Co-Occurring Disorders Commonly Diagnosed During Childhood and Adolescence

1. Co-Occurring Disorders Commonly Diagnosed During Childhood and Adolescence Rochelle Head-Dunham, M.D., FAPA Board Certified Psychiatrist and Addictionologist Medical Director Louisiana Office of Addictive Disorders

2. 2 Goals and Learning Objectives Discuss distinguishing features of conditions commonly diagnosed during childhood and adolescence Highlight the complexities of co-occurring drug use Discuss treatment implications and sustainability issues for clinicians

3. 3 DSMIV Disorders Diagnosed in Infancy, Childhood, or Adolescence Mental Retardation Learning Disabilities Motor skills Disorders Communication Disorders Pervasive Developmental Disorders Feeding and Eating Disorders Tic Disorders Eliminative Disorders Other Disorders (Separation Anxiety D/O) Attention Deficit Disorder Mood Disorders Anxiety Disorders Substance-Related Disorders Disruptive Behavioral Disorders (Conduct and Oppositional Defiant Disorders) Psychotic Disorders Sleep Disorders Eating Disorders

4. 4 What is ADHD? The most chronic neurobiological disorder of childhood, characterized by inattention, hyperactivity and impulsivity Pediatrics, Vol 105, Number 5, 2000 May.

5. 5 ADHD DSMIV Criteria Either (1) symptoms of inattention, (2) symptoms of hyperactivity-impulsivity or (3) both Onset <7 years (childhood-onset) >6 months of disturbance Cross-situational (home, school, work�) Impairment in functioning (socially, academically or occupationally) Diagnostic and Statistical Manual, Text Revision,2000.

6. 6 Neurobiology of ADHD Abnormal brain structure involving dorsolateral prefrontal-subcortical circuitry Primary deficiencies: Executive function (planning, organizing, sequencing, focusing/attending) Establishing priorities Willcutt EG et al. Biol Psychiatry, 2005.

7. 7 Symptom Criteria Common for all Types Short attention span (poor attention to detail, frequent silly mistakes) Distractibility (hypersentive to environmental stimuli) Poor internal supervision (lives in the moment, problems with long-term goals) Organizational problems (frequently late, haphazard approach, trouble focusing on long term goals) Poor Follow-through (multiple interests without completions)

8. 8 Causes of ADHD �Highly Heritable� The heritability of ADHD is estimated to be 76%, the result of complex genetic mechanisms involving several genes. Dysregulation of central dopaminergic and noradrenergic networks underlie the pathophysiology. Farone, SV. Biological Psychiatry, 2005. Biederman J et al. J Atten Disorders, 2002

9. 9 Causes (cont.) �Prenatal Factors� Maternal smoking and drinking during pregnancy increase risk of development of ADHD Biederman J, et al.. J Am Acad CAPsych, 2002. �Environmental Factors� Chaos, psychosocial adversity and family discord are risk factors for expression without recognition and adequate treatment for ADHD. Additionally, lead exposure has been linked to causality. Psycho Med. 2002 July, 32. Environmental Health Online, 2006.

10. 10 Prevalence 4%-12% of school-aged communities 40%-60% persistence into adulthood 9.3% males and 2.9% females in the general population Non-hyperactive boys and all females are generally under diagnosed Females primarily exhibit symptoms of the inattentive type In relation to Mood Disorders: 18% Coexistence (1/5) Usually the inattentive and combined subtypes Pediatrics, Vol 105, Number 5, 2000 May

11. 11 Consequences of Underdiagnosing: 54% develop a history of alcohol or drug abuse /dependence! 43% of untreated aggressive hyperactive boys will be arrested for a felony by age 16! 75% have interpersonal problems! 35% never finish high school!

12. 12 ADHD: Lifespan Disorder

13. 13 Lifespan Impairment

14. 14 Assessment Scales Connors Scales Conners Teachers Rating Scale (CTRS-R) 28-item scale for children 3-17 Differentiates hyperactive and learning-disabled vs. normal Sensitive to medication effects Conners Parents Rating Scale (CPRS-R) 48-item scale Distinguishes groups of children vs normal Sensitive to effects of treatment Conners Adult ADHD Rating Scale (CAARS) 93�item scale for adults Correct classification rate 85% Connors,CK. J. Clin Psychiatry 1998

15. 15 Psychiatric Disorders and ADHD(Differential Diagnosis)

16. 16 Childhood ADHD or Bipolar Disorder? Overlapping Symptoms Irritability Hyperactivity Accelerated Speech Distractibility Distinct BPD Symptoms Elation Grandiosity Flight of ideas/racing <need for sleep hypersexuality Key Points: Differentiation is extremely difficult Stimulant response not diagnostically helpful 25% youth with ADHD meet criteria for mania Onset of BPD with h/o ADHD is 11-12 yrs of age Depressive D/O usually first manifested. Landsford, A. Am Academy of Peds, 2005.

17. 17 Practice Guidelines for ADHD The American Academy of Pediatrics Recommends the following guidelines: Complete evaluations if symptoms of ADHD and poor performance, underachievement & behavioral problems Diagnose using DSMIV-TR criteria Obtain information from more than one setting (especially schools) Always assess for coexisting conditions Stimulant medications and behavioral therapy are first line

18. 18 Mood Disorders in Youth Usually a family history of mood disorders Poorer outcomes during adolescents due to increased risk of suicides Pediatrics, Vol 105, Number 5, 2000 May.

19. 19 MOOD DISORDERS in Youth Major Depressive Disorder A two week period or more of depressed mood associated with hopelessness, despair, impaired sleep, appetite, concentration, energy and interests Bipolar Disorder Periods of depression alternating with manic periods, which may include irritability, "high" or happy mood, excessive energy, behavior problems, staying up late at night, and grand plans lasting at least one week Dysthymia Sad, irritable mood most of the time for a minimum of one year DSMIV, Fourth Edition, 1994.

20. 20 Depression in Childhood Symptoms similar to Adults: sadness hopelessness feelings of worthlessness excessive guilt change in appetite loss of interest in activities recurring thoughts of death or suicide loss of energy helplessness fatigue low self-esteem inability to concentrate change in sleep patterns

21. 21 Depression in Childhood Behaviors more common in kids: a sudden drop in school performance inability to sit still, fidgeting, pacing, wringing hands pulling or rubbing the hair, skin, clothing or other objects; In contrast: slowed body movements, monotonous speech or muteness outbursts of shouting or complaining or unexplained irritability crying expression of fear or anxiety aggression, refusal to cooperate, antisocial behavior use of alcohol or other drugs complaints of aching arms, legs or stomach, when no cause can be found

22. 22 Depression in Childhood

23. 23 Grief The emotional suffering and confusion we feel after a significant loss of any kind. Grief is commonly equated to mean loss of another human being, but it also includes a pet, a neighborhood, an object of affection� Grief can last as long as it takes to accept and learn to live with the loss. For some that can be months, for others, years.

24. 24 Grief vs. Clinical Depression Depression Involves: emotional, behavioral, and physiological changes such as hopelessness, appetite and weight and activity changes, guilt, poor academic performance, aches and pain and possible suicidal ideation/attempts recurrent, impairment requiring professional interventions Grief generally resolves with time and progression through the four stages of acceptance, working through, adjusting to the loss, and moving on

25. 25 Youth Suicide Rates Suicide rates under age 30 increasing largely due to association with alcohol and drug use. Among adolescents and young adults suicide is: 3rd leading cause of death ages 15-24yrs 6th leading cause of death ages 5-14yrs >50% of teens who commit suicide have a history of alcohol and drug use

26. 26 Youth Risk Factors for Attempted Suicide depression alcohol or other drug use disorder (including binge drinking and substance abuse) interpersonal problems/loss (parents' divorce, family violence, a breakup with a boyfriend or girlfriend, stress to perform and achieve, and school failure) and aggression or disruptive behaviors, prior attempt (Roy, 1992)

27. 27 Drug Use Data and Youth Suicide Risk Among those with cocaine use disorders, 31% reported previous suicide attempts, (Darke & Kaye, 2004). Prevalence of cocaine use is reported as 20% in completed suicides in New York City (Marzuk et al., 1992). Methamphetamine-dependent individuals are reported to have high rates of depression and suicidal ideation (Kalechstein et al., 2000; Zweben et al., 2004). In one study of suicide completers done in Utah, the prevalence of methamphetamine found by toxicology screens was 9% in youth and 8% in adults (Callor et al., 2005).

28. 28 Drug Use Data and Youth Suicide Risk Marijuana (MJ) Several studies have linked youth MJ use to depression, suicidal thoughts and schizophrenia: Young people who use MJ weekly have double the risk of developing depression Teens age 12-17 who smoke MJ weekly are 3xs more likely to have suicidal thoughts than non users MJ use in some teens has been linked to increased risk for schizophrenia in later years (Office of National Drug Control Policy/ONDCP, 2005)

29. 29 Anxiety Disorders 25% Coexistence with ADHD-inattentive and combined subtypes (i.e.,obsessive-compulsive disorder, generalized anxiety disorder) Higher risk of anxiety disorders among relatives, however transmission may not be genetic Pediatrics, Vol 105, Number 5, 2000 May. Simple phobias and Separation Anxiety Disorder are very common in young kids Post-traumatic stress disorder (PTSD) is particularly problematic post Katrina and Rita

30. 30 What is Post Traumatic Stress Disorder (PTSD)? Definition: An anxiety disorder elicited when anyone experiences, witnesses, or is confronted with an event or �disaster�, which entails actual or threatened death, or injury or a threat to the physical integrity of themselves or others. DSMIV-TR, 2000.

31. 31 Post Traumatic Stress Disorder (PTSD) Symptoms of PTSD: Intrusive recollections: terrifying memories, nightmares, or flashbacks Extreme emotional numbing: inability to feel emotions, diminished interest, sense of impending doom Extreme attempts to avoid disturbing memories: substance use problematic Hyperarousal: panic attacks, rage, irritability, violence, poor sleep, concentration, and attention DSMIV-TR 2000.

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33. 33 Clinical Outcomes of Trauma Severe Anxiety (Generalized and/or PTSD, with obsessive traits) Severe Depression and/or Grief Posttraumatic Stress Disorder (PTSD) Dissociation: fragmented thoughts, amnesia Addictive Disorder and/or Co-occurring D/O�s Sub-threshold Trauma-based Syndrome (STS): experience of clinically disabling feelings and behaviors, not sufficient to constitute a diagnosis of PTSD, but may impact functioning.

34. 34 �Disaster Response� in Children and Adolescents Psychological impact of disaster on children is greater than on adults with similar exposure (Davis and Siegel, 2000; LeGreca, 1996; McNally, 1993; Norris et al, 2000) Research supports correlates between traumatized parents and their children Too few definitive studies for conclusion

35. 35 �Victimization Trauma� or �Bullying� Victimization is consistently correlated with increased co-occurring psychiatric problems, substance dependence, negative peer pressure and family influence, HIV risk behavior, and health problems Prevalence Rates: for lifetime (67%), past 90 days (36%), and acute/ current (48%) � victimization rates are higher than the diagnosis of PTSD (28%) (Grella et al; Stevens, Murphy & McKnight 2003)

36. 36 Conduct Disorder and Oppositional Defiant Disorders Conduct Disorder (CD) �a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated� Largest single group of psychiatric disorders (9% boys, 2% girls) Most likely, an inherited predisposition with environmental and parenting influences Poorer outcomes combined with ADHD (delinquency, substance abuse) Behavioral therapy and psychotherapy, group or individual; Medication for co-morbid conditions DSMIV, Fourth Edition, 1994.

37. 37 Conduct Disorder and Oppositional Defiant Disorders Oppositional Defiant Disorder (ODD) � negativistic, defiant, disobedient, and hostile behaviors toward authority figures� 35% coexistence with ADHD (hyperactive-impulsive and combined subtypes) #1 co-morbidity with ADHD in adolescents Often children with ODD later develop severe symptoms consistent with CD Pediatrics, Vol 105, Number 5, 2000 May.

38. 38 Learning Disabilities 3% of the population; 30-50% Psychiatric disorders (often autism and hyperkinetic disorders) 12%-60% (reading disorders/dyslexia) coexist with ADHD (inattentive and combined types) More difficult to assess�articulation and professional skill limitations IEP�s and Special education services required Pediatrics, Vol 105, Number 5, 2000 May.

39. 39 Complexities of Youth Substance Use Is ADD a risk factor for substance use? Is stimulant treatment for ADD predisposing to substance use? Is psychiatric co-morbidity a risk factor for substance use? Are there identified risk and protective factors for substance use?

40. 40 ADD and Substance Use Findings from a 4 year prospective study of adolescents Conclusions: ADHD and PSUD rates are both increased with co-existent Conduct Disorder and Bipolar Disorder Untreated ADHD adolescents are more likely to experiment with drugs and alcohol Untreated ADHD adults are more likely to become dependent on drugs and alcohol Biederman J, et al. APP Focus 2003

41. 41 Stimulant Medication and PSUD Data collected from 6 studies involving 674 medicated and 360 non-medicated ADHD adolescents over a 4 year period Findings: 1.9 fold decrease in risk of SUD in treated group Similar decreased risk of later alcohol and drug use disorders Conclusion: Stimulant medication was protective against SUD, decreasing the risk of later alcohol and drug dependence Wilens T E, et al. Pediatrics 2003 Jan.

42. 42 Misuse and DiversionAmong College Students Most students not using (93.2%) or misusing (5.4%) stimulants for ADHD 2 of 3 prescribed stimulant for ADHD use them for medical use only (1.5% vs. 0.7%) Likelihood of students who use stimulants for ADHD being approached about diverting their medication: Twice that of college students in general (54% vs. 27%) At least 3 times that for pain medication, sedatives/anxiety agents, or sleeping medications (54% vs. 19%, 19%, 14%) McCabe SE, et al. J Am Coll Health, 2006.

43. 43 PSUD & ADHD in Adults Study examined association between ADHD, PSUD and co-existing conditions in adults Conclusions: ADHD is an independent risk factor for SUD ASPD is a risk factor for SUD independent of ADHD Mood and Anxiety Disorders are risk factors for SUD Biederman J et al. AmJPsych 1995.

44. 44 �Caring Communities Youth Survey�(CCYS) 2002, 2004, 2006 Report summarizes �risk and protective factors� based on survey responses by 6th, 8th, 10th, and 12th graders in Louisiana public schools, to drug related questions Four Domains: Family Factors Community Factors School Factors Peer/Individual Factors

45. 45 CCYS Risk Factor Scales Community Domain Low neighborhood attachment Community disorganization Transitions and mobility Laws and norms favorable toward drug use Perceived availability of drugs Perceived availability of guns Family Domain Poor family management Family conflict Family history of antisocial behavior Parental attitudes favorable toward drugs Parental attitudes favorable toward antisocial behavior

46. 46 What Substances Do Adolescents Use? National Survey on Drug Abuse and Health (NSDUH) 2006 Ages 12-17 Trends 2002-2006: MJ and Nicotine (cigarettes)-decline, Alcohol and Cocaine-no change Increased prescription �pain medicine� drug use (non-medicinal use) Illicit Prescription Drug use = Gateway to Street Drug use

47. 47 What Substances Do Adolescents Use? National Survey on Drug Abuse and Health (NSDUH) 2006 Ages 12-17 Illegal drugs not perceived as more problematic than prescription drugs Methamphetamine one time use not perceived as dangerous 1/3 of all new drug abuse ages 12-13 yrs but as early as 10 yrs Girls more than boys use prescription drugs (especially pregnant teens, and young adults)

48. 48 Access to Drugs HOME environment is number one source! >50% from family members (medicine cabinets/friends or taking it from them; degree of availability predictive of degree of use �The Internet �.The New Drug Dealer� (Availability of Addictive opioids (pain meds), depressants (alcohol, Xanax�), stimulants (Ritalin, Adderall, Methamphetamine�)

49. 49 Internet Drugs �Anything Goes� scenario not requiring prescriptions for purchases. �online consultations� (intended to replace a face-to-face evaluation from a physician; does not constitute a legitimate doctor-patient relationship�) (Alcoholism & Drug Abuse Weekly, June 26, 2006)

50. 50 Internet Drugs Benzodiazepines most widely available on Internet Xanax and Valium are the most frequently offered Breakdown of the classes of drugs available on the 185 selling sites: � Benzodiazepines: 155 � Opioids: 126 � Stimulants: 14 � Barbiturates: 2 �broad advertising,� computer based, with no controls to block sales to minors 20/185 sites required buyers to have a prescription 14/20 sites allow buyers to fax prescriptions 3/20 sites require a prescription 60% now using the online consultation National Center on Addiction and Substance Abuse at Columbia University, 2004.

51. 51 Internet Drugs: What should we do? Improved Parental monitoring of and education about internet use Curriculum development on subject with updates Clarification of federal law prohibiting online sale or purchase of controlled prescription drugs without an original copy of a prescription issued by a physician with DEA # Warnings of illegal use and blockage of sites that fail to require a legitimate prescriptions Public service announcements on the dangers of online purchasing (could appear during Internet searches for prescription drugs.) a national nonprofit clearinghouse designed to identify and shut the operations of illegal Internet pharmacies

52. 52 Intervention Strategies What can we Do?

53. 53 Prevention Identify at risk kids based on risk factors typically associated with adverse behaviors. Advocate for inclusion of identified protective factors in settings you control

54. 54 CCYS Risk Factor Scales Community Domain Low neighborhood attachment Community disorganization Transitions and mobility Laws and norms favorable toward drug use Perceived availability of drugs Perceived availability of guns Family Domain Poor family management Family conflict Family history of antisocial behavior Parental attitudes favorable toward drugs Parental attitudes favorable toward antisocial behavior

55. 55 What can We Do? CCYS Protective Factor Scales Community Domain Opportunities for prosocial involvement in the community Rewards for prosocial involvement in the community Family Domain Family attachment Opportunities for prosocial involvement in the family Rewards for prosocial involvement in the family Protective factors all revolve around bonding to healthy adults, peers, and institutions.Protective factors all revolve around bonding to healthy adults, peers, and institutions.

56. 56 Treatments Aggressive diagnosis of substance abuse problems as well as mental health problems (diagnosing with expectation, during acute intoxication and visits for treatment of psychiatric distress,) Appropriate combinations of medication management, behavioral interventions and psychotherapy.

57. 57 Medication Guidelines Medication may be prescribed for psychiatric symptoms and disorders, including, but not limited to: Bedwetting - if it persists regularly after age 5 and causes serious problems in low self-esteem and social interaction. Anxiety (school refusal, phobias, separation or social fears, generalized anxiety, or posttraumatic stress disorders)-if it keeps the youngster from normal daily activities. Attention deficit hyperactivity disorder (ADHD) -if it interferes with school work and ability to get family and friends Obsessive-compulsive disorder (OCD) - if excessive time is lost to rituals and it interfere with a youngster's daily functioning. Depression - if it results in a decline in school work and changes in sleeping and eating habits. Bipolar (manic-depressive) disorder � if the behavior interferes with school performance or social functioning or is life threatening

58. 58 Medication Guidelines (con�d) Eating disorder � if behavior is life threatening, either self-starvation (anorexia nervosa) or binge eating and vomiting (bulimia), or a combination of the two. Psychosis � typically requires medication interventions; symptoms include irrational beliefs, paranoia, hallucinations (seeing things or hearing sounds that don't exist) social withdrawal, clinging, strange behavior, extreme stubbornness, persistent rituals, and deterioration of personal habits. May be seen in developmental disorders, severe depression, schizoaffective disorder, schizophrenia, and some forms of substance abuse. Autism - (or other pervasive developmental disorder such as Asperger's Syndrome) � when behaviors are harmful typically to self; characterized by severe deficits in social interactions, language, and/or thinking or ability to learn, and usually diagnosed in early childhood. Severe aggression � typically requires medication to prevent harm to self or others Sleep problems � if depravation interferes with daytime functioning or nighttime behaviors are dangerous; symptoms can include insomnia, night terrors, sleep walking, fear of separation, anxiety.

59. 59 Behavioral Therapy Consists of interventions designed to modify physical and social environments Requires training of parents and teachers Involves rewards for desired behaviors (positive reinforcement); removal of access to positive reinforcement (time-out); Withdrawal of rewards or privileges contingent on performance (response cost); combining positive reinforcement and response cost (token economy) Pediatrics Vol 108, 2001 October.

60. 60 Healthcare Professional Maintenance and Sustainability Academic� CEU�s/Continuing Education Units (child and adolescent specific) Journal Subscriptions (Brown University � Child and Adolescent Pharmacology) Multidisciplinary Teams/Consultations, Engage professional partners � avoid the vacuum! Engage Family (expand definition) Explore non-traditional approaches/interventions Personal� Do Fearless and Moral Inventory of Strengths and Limitations�respect both! Avoid Burnout: 3B�s -- Balance, Boundaries, Beliefs

61. 61 Questions and Comments