence, as well as related young adult outcomes. Adolescents (mean age: 16.4 years; range: 14-18 years) were recruited from clinical and community sources and classified into four groups: (1) AUD+PS Abuse (n = 154), (2) AUD only (n = 255), (3) PS Abuse only (n 74), and (4) Controls (n = 268). Subjects were longitudinally assessed through young adulthood (age 19 years or older). Measures included interview assessments of DSM-IV AUD and MDD, classified as "primary" or "secondary", and questionnaire measures of alcohol consumption and depression. Primary MDD preceded AUD whereas secondary MDD had a later onset than AUD. PS Abuse accelerated the onsets of primary MDD, secondary MDD and AUD. While affected adolescents had typically improved in both alcohol consumption and depression at the young adult assessment, the majority of those with adolescent AUD had AUDs in young adulthood, and MDD remained common in those with a history of PS Abuse. These results indicate that MDD among adolescents with AUD may be partly attributable to PS Abuse.

Clark DB; Wood DS; Cornelius JR; Bukstein OG; Martin CS. Clinical practices in the pharmacological treatment of comorbid psychopathology in adolescents with alcohol use disorders. (rapid communication). Journal of Substance Abuse Treatment 25(4): 293-295, 2003. (14 refs.)

This study examined the use of psychiatric medications in 277 adolescents in treatment for alcohol use disorders. Subjects were recruited from addictions treatment sites, psychiatric programs, and juvenile justice settings. Characteristics studied included the use of and indications for specific medications, changes in clinical practices from 1991 through 2000, and continuation of psychopharmacological treatment over a 1-year followup period. Among adolescents taking psychiatric medications at baseline (n = 51), indicated DSM-IV mental disorders were typically present, use of antidepressants was most common (n = 41), benzodiazepine prescription was rare, and about one third reported continuing pharmacological treatment at one-year followup. In those with comorbid major depressive disorder and alcohol use disorders (n = 110), antidepressant medication use increased significantly from 18% to 55% over the decade studied. The treatment setting did not significantly influence antidepressant prescribing practices. The common and increasing use of psychiatric medications in this population emphasizes the urgent need for empirically based clinical guidelines.

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; 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.

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.

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.

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.

Curry JE; Wells KC; Lochman JE; Craighead WE; Nagy PD. Cognitive-behavioral intervention for depressed, substance-abusing adolescents: Development and pilot testing. Journal of the American Academy of Child and Adolescent Psychiatry 42(6): 656-665, 2003. (35 refs.)

To develop a cognitive-behavioral treatment for depressed, substance-abusing adolescents, determine its feasibility, and test its association with symptomatic improvement. Method: Based on the efficacy of cognitive-behavioral interventions for either adolescent depression or substance abuse, an integrated group and family therapy intervention was developed for adolescents with both problems. The developers treated a group of six adolescents and families, and then trained experienced therapists to deliver the treatment to a second group of seven. Adolescents were 14 to 18 years of age. Measures of depression and substance abuse were collected before, during, and after treatment. Results: High retention in treatment and attendance at sessions supported feasibility. Parent interviews demonstrated significant improvement in adolescent substance abuse, and adolescent measures demonstrated significant improvement in both domains. Conclusions: Integrated outpatient cognitive-behavioral intervention is feasible and associated with improvement for depressed, substance-abusing adolescents. Controlled efficacy studies are needed. Additional treatment modalities will be required for a proportion of these adolescents.

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.

Delligatti N; Akin-Little A; Little SG. Conduct Disorder in girls: Diagnostic and intervention issues. Psychology in the Schools 40(2): 183-192, 2003. (27 refs.)

Current prevalence rates of Conduct Disorder (CD) in girls may be an underestimate due to inappropriate diagnostic criteria, biased perceptions by those responsible for reporting problematic behavior, and differential social constraints for each gender. Relatively few published studies of CD and related behaviors in girls exist. Available evidence suggests adolescent girls with CD have a poor outcome including early and violent death, arrest, substance abuse and dependence, antisocial personality disorder, failure to finish high school, pregnancy, sexual promiscuity, and contraction of sexually transmitted disease. Even with its relatively low, possibly underestimated prevalence rate in comparison with that of boys, CD has been found to be the second most common psychiatric disorder in adolescent girls. In addition to examining possible reasons for the lack of research on CD in girls, this article reviews possible risk factors and suggested assessment and intervention strategies for this population. Particular attention is paid to implications for practitioners in the school setting.

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.

Fisckenscher A; Novins D. Gender differences and conduct disorder among American Indian adolescents in substance abuse treatment. Journal of Psychoactive Drugs 35(1): 79-84, 2003. (25 refs.)

Studies have found high prevalences of conduct disorder among youth in residential substance abuse treatment programs, but no studies have examined this issue among American Indian adolescents while taking into account gender differences. The Diagnostic Interview Schedule for Children, Youth Version and the Composite International Diagnostic Interview, Substance Abuse Module were used to determine the diagnostic status of 89 American Indian adolescents aged between 13 and 18 years who were admitted to a residential treatment program. Seventy-four percent of the adolescents met full DSM-IV criteria for conduct disorder. More than 85% of the participants met at least one criterion for conduct disorder. Conduct disorder was common among both boys and girls in this sample of American Indian adolescents, but the specific antisocial behaviors displayed and their relationships to other psychiatric disorders varied by gender.

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.

Garland AF; Aarons GA; Brown SA; Wood PA; Hough RL. Diagnostic profiles associated with use of mental health and substance abuse services among high-risk youths. Psychiatric Services 54(4): 562-564, 2003. (10 refs.)

This study examined use of mental health services by 947 high-risk youths in a publicly funded system of care to determine how single and comorbid diagnostic profiles (psychiatric and substance use disorders) were associated with use of a variety of types of formal and informal services. It was found that use of professional services was most likely for youths with non-substance use psychiatric disorders, those with comorbid disorders, and those for whom high caregiver strain was reported. Also, the use of informal services, such as peer support groups, was most likely for youths with substance use disorders, those with comorbid disorders, and those who had had police contact. Unmet need for mental health services was greatest among youth with substance use disorders only.

Giaconia RM; Reinherz HZ; Paradis AD; Stashwick CK. Comorbidity of substance use disorders and Posttraumatic Stress Disorder in adolescents. IN: Ouimette P; Brown PJ, eds. Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders. Washington DC: American Psychological Association, 2003. pp. 227-242. (645 book refs.)

There is relatively little research on the association of PTSD and substance use disorders among adolescents. This chapter reviews the evidence on this comorbidity in the adolescent age group. It evaluates the prevalence, patterns of onset, and impact on psychosocial functioning. It begins with consideration of the risks for these disorders individually and then in combination. The next major topic discussed in the patterns of onset, followed by explanations of the link between substance use disorders and PTSD in this age group. One explanation is that the substance use increases the risk for exposure to trauma because substance users may engage in risky behaviors that enhance the likelihood of trauma. (There is substantial evidence that those with substance use problems are three to five times more likely to have experienced a trauma involving harm to themselves, or 3-5 times more likely to witness harm to others.) Another explanation is that substance use may increases the odds of PTSD because it diminishes the capacity to cope effectively with trauma. (The evidence suggests that following trauma those with a substance use problem are at increased risk for developing PTSD. However, there is no direct evidence documenting how the ability to manage trauma is diminished.) A third explanation is the "self-medication" hypothesis, suggesting that substance use begins after the onset of trauma to manage the distress. (While some research supports this temporal relationship that does not provide direct evidence of a causal relationship or indicate self-medication.)

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.

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.

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.

Hauenstein EJ. Depression in adolescence. Journal of Obstetric, Gynecologic and Neonatal Nursing 32(2): 239-248, 2003. (32 refs.)

Major depressive disorder is a common problem for adolescents. It has a wide array of symptoms affecting somatic, cognitive, affective, and social processes. Academic failure, poor peer relationships, behavioral problems, conflict with parents and other authority figures, and substance abuse are some of the consequences of major depressive disorder in this age group. Effective treatments include nontricyclic antidepressants and coping skills training. The nurse is key to depression detection and suicide prevention, especially in primary care settings. Through psychoeducation, nurses can promote recovery from depression by encouraging a healthy lifestyle, enhancing social skills, and assisting the adolescent to identity and use sources of social support. These measures can prevent premature death and promote long-term well-being of the adolescent.

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.

Hser YI; Grella CE; Collins C; Teruya C. Drug-use initiation and conduct disorder among adolescents in drug treatment. Journal of Adolescence 26(3): 331-345, 2003. (27 refs.)

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.

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.

Kelly TM; Donovan JE; Cornelius JR; Bukstein OG; Delbridge TR; Clark DB. Psychiatric disorders among older adolescents treated in emergency departments on weekends: A comparison with a matched community sample. Journal of Studies on Alcohol 64(5): 616-622, 2003. (24 refs.)

Objective: This study was undertaken to explore the characteristics of young patients treated in emergency departments (EDs) who follow through with an evaluation for psychiatric disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and to investigate differences in rates of psychiatric disorders between ED-treated adolescents and demographically similar adolescents recruited from the community. Method: Sixty three older adolescents (40 males) who were treated at two urban university hospital EDs were matched one-to-one on age, gender and race with 63 adolescents recruited from the community for participation in studies at an alcohol research center. Comprehensive psychiatric interviews were conducted with both groups. Results: ED-treated adolescents were diagnosed with higher rates of current alcohol use disorders (AUDs), current drug use disorders and current major depression than were community controls. The ED sample had a particularly high rate of the DSM-IV "hazardous use" of alcohol symptom. ED-treated adolescents also had a higher rate of lifetime comorbid alcohol use disorders and drug use disorders, as well as a higher rate of lifetime comorbid alcohol use disorders and major depression, compared with the community controls. Conclusions: Adolescents who are treated in EDs should be routinely assessed for the presence of AUD, drug involvement and depressive disorders.

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.

Kinney J. Loosening the Grip: A Handbook of Alcohol Information. Seventh Edition. New York: McGraw-Hill, 2003. (chapter refs.)

This is the seventh edition of a handbook on alcohol use and alcohol problems. The book examines the full range of psychological factors, physiological effects, prevention strategies, treatment options, and family concerns related to substance abuse, focusing on alcohol as the most common substance. The chapters deal with (1) (2) acute effects of alcohol on the body; (3) the nature and course of alcohol dependence; (4) etiology, in terms of genetic, psychological, and environmental factors; (5) medical complications (6) behavioral aspects of alcohol dependence; (7) family issues; (8) evaluation and treatment; (9) special populations; (10) psychiatric considerations; (11) other drugs use, by drug class, with information of desired effects, acute effects, chronic effects, use patters, and types and patterns; and (12) professional principles and issues. Appendices include a list of North American substance abuse field organizations, a table presenting alcohol's interaction with other drugs, and online Internet resources for educators.

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.

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.

Lipschitz DS; Rasmusson AM; Anyan W; Gueorguieva R; Billingslea EM; Cromwell PF; Southwick SM. Posttraumatic stress disorder and substance use in inner-city adolescent girls. Journal of Nervous and Mental Disease 191(11): 714-721, 2003. (27 refs.)

The purpose of this study is to examine rates of nicotine, marijuana, and alcohol use as well as patterns of problematic substance use and posttraumatic stress disorder (PTSD) symptoms in inner-city adolescent girls. One hundred four adolescents who obtained medical care at a hospital-based adolescent clinic were systematically surveyed for trauma exposure, posttraumatic stress symptoms, and substance use. A subset (N = 54, 52%) of girls completed a semistructured psychiatric diagnostic interview (K-SADS-PL) to ascertain timing of PTSD symptoms relative to substance use. Compared with traumatized girls without PTSD, girls with full and partial PTSD were significantly more likely to use nicotine, marijuana, and/or alcohol on a regular basis. Fifteen girls met criteria for both PTSD and a substance-use disorder. For 80% of these girls, the age of onset of PTSD was either before or concurrent with the onset of their substance-use disorder. Inner-city adolescent girls with PTSD exhibit problematic substance use and may be at high risk of developing a comorbid substance-use disorder.

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.

Marshal MP; Molina BSG; Pelham WE. Childhood ADHD and adolescent substance use: An examination of deviant peer group affiliation as a risk factor. Psychology of Addictive Behaviors 17(4): 293-302, 2003. (56 refs.)

Deviant peer group affiliation was evaluated as a risk factor for substance use in adolescents with childhood attention-deficit/hyperactivity disorder (ADHD). Results showed that deviant peer affiliation mediated the relationship between ADHD and substance use, suggesting that children with ADHD are more likely than children without ADHD to become involved with deviant peers and, as a result, more likely to use substances. Moreover, the relationship between deviant peer affiliation and substance use was stronger for adolescents with ADHD, suggesting that once they are immersed in a deviant peer group, adolescents with ADHD are more vulnerable to the negative social influences of that group. This study is the first step in identifying high-risk pathways from childhood ADHD to substance use in adolescence.

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.

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.

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.

O'Neill ML; Lidz V; Heilbrun K. Adolescents with psychopathic characteristics in a substance abusing cohort: Treatment process and outcomes. Law and Human Behavior 27(3): 299-313, 2003. (49 refs.)

Psychopathy is a condition with important consequences both for individuals who experience it and for the communities in which they live. Although the assessment of psychopathy among adolescents remains controversial, some evidence suggests that the affective and behavioral traits of adult psychopathy begin to emerge in childhood (B.B. Lahey & A. Kazdin, 1990) and continue across the lifespan (A. E. Forth, S. D. Hart, & R. D. Hare, 1990). The present study used the Psychopathy Checklist: Youth Version (PCL: YV; A. E. Forth, S. D. Kosson,& R. D. Hare, in press) to retrospectively assess psychopathic characteristics, treatment process, and outcomes of 64 individuals referred for treatment to a substance abuse program for adjudicated adolescents. This study focused on the relationship between psychopathic characteristics and treatment process and outcome variables, including attrition rates, quality of participation, substance use throughout treatment, clinical improvement, and 12-month recidivism rates. Psychopathic characteristics were negatively related to treatment process and outcome variables, including attrition, participation, substance use, and clinical improvement. Psychopathic characteristics were positively related to the number of arrests in the 12 months following treatment completion. Implications for treatment and future research with adolescents displaying psychopathic characteristics are discussed.

Potter CC; Jenson JM. Cluster profiles of multiple problem youth: Mental health problem symptoms, substance use, and delinquent conduct. Criminal Justice and Behavior 30(2): 230-250, 2003. (47 refs.)

The prevalence and patterns of co-occurring mental health problem symptoms, substance use, and delinquent conduct were examined in a sample of multiple problem, detained youth. Three distinct patterns of co-occurrence were found using cluster analysis. Youth in two of the clusters had moderate mental health problems but differed in the severity of substance abuse and delinquent conduct. A third group displayed serious mental health symptoms and suicidality coinciding with high rates of substance use and crime.

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.

Riggs PD. Treating adolescents for substance abuse and comorbid psychiatric disorders. Science & Practice Perspectives 2(1), 2003. (25 refs.)

Recent research has identified a cluster of standardized approaches that effectively treat adolescents with substance abuse disorders. Many of these approaches share elements that may be adopted to improve outcomes in substance treatment programs. In adolescents, treatment goals should be informed by a comprehensive assessment that includes the adolescent patient's developmental history and evaluation of psychiatric comorbidity. Treatment for behavioral, psychosocial, and psychiatric problems should be integrated with substance abuse interventions. The author describes practical clinical guidelines, grounded in current research, for providing integrated treatment services. Special emphasis is given to strategies for integrating the treatment of comorbid psychiatric disorders with substance use disorders in adolescents.

Public Domain

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.

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.

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.

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.

Shane PA; Jasiukaitis P; Green RS. Treatment outcomes among adolescents with substance abuse problems: The relationship between comorbidities and post-treatment substance involvement. Evaluation and Program Planning 26(4): 393-402, 2003. (53 refs.)

This study examines comorbid mental disorders in relation to post-treatment outcomes (12 months post-intake) among adolescents (N = 419) who entered three residential drug treatment programs. When contrasted with youths who had no comorbid mental disorders or youths with a single comorbid condition, those with combined internalizing and externalizing disorders (mixed comorbidity) had higher levels of substance-related problems and poly-drug use at entry to treatment, and poorer outcomes, e.g. relapse, particularly evident for drugs other than alcohol or marijuana. A significantly higher proportion of those with mixed comorbidity were admitted to short term residential treatment, as compared to long term residential care. However, the effects of comorbidity were independent of both planned and actual length of stay, suggesting that comorbidities can negatively impact treatment outcome in multiple ways, apart from length of stay. Since co-occurring problems appear to profoundly limit treatment effectiveness, treatment strategies that address comorbidity are needed to improve outcomes.

Shrier LA; Harris SK; Kurland M; Knight JR. Substance use problems and associated psychiatric symptoms among adolescents in primary care. Pediatrics 111(6): E699-E705, 2003. (56 refs.)

Objective. Substance use disorders (SUDs) are associated with other mental disorders in adolescence, but it is unclear whether less severe substance use problems (SUPs) also increase risk. Because youths with SUPs are most likely to present first to their site of primary care, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent primary care patients with subdiagnostic use of alcohol or other drugs. The objective of this study was to determine the association between level of substance use and psychiatric symptoms among adolescents in a primary care setting. Methods. Patients who were aged 14 to 18 years and receiving routine care at a hospital-based adolescent clinic were eligible. Participants completed the Problem Oriented Screening Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect social and legal problems associated with alcohol and other drugs, and the Adolescent Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8 types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic substance use (NSU), SUP, and SUD with psychiatric symptom presence ( any symptoms within each type), score ( symptom scores summed across all types), and number of types ( number of different symptom types endorsed). Results. Of 538 adolescents (68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most common (60% of both boys and girls), followed by symptoms of depression among girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%). Compared with those with NSU, youths with SUP and those with SUD were more likely to report symptom presence for several types of psychiatric symptoms. Girls with SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct disorder; girls with SUD were at increased risk for symptoms of depression, eating disorders, and hallucinations or delusions. Boys with SUP had increased odds of ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom scores and reported a wider range of psychiatric symptom types ( number of types) compared with youths with NSU. Conclusions. Like those with SUD, adolescents with subdiagnostic SUP were at increased risk for experiencing a greater number of psychiatric symptoms and a wider range of psychiatric symptom types than youths with NSU. Specifically, adolescents with SUP are at increased risk for symptoms of mood ( girls) and disruptive behavior disorders ( girls and boys). These findings suggest the clinical importance of SUP and support the concept of a continuum between subthreshold and diagnostic substance use among adolescents in primary care. Identification of youths with SUP may allow for intervention before either the substance use or any associated psychiatric problems progress to more severe levels.

Silberg J; Rutter M; D'Onofrio B; Eaves L. Genetic and environmental risk factors in adolescent substance use. Journal of Child Psychology and Psychiatry and Allied Disciplines 44(5): 664-676, 2003. (81 refs.)

Background: The present study was undertaken with the goal of understanding the causes of association between substance use and both conduct disturbance (CD) and depression in adolescent boys and girls. Method: Multivariate genetic structural equation models were fitted to multi-informant, multi-wave, longitudinal data collected in extensive home interviews with parents and children with respect to 307 MZ male, 392 MZ female, 185 DZ male, and 187 DZ female, same-sex twin pairs aged 12-17 years from the Virginia Twin Study of Adolescent Behavioral Development (VTSABD). Results: Although conduct disturbance and depression were moderately associated with substance use, the pattern of genetic and environmental risk differed for males and females and across the two disorders. Genetic factors were predominant in girls' substance use whereas boys' use was mediated primarily by shared environmental factors reflecting family dysfunction and deviant peers. The patterns of correlations across the two waves of the study were consistent with conduct disturbance leading to substance use in both males and females, but depression leading to smoking, drug use and, to a lesser extent, alcohol use in girls. Conclusions: The comorbidity between substance use and depression, and between substance use and conduct disturbance in childhood/adolescence, probably reflects rather different mediating mechanisms - as well as a different time frame, with conduct disturbance preceding substance use but depression following it. In both, the co-occurrence partially reflected a shared liability but, in girls, genetic influences played an important role in the comorbidity involving depression, whereas in both sexes (but especially in boys) environmental factors played a substantial role. The extent to which these differences reflect genuine differences in the causal mechanisms underlying substance use and CD/depression in boys and girls revealed in the present analysis awaits replication from studies of other general population samples.

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.

Spirito A; Mehlenbeck R; Barnett N; Lewander W; Voss A. The relation of mood and behavior to alcohol use in adolescent suicide attempters. Journal of Child & Adolescent Substance Abuse 12(4): 35-53, 2003. (46 refs.)

Background: Substance use has been shown to be an important risk factor for suicidal behavior in adolescence. In this study, rates Of Substance use in a sample of adolescents who had attempted suicide were examined as were the relationships of mood state and behavior problems to substance use.Method: Adolescents (N = 106) treated in an emergency department or pediatric inpatient unit following a Suicide attempt were administered a standardized clinical assessment battery including detailed measures of alcohol involvement.Results: Seven percent of the sample reported alcohol or other drug use at the time of the attempt. About one third of the sample reported having been drunk at least once and one fifth reported at least one alcohol-related problem; 6% of the sample met diagnostic criteria for either alcohol abuse or dependence. Behavior problems were more strongly related to quantity and frequency of alcohol use than mood state. Hopelessness and behavior problems were both related to the severity of alcohol involvement.Conclusions: Results suggest that alcohol use among suicide attempters is more strongly related to conduct than mood disturbance.

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.

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.

Swadi H; Bobier C. Substance use disorder comorbidity among inpatient youths with psychiatric disorder. Australian and New Zealand Journal of Psychiatry 37(3): 294-298, 2003. (30 refs.)

Objective: Substance abuse/dependence has been reported to show significant association with psychopathology, and is likely to influence the course and outcome of psychiatric illness. The aim of this study was to determine the rate of substance use disorders (other than alcohol) comorbidity among inpatient adolescents with severe Axis 1 psychiatric disorder. Method: A retrospective analysis of systematically collected data was carried out. The subjects were 16-18-year-old youths, admitted to an inpatient unit for severe psychiatric disorder. The data collection process utilized the DSM-IV criteria for diagnostic categorization of psychiatric disorder and substance use disorder. Demographic data, and data on suicide attempts were also collected. Results: Over a period of one year (March 2001-March 2002), 62 patients were admitted to the Christchurch Youth Inpatient Unit; 40 (64.5%) had a comorbid Substance Abuse Disorder (SAD) according to DSM-IV criteria and none had a Substance Dependence Disorder. The vast majority involved cannabis and stimulants. Sixty per cent of those with mood disorder, 63% of those with anxiety disorder and 80% of those with schizophrenia spectrum disorder had a comorbid SAD. Internalizing problems, especially mood disorders, pre-dominated among those with SAD reflecting the Unit's admission criteria. There were no differences in attempted suicide rates between those with SAD and those without SAD, but those with SAD were more likely to have unstable accommodation/living arrangements than those without SAD. Conclusions: Our findings confirm previous reports suggestive of high rates of SAD comorbidity among youth with severe psychiatric illness. There are clinical and process implications for these findings particularly identification of substance use disorders and their treatment as well as resource availability and staff training.

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.

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.

Vermeiren R; Schwab-Stone M; Deboutte D; Leckman PE; Ruchkin V. Violence exposure and substance use in adolescents: Findings from three countries. Pediatrics 111(3): 535-540, 2003. (111 refs.)

Objective. To investigate relationships between exposure to community violence (witnessing and victimization) and reported substance use (cigarettes, alcohol, marijuana, and hard drugs) in a cross-national sample of adolescents, after controlling for the level of the adolescents' own violent behavior. Method. A self-report survey was conducted in 3380 14- to 17-year-old adolescents in urban communities of 3 different countries: Antwerp, Belgium (N = 958); Arkangelsk, Russia (N = 1036); and New Haven, Connecticut (N = 1386). Results. In all 3 countries, levels of reported smoking, alcohol use, marijuana use, and hard drug use showed increases with adolescent exposure to violence. Although positively related, substance use was increased less markedly in US adolescents who witnessed violence. Conclusion. Current findings further emphasize the association between violence exposure and potential severe physical and psychosocial health problems in adolescents. In addition, the findings suggest that violence exposure and its consequences are a worldwide urban phenomenon. Cross-national differences were found, however, that warrant additional research, and prospective studies are needed to investigate the pathways from violence exposure to substance abuse.

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.

Weiser M; Reichenberg A; Rabinowitz J; Kaplan Z; Caspi A; Yasvizky R; Mark M; Knobler HY; Nahon D; Davidson M. Self-reported drug abuse in male adolescents with behavioral disturbances, and follow-up for future schizophrenia. Biological Psychiatry 54(6): 655-660, 2003. (30 refs.)

Background: The prevalence of illicit drug abuse in persons with schizophrenia is greater then in the general population and has been attributed to self-medication of the symptoms of the illness; however, limited data indicate that drug abuse is already, prevalent before the manifestation of psychosis, consistent with the possibility that drug abuse might be associated with increased risk for schizophrenia. Methods: The Israeli Draft Board screens the entire, unselected population of 16- to 17-year-old male adolescents for behavioral or personality, disturbances. In a cohort of 270,000 male adolescents screened, 50,413 adolescents were suspected of having behavioral or personality disturbances and were questioned about drug use and abuse. These adolescents were followed for hospitalization for schizophrenia using a national, population-based psychiatric hospitalization registry; 268 of 50,413 (.5%) were hospitalized for schizophrenia over the following 5-11 years. Results: The Prevalence of self-reported drug abuse in adolescents later hospitalized for schizophrenia was 12.4%, compared with 5.9% prevalence of drug abuse in adolescents not later hospitalized; adjusted RR=2.016, 95% confidence interval: 1.309-3.104. Conclusions: In this cohort of male adolescents with behavior disturbances, these results further support the hypothesis that drug abuse may be associated with increased risk for future schizophrenia.

Whalen CK; Jamner LD; Henker B; Gehricke JG; King PS. Is there a link between adolescent cigarette smoking and pharmacotherapy for ADHD? Psychology of Addictive Behaviors 17(4): 332-335, 2003. (17 refs.)

There is continuing concern that pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) may raise the risk of smoking (the gateway hypothesis). Alternatively, unmedicated people with ADHD may use nicotine to improve attentional and self-regulatory competence (the self-medication hypothesis). From a community sample of 511 adolescents participating in a longitudinal health study, 27 were identified as having ADHD, and 11 of these were receiving pharmacotherapy. Self-report surveys, electronic diaries, and salivary cotinine all indicated that adolescents treated with pharmacotherapy for ADHD smoked less than their untreated counterparts over 2 years of high school. These convergent findings from 3 disparate indicators tend support to the self-medication hypothesis over the gateway hypothesis, although alternative explanations need further study. The findings also suggest that early treatment of psychological and behavioral problems may prevent or delay smoking initiation.