Child/Youth & Co-Occurring Disorders

1. Child/Youth & Co-Occurring Disorders 2014 4th ANNUAL DC SUMMIT

2. Objectives • Review the prevalence of co-occurring substance use and psychiatric disorders in youth. • Review the relationship between substance use and specific co-occurring mental health disorders. • Understand effective treatment approaches and challenges for youth with co-occurring disorders.

3. Introduction • Psychiatric disorders • 3/4 by age 24 • Most adults with SUD started using as adolescents • 60-85% adolescents with SUD have co-occurring psychiatric disorder(s).

4. Co-Occurrence of MH & SUD • Substance abuse treatment helps to reduce the frequency of use and the number of abuse/dependence symptoms but has only indirect impact on emotional and behavioral problems (M. Dennis, 2004) • Psychiatric treatment alone for youth with mood disorders and co-occurring SUD does not significantly reduce substance use (Geller et al., 1998)

5. Risk Factors:Familial Influence on Substance Use • Familial influence—biological and behavioral • A common genetic influence accounts for comorbid substance use during adolescence, specifically problem use of tobacco, alcohol, and cannabis. • Approximately 50% of the risk of substance abuse or dependence in adolescence is genetically influenced. • Exposure to parental substance use increases children’s risk

6. A Day in the Life of American Adolescents: Substance Use Facts

7. Table 1. Illicit drug use in the past month among individuals aged 12 or older: 2013 SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH)

8. Substance use disorder (SUD) in the past year among individuals aged 12 or older: 2013

9. Mental health issues in the past year among adolescents aged 12 to 17 and adults aged 18 or older: 2013

10. Co-occurring Substance Use Disorders and Mental Health Issues among Adolescents and Adults

11. 4,333 Total Child/Youth Served (DBH) - FY13

12. Primary Substance Type

13. Diagnoses vs. Medications

14. CFSA Youth with Co-occurring Disorders

15. PIW Stats • 75-85% of children/adolescents treated at PIW have past or current substance use issues

16. Chicken or Egg? • “Substance-induced Mood Disorder” • There is no Cannabis-induced Depressive D/O • Not in DSM-IV TR • Not in DSM-5 • Self-medication

17. ADHD • Prevalence approx. 3-5% • but those receiving medications for ADHD is 1-20% • Male:Female is 4:1 • Medication treatment for ADHD is one of the most studied areas in C&A psychiatry • Over- vs. under-medication

18. Course of ADHD • Rule of 1/3’s: • 1/3 show significant improvement over time • 1/3 have a few symptoms into adulthood (inattention) • 1/3 continue to have significant problems into adulthood • Untreated: • Increased risk of MVAs, drop outs, family discord, and substance use (15% comorbidity)

19. Stimulant Medications Absolute Contraindications: • Cardiovascular disorders, hypertension • Hyperthyroidism • Glaucoma • Active Psychosis • Co-administration with MAO-Is Relative contraindications: • Seizures (no evidence of decreasing szthresold) • Drug Abuse

20. Major Depressive Disorder • At least 2 wks pervasive change in mood manifested by either: • Depressed or irritable mood and/or • Loss of interest/pleasure • Other sx: • Same criteria as for adult MDD but presents differently • Lack of joy • Withdrawal • Irritability • Boredom • Failing grades • Act out • Aggression

21. Treatment Options • Mild-moderate depression: psychotherapy • Cognitive Behavior Therapy (CBT) • Moderate-severe: pharmacotherapy + psychotherapy • Pharmacotherapy may not be sufficient alone due to strong psychosocial influences

22. Pharmacotherapy • SSRIs are the predominant medications used for both depressive disorders and anxiety disorders • Older antidepressants (TCAs) have not shown much benefit and have more side effects

23. FDA Black Box Warning • 24 placebo-controlled trials, >4400 patients: • Placebo 2%; on antidepressants 4% • Double risk of suicidal thinking/behavior • No completed suicides • Could be linked to behavioral activation or akathisia • Impulsive • Agitated • UK banned use of all SSRIs except fluoxetine for C/A

24. Anxiety Disorders • Probably the 2nd most common group of disorders; however, do not get recognized so people often do not present for tx • Prevalence rates from 6-20% for one disorder • Children/youth may not recognize fear as unreasonable • Very common to have somatic c/o, crying, irritability, outbursts

25. Anxiety Disorders • Obsessive Compulsive Disorder* • DSM-5: Obsessive-Compulsive and Related Disorders • Post Traumatic Stress Disorder* • DSM-5: Trauma and Stress-Related Disorders • Separation Anxiety Disorder • School refusal • Generalized Anxiety Disorder • Panic Disorder • Social Phobia • Selective mutism • Specific Phobia

26. Anxiety Disorders Treatment Guidelines • Begin with psychotherapy for mild cases: • CBT- exposure/response prevention • Family and Parent-Child • Consider psychotherapy + medication for: • Acute symptom reduction for moderately-severely anxious child • BZDs vs. buspirone • Co-morbid disorder that requires treatment • Partial response to psychotherapy • Potential for improved outcome with combination

27. Bipolar Disorder • Commonly has onset in adolescence • Gen population lifetime prevalence for Bipolar I is 0.4%-1.6% • For C/A ranges from 1%-13% • Overall affects both sexes equally, early-onset pre-dominantly male (esp. onset <13yo) • 20% of youths with MDD develop Mania by adult

28. FIND Guidelines Frequency: most days in a week Intensity: severe enough to give extreme disturbance in one domain or moderate in 2 or more domains Number: sx occur 3-4 times a day Duration: sx occur ≥ 4 hrs a day in total, not necessarily consecutive (Kowatch, et al)

29. Bipolar Disorder- TX of Co-morbidities • Most C/A will have co-morbid d/o: ADHD, ODD, CD, Anxiety, Substance Use • Stabilize Bipolar D/O first, but must treat co-morbid d/o due to worse prognosis (attempt psycho-social tx first) • ADHD: • most common- 70-90% pre-pubertal, 30-40% adolescents • tx ADHD sx after Bipolar sx controlled

30. Disruptive Mood Dysregulation Disorder (DMDD) • Added to DSM-5 to address concerns about potential: • Overdiagnosis • Overtreatment • Only applies children/adolescents up to 18 y/o • Basic criteria • Persistent irritability • Frequent episodes of extreme behavioral dyscontrol

31. Schizophrenia • Childhood or Very Early Onset Schizophrenia (COS or VEOS): onset of symptoms before 13 y/o • Early Onset Schizophrenia (EOS): onset of symptoms before 18 y/o • Clinically resembles adult form in positive and negative symptoms, BUT usually has more severe and chronic course

32. Treatment Considerations • Youth may be less likely to respond adequately to Rx • Atypical Antipsychotics as effective for positive sx, and possibly more effective for negative sx • Atypicals lower risk of EPS, but significant wt gain

33. Childhood Schizophrenia:“Born Schizophrenic – Jani” http://www.youtube.com/watch?v=35gcBL1ZwY4‎

34. New(ish) Drug Crazes • Alcoholic Energy Drinks • K2/Spice (Herbal Incense) • MDMA / “Molly” “Ecstasy”

35. K2 • Mixture of herbal and spice plant products • Sprayed with synthetic cannabinoids • Marketed as incense and “not for human consumption” • No regulations to list ingredients or age requirements to purchase • First generation called “K2” or “Spice” • Second generation called “K3” or “Splice” • Effects: • Tachycardia, Heart attack, Dry Mouth, Thought Impairment, Auditory & visual hallucinations, Delirium, Impaired sense of time, Anxiety, Fear, Panic attacks, Paranoia, Sedation, Post-intoxication exhaustion, Dissociation • https://www.youtube.com/watch?v=Af5P1e0Uk-I

36. Local Case – W.D. • 9th grader with no prior MH or JJ history • Living with bio. mother and older brother • Good school attendance, behavior, and grades • Sudden onset of unusual behavior • “The world is coming to an end” • “I’m Jesus” • Brother took him UMC ER • U tox positive for MJ

37. W.D. Case (cont’d) • Brother reported W.D. has been smoking MJ for the past year • Discharged home because no SI or HI • Later that night W.D. climbed up on the roof with a handgun • MDP responded • W.D. fired, hitting one officer 3 times in chest • W.D. charged with Attempted Murder 1

38. W.D. Case (cont’d) • While in custody, W.D. continued to act bizarre • Taken to PIW • Found to have written (illogically) all over his body with magic marker • Didn’t recall anything about the shooting • “I am God” • Found incompetent to stand trial • Treated with antipsychotic medication • Restored to competence

39. W.D. Case (cont’d) • Plead to 2nd Degree Attempted Murder • Committed to DYRS • Sent to PRTF • Continued to have difficulty remembering the shooting • Recalled smoking K2 prior to the event

40. “Molly” • MDMA is man-made…it doesn't come from a plant like marijuana or tobacco. • Other chemicals or substances such as caffeine, dextromethorphan (found in some cough syrups), amphetamines, PCP, or cocaine are sometimes added to, or substituted for, MDMA in Ecstasy or Molly tablet. • a “hit” of MDMA lasts for 3 to 6 hours. Once the pill is swallowed, it takes only about 15 minutes for MDMA to enter the bloodstream and reach the brain. • Effects: • Hyper-alertness, Changes in perception, Anxiety, Agitation, Depression, Memory impairment, Sweats, Chills, Muscle tension, Nausea, Blurred vision, Increased heart rate and blood pressure, Feelings of sadness, depression, and memory difficulties.

41. Molly • https://www.youtube.com/watch?v=90xMmuQtV1M

42. Changes in Brain Activation Patterns Before and After Treatment in Adolescents Addicted to Marijuana Pre-Treatment Post-Treatment Before treatment, adolescents showed greater brain reward activation to marijuana cues vs food* After 16 weeks of CBT adolescents showed greater activation to marijuana vs food in areas of cognitive control than before treatment Riggs et al., Drug and Alcohol Dependence,91, 2007

43. Cannabis Withdrawal • New to DSM-5 • Cessation after heavy/prolonged use • Daily/almost daily • Over at least a few months

44. Cannabis Withdrawal (cont’d) • 3 or more of the following within 1 wk • Irritability, anger, or aggression • Nervousness or anxiety • Sleep difficulty (e.g., insomnia, disturbing dreams) • Decreased appetite or weight loss • Restlessness • Depressed mood • At least 1 of the following physical symptoms • Abdominal pain Fever • Shakiness/tremors Chills • Sweating Headache

45. Behavioral Treatment Interventions for Adolescents (Non-Medication Treatment)

46. Outpatient/Intensive Outpatient/Partial Hospitalization • Counseling • Individual and/or group • Other behavioral therapies include: • Adolescent Community Reinforcement Approach (A-CRA) • Cognitive–behavioral therapy • Multidimensional family therapy • Motivational interviewing • Contingency Management (motivational incentives) • Community/family-based recovery support systems • Brief Strategic Family Therapy (BSFT) • 12-Step Participation • Alcoholics Anonymous • Narcotics Anonymous

47. Family Based Approaches • Community/family-based recovery support systems • Brief Strategic Family Therapy (BSFT) • Family Behavior Therapy (FBT) • Multidimensional Family Therapy (MDFT) • Functional Family Therapy (FFT) • Multisystemic Therapy (MST)

48. Residential/Inpatient Treatment • Residential/Inpatient Treatment • Therapeutic Community (TC)

49. Medication-Assisted Treatment (MAT) • The use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders • Research shows that when treating substance-use disorders, a combination of medication and behavioral therapies is most successful. • Clinically driven with a focus on individualized patient care.

50. MAT • Has been shown to: • Improve survival • Increase retention in treatment • Decrease illicit opiate use • Decrease hepatitis and HIV seroconversion • Decrease criminal activities • Increase employment • Improve birth outcomes with perinatal addicts