Oregonian Headline March 3, 2006

2. Oregonian HeadlineMarch 3, 2006

3. The Most Vulnerable Victims: Children of Methamphetamine Users Plus: An Update on Adolescent Substance Abuse Treatment OPA Spring Meeting March 3-4, 2006 Keith Cheng MD Medical Director, Trillium Family Services Adjunct Associate Professor Department of Psychiatry Oregon Health Sciences University

4. The Most Vulnerable Victims: Children of Methamphetamine Users • In Utero Exposure to Meth Using Parents • Childhood Exposure Meth Using Parents • Adolescent Exposure Meth Using Parents

5. In Utero Exposure • The effects of prenatal methamphetamine exposure on the developing fetus have not been well characterized. • There are conflicting studies, findings are confounded by the observations that approximately 80% of the methamphetamine-using women also used nicotine and alcohol • Methamphetamine use during pregnancy is associated with an increased incidence of premature delivery, birth weights, head circumference, and placental abruption. • Cases of cardiovascular collapse and seizures have also been reported in women using methamphetamine during pregnancy. • Isolated cases of cardiac defects, cleft lip, and biliary atresia have been reported in infants exposed to methamphetamine in utero.

6. Prenatal Exposure StudySmith et al: (2003) Effects of Prental Methamphetamine Exposure on growth and withdrawal sxs in infants born at term. Developmental and Behavioral Pediatrics. 24(1):17-23 • Study done at UCLA Meth Exposed n=134, Meth Unexposed n=160 • Apgar Scores Birth Weight and Length were not significantly different from unexposed controls • Methamphetamine-exposed infants whose mothers smoked had significantly decreased growth relative to infants exposed to methamphetamine alone • Withdrawal symptoms requiring pharmacologic intervention were observed in 4% of methamphetamine exposed infants

7. Childhood Exposure“In These Bleak Days: Parent Methamphetamine Abuse and Child Welfare in the Rural Midwest,” in press Journal of Children and Youth Services Review • Profound neglect and abuse • Physical danger resulting from in-house manufacture of the drug • Parents teaching their children criminal behavior and a paranoid distrust of authority

8. Childhood Exposure • Children becoming surrogate parents to younger siblings • Children Exposed to toxic fumes and the danger of explosions or fires • Children asked to steal items needed for making the drug or to stand guard, armed with a gun, looking out for police or other authorities

9. Children in State Care • Oregon's Meth Epidemic creates thousands of "orphans," abused and neglected children who fall into the state's care after their parents are arrested • Department of Human Services conducted its first statewide analysis last year, when 5,438 children entered state foster homes, up from 4,906 in 2003. • Last year, roughly 2,750 children -- more than half of all foster cases -- were taken from parents using or making the potent drug, the study found • The Children of Meth,”---Joseph Rose, Oregonian, August 28, 2006

10. Case Vignette: 3 Admissions for Residential Placement in 1 Week period • Ages 7-10 years • All referred from DHS • All came from emergency foster placements • All were abandoned by Meth using mothers • All had previous foster placements • All had become too physically aggressive to be managed in their emergency foster home • All had to wait 1-3 months before a new placement could be found

11. Adolescent Exposure • No Specific data or publications in peer review journals • Questions: Are they more likely to use meth themselves? Are they more likely to drop out of school? Are they more likely to have a criminal record? Are they more likely to require long-term care?

12. Adolescent Case Vignette • Ryan 17 year old male referred for admission from OYA for evaluation of psychosis • Exposed in utero to meth and other drugs • Mother continued to use till he was age 5 yrs, “I was brought up by my sister till I was 8 years then I took care of my mother.” • Mother had bilateral bka for complications of diabetes • Mother died of diabetes when Ryan was 10 yrs, Father died from cirrhosis when Ryan was 13 • Had ADHD sxs since first grade • Started using tobacco and marijuana at age 7 years, Meth at age 13. Hasn’t been in school for two years. • Used Meth for 2 years says he quit for 4 months till present. “I decided I wanted a future.”

13. Adolescent Case Vignette #2 • Sheila is 15 in custody of DHS, placed in treatment because of runaway behaviors, got caught by police for theft • Been living on the streets, supports meth habit through prostitution, has been in OYA custody in the past • Uses meth IV, rectally, and thru smoking has been using since age 12 yrs, has also used cocaine, marijuana, and alcohol • Father died when Sheila was 5 yrs old in MVA • Mother recently incarcerated for multiple drug charges • Made suicide attempt by overdose in Nov 2005 • Gives history that she used to smoke meth with mother • Ran away from last residential placement has hx of multiple residential placements • Has not been in school since 7th grade • Has history of sexual and physical abuse, PTSD, MDD, & CD

14. Trillium Experience • Psychiatric Residential and Intensive Community Based Programs--Not a substance abuse treatment center • Average Range 350-450 ITS level admissions per year the past 4 yrs • Four years ago-admissions for children known to have “Meth” using parents approximately relatively uncommon, “Monthly admissions” • Currently seems that these admissions are more common, “Weekly”

15. Trends in Use (from MTF Study) • Use of amphetamines rose in last half of 1970s and peaked in 1981 with 26% use • After 1981 there was a steady decline ended in 1992 • Use peaked in the lower grades in 1996 and 1997 • There has been a slow drop off since the mid 1990 • No significant Changes in 2004

16. Trends in Use • Use of amphetamines rose in last half of 1970s and peaked in 1981 with 26% use • After 1981 there was a steady decline ended in 1992 • Use peaked in the lower grades in 1996 and 1997 • There has been a slow drop off since the mid 1990 • No significant Changes in 2004

17. Perceived Risk • Overall changes in perceived risk have been less strongly correlated with changes in usage of other drugs • However the perceived risk has been rising the past several years possibly accounting for the decline in use that occurred in 2003 with 12th graders

18. Disapproval • Disapproval rates have been high 70% - 87% throughout the life of the study • From 1981 to 1992 disapproval rose gradually as use steadily declined • Disapproval then fell back 6-7 percentage points for a few years and the use rate rose slighted

19. Availability • In 1975 when MTF started amphetamines had a reported high level of availability • The level fell 10% in 1977 • Drifted back up in 1980, then jumped sharply in 1981 • Declined slowly till 1991, when there was a modest rise then seem to stabilize during the late 90s • There has been further decline during the first year few years of this decade

20. More Oregon Youth being treated for Methamphetamine Abuse • The Oregon Department of Human Services said that over the past five years the number of meth treatment admissions for boys under age 17 has grown steadily, and has skyrocketed 57 percent among girls. • In 2003 the state Office of Mental Health and Addiction Services reported that more than 1,700 children were treated for methamphetamine misuse in the state. Of that number, more than 1,000 were girls, up from 630 in 1999, and 742 were boys, up from 600

21. An Update on Adolescent Substance Abuse Treatment

22. SUD Assessment • History & MSE • SUD Assessment Scales • Drug Testing • Risk Factor Analysis

23. History/MSE/PE • Because substance-using youth commonly keep their substance-using behaviors covert, there is a need to gather information from multiple sources, including parents, siblings, teachers, caseworkers, peers if available. • Polysubstance use by adolescents is the rule rather than the exception; therefore, adolescents often present with multiple SUD diagnoses. Determine how many psychoactive substances are being used, and how available they are to the youth. • Determine whether there is substance use or abuse occurring by other members in the home or whether there is a lack of rules against substance use by juvenile members of the family. • Determine who are the youth’s peers and associates and whether they use substances or are involved in conduct-disordered and where the youth uses substances. Does he or she use alone or tend to be with groups of certain people and settings? • Be sure to assess for other psychiatric disorders, as there is a high level of comorbidity, and many symptoms of SUD can mimic psychiatric symptoms.

24. SUD Assessment Instruments • Substance Abuse Rating Instruments can be helpful in screening for SUDs and for monitoring treatment response. “Lie scales” can be especially helpful in identifying youths that deny their substance use • There are now several adolescent assessment instruments such as: CRAFFT, SASSI, PESQ, and ADI

25. CRAFFT Questions(2 or more “yes” answers suggests a serious problem & warrants further evaluation) • Have you ever ridden in a Car driven by someone who was high or had been using alcohol or drugs • Do you drink or take drugs to Relax • Do you ever drink or take drugs while you are Alone? • Do you ever Forget things you did while using alcohol or drugs • Do you Family and Friends ever tell you that you should cut down on your use? • Have you gotten into Trouble from drinking or taking drugs? Kay DL: (2004) Office recognition and management of adolescent substance abuse. Curr Opin Pedia 16:532-541

26. Drug Testing • Use of urine drug screens can be helpful in identifying SUDs in youth that are skilled in hiding their drug use from adults. However, a single negative drug screen does not rule out drug use, abuse, or dependence; and a single positive drug screen does not establish an SUD

27. Urine Drug Screen Detection

28. Risk Factor Analysis • Chaotic home environment • Parental Substance Abuse • Parental Mental Illness • Ineffective Parenting • Lack of Parental involvement/supervision • Failing School Performance • Poor Social Coping Skills • Association with Conduct Disordered Peers • Perceived parental/peer/community approval of drug use

29. SUD Treatment • Traditional Treatments • Peer Deviancy Training • Limitations of Psychoeducational Interventions • Medications • Community Based Interventions

30. Traditional Treatments • Alateen • Narcotics Anonymous • Group Therapy • Individual Therapy/Counseling

31. Peer Deviancy TrainingDishion, T.J., McCord, J., & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54, 755-764 • Dishion: at Oregon Social Learning Center @ UO • 158 youth grades 6 to 8 studied 83 boys, 75 girls in 12 week program to reduce problem behaviors • Three study groups: peer only, parent and peer groups, self study, and no intervention control group • All study group showed improvement after 12 weeks • Peer only groups exhibited significantly worse behaviors after one year, and three year followup, than similar at risk youths who were given prevention materials to study on their own or who had no interventions at all • For peer only group a 75% higher rate of delinquency

32. Medications • Evidence for use in children specifically for SUDs: Meager to date, mostly case reports of small sample size studies • Treatment of comorbid disorders can help prevent development of SUD • Needs to be in combination with other interventions

33. The Evidence with ADHD Treatment • Biederman, J., et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 104(2):e20, 1999 • 56 boys with ADHD who were being treated with either stimulants or TCAs at the beginning of the study, 19 boys with ADHD who were not receiving any medications, and 137 boys without ADHD. All boys were Caucasian and were followed for 4 years and then evaluated for abuse of or dependence on marijuana, alcohol, hallucinogens, stimulants, or cocaine. At the time of evaluation, the boys were at least 15 years old. • Treating ADHD with medications appeared to reduce the tendency to abuse drugs and alcohol. While 75 percent of the unmedicated ADHD boys had started abusing these substances in the previous 4 years, this was true of only 25 percent of the medicated ADHD boys and 18 percent of the boys without ADHD. The researchers calculated that treating ADHD with medications reduced the risk of substance abuse or dependence by 84 percent.

34. Long-term Stimulant Treatment and Brain Size • Individuals with ADHD had significantly smaller brain volumes in all regions • Compared with controls, previously unmedicated children with ADHD demonstrated significantly smaller total cerebral volumes and cerebellar volume • Unmedicated children with ADHD also exhibited smaller total white matter volumes compared with controls and with medicated children with ADHD • Castellanos FX, Lee PP, Sharp W et al. (2002), Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. JAMA 288(14):1740-1748.

35. “Eightball” (eighth of an ounce) = 3.5 grams “Baggie or Teena” (sixteenth of an ounce) = 1.75 grams Desoxyn (methamphetamine) 10 - 40 mg/day 50 - 100 x’s larger Dose difference between Meth Addict and Patient being treated for ADHD Difference in amounts used between addict and patient

36. Long-term effects of Amphetamines on the Brain Descriptions from NIDA Website • Intense paranoia • Visual and auditory hallucinations, and • Out-of-control rages that can be coupled with • Extremely violent behavior • Withdrawal syndrome sxs include: depression, anxiety, fatigue, paranoia, aggression, and an intense craving for the drug.

37. 17 year old Asian female Drinking not part of the family culture History of success in academically Many in peer group used drugs and etoh Wanted to stop after psychiatric admission for suicide attempt Did not want parents involved in treatment 17 year old Hispanic Drinking part of the culture of some family members Marignally engaged in school Many in peer group used drugs and etoh Wanted to stop etoh after psychiatric admission for suicide attempt Allowed parents to be involved in treatment Case Vignettes: Antabuse

38. Prevention

39. Psychoeducational Limitations • The DARE Story • School programs should also enhance academic and social competence • Education should focus on self-control, emotional awareness, communication, social problem-solving, and drug resistance skills

40. Prevention Programs Examples of evidence based practice: • Multisystemic Therapy (MST), • Incredible Years, • Strengthening Families Program • Project Chrysalis

41. Scott Henggler’s MST • Developed in the late 1970s to address several limitations of existing mental health services for serious juvenile offender • MST interventions aim to attenuate risk factors by building youth and family strengths (protective factors) on a highly individualized and comprehensive basis • MST is a family-based treatment model. The treatment plan is designed in collaboration with family members and is, therefore, family driven rather than therapist driven • MST services are delivered in the natural environment (e.g., home, school, community) • The typical duration of home-based MST services is approximately 4 months, with multiple therapist-family contacts occurring each week • Local MST program offered through “Options” 503.335.5975

42. NIDA Focus on Prevention • Analysis of Risk Factors • Prevention programs should enhance protective factors and reverse or reduce risk factors • An emphasis on Family Interventions and Parental Management Training

43. NIDA Prevention Principles Programs Should: • Enhance protective factors and reverse or reduce risk factors • Address all forms of drug abuse, alone or in combination • Address the type of drug abuse problem in the local community, target modifiable risk factors and strengthen identifiable protective factors • Be tailored to address risks specific to population or audience characteristics like age, gender, or ethnicity

44. NIDA Prevention Principles for Family & School Prevention Programs Should Also: • In family based prevention programs, enhance family bonding, relationships & include parenting skills training and enforcement of family rules • Be designed to intervene as early as preschool to address risk factors such as aggression, poor social skills & academics • In school age children target academic and social emotion learning and self control skills • In adolescent school programs enhance academic and social competence and drug resistance skills

45. NIDA Prevention Principles for Community Programs Should: • Be aimed at key transition points • Combine two or more effective programs • Reach populations in multiple settings • Adapt to match community norms or differing cultural elements • Be long-term with repeated interventions. Research shows that benefits from early programs diminish without followup programs at a later age