Alcohol use disorder in adolescents.

Alcohol use and abuse by children and adolescents remains a critical problem for modern developed countries. Although tolerance and public policy for alcohol use varies among Western countries, the use of alcohol and other harmful substances is common among adolescents. The use of alcohol can lead to a variety of negative consequences for youth. The risk for alcohol use and abuse, the acquisition of use behaviors, and development into alcohol use disorders and interventions for such problems should be considered in a comprehensive manner that considers neurobiology, development, and the adolescent's environmental ecology. Although the nature and extent of the alcohol problems between countries may vary, approaches to assessment and treatment from the United States may be useful to clinicians in other countries. This paper presents essential background information for the clinician in order to understand the presentation, risk, prevention and treatment of adolescents with alcohol use problems.

Fluoxetine in adolescents with major depression and an alcohol use disorder: an open-label trial.

Recently, a first placebo-controlled study of an selective serotonin reuptake inhibitor (SSRI) medication was conducted among a sample of adolescents with major depression by Emslie et al. [Arch. Gen. Psychiatry 54 (1997) 1031.]. That study demonstrated efficacy for fluoxetine vs. placebo for treating adolescents with major depression. However, to date, no studies have been conducted to assess the efficacy of fluoxetine or any other SSRI medication in adolescents with major depression in combination with an alcohol use disorder (AUD). In this study, the authors investigated whether fluoxetine decreases the depressive symptoms and the drinking of adolescents with comorbid major depression and an AUD. The authors conducted a 12-week open-label study of fluoxetine (20 mg) in 13 adolescents with current comorbid major depression and an AUD. A significant within-group decrease (improvement) was found for both depressive symptoms and drinking during the course of the study. The fluoxetine was well tolerated during the study. These data suggest promise for fluoxetine for decreasing both the depressive symptoms and the drinking of adolescents with comorbid major depression and an AUD.

Methylphenidate dosage for children with ADHD over time under controlled conditions: lessons from the MTA.

OBJECTIVES: To examine the trajectory of methylphenidate (MPH) dosage over time, following a controlled titration, and to ascertain how accurately the titration was able to predict effective long-term treatment in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: Using the 14-month-treatment database of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), the outcome of the initial placebo-controlled, double-blind, randomized daily switch titration of MPH was compared with the subsequent maintenance pharmacotherapy. Children received monthly monitoring visits and, when needed, medication adjustments. RESULTS: Of the 198 children for whom MPH was the optimal treatment at titration (mean +/- SD dose: 30.5 +/- 14.2 mg/day), 88% were still taking MPH at the end of maintenance (mean dose 34.4 +/- 13.3 mg/day). Titration-determined dose and end-of-maintenance dose were significantly correlated (r = 0.52-0.68). Children receiving combined pharmacotherapy and behavioral treatment ended maintenance on a lower dose (31.1 +/- 11.7 mg/day) than did children receiving pharmacotherapy only (38.1 +/- 14.2 mg/day). Of the 230 children for whom titration identified an optimal treatment, 17% continued both the assigned medication and dosage throughout maintenance. The mean number of pharmacological changes per child was 2.8 +/- 1.8 (SD), and time to first change was 4.7 months +/- 0.3 (SE). CONCLUSIONS: For most children, initial titration found a dose of MPH in the general range of the effective maintenance dose, but did not prevent the need for subsequent maintenance adjustments. For optimal pharmacological treatment of ADHD, both careful initial titration and ongoing medication management are needed.

Impairment and deportment responses to different methylphenidate doses in children with ADHD: the MTA titration trial.

OBJECTIVE: Results of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were analyzed to determine whether a double-blind, placebo-controlled methylphenidate (MPH) titration trial identified the best MPH dose for each child with attention-deficit/hyperactivity disorder (ADHD). METHOD: Children with ADHD assigned to MTA medication treatment groups (n = 289) underwent a controlled 28-day titration protocol that administered different MPH doses (placebo, low, middle, and high) on successive days. RESULTS: A repeated-measures analysis of variance revealed main effects for MPH dose with greater effects on teacher ratings of impairment and deportment (F3 = 100.6, n = 223, p = .0001; effect sizes 0.8-1.3) than on parent ratings of similar endpoints (F3 = 55.61, n = 253, p = .00001; effect sizes 0.4-0.6). Dose did not interact with period, dose order, comorbid diagnosis, site, or treatment group. CONCLUSIONS: The MTA titration protocol validated the efficacy of weekend MPH dosing and established a total daily dose limit of 35 mg of MPH for children weighing less than 25 kg. It replicated previously reported MPH response rates (77%), distribution of best doses (10-50 mg/day) across subjects, effect sizes on impairment and deportment, as well as dose-related adverse events.

Inter-rater reliability of the SCID alcohol and substance use disorders section among adolescents.

Diagnostic interviews for substance use disorders tend to have high reliability among adults. We examined the inter-rater reliability of the substance use disorders section of the Structured Clinical Interview for the DSM, using 46 male and 25 female adolescent drinkers recruited from community and treatment sources. Inter-rater reliability was high for individual DSM-IV alcohol symptoms (kappa=0.84-1.0) and diagnoses (kappa=0.94), and for other substance use disorder diagnoses (kappa=0.82-1.0).

Disruptive behavior disorders and substance use disorders in adolescents.

Disruptive behaviors disorders in the form of conduct disorder, oppositional defiant disorder and/or attention-deficit hyperactivity disorder are found in a majority of adolescents with substance use disorders These disorders influence the risk for and the course of substance use disorders in adolescents and potentially provide important targets for intervention. Interventions such as family therapy and multisystemic therapy can focus on important environmental factors that help to produce and sustain substance use, related problems and disruptive/deviant social behavior. Researchers and clinicians are increasingly utilizing multimodal approaches that use several psychosocial approaches in addition to medication, if indicated. This article reviews our current understanding of the relationship between disruptive behavior disorders and substance use disorders in adolescents and the importance of this understanding in the prevention, assessment and treatment of adolescents with substance use disorders.

Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings.

OBJECTIVE: Although the combination of methylphenidate (MPH) and behavior modification (BMOD) has been advocated to enhance clinical outcome for children with attention-deficit hyperactivity disorder (ADHD) and comorbid disruptive disorders, few group studies have been conducted. This study evaluates the separate and incremental effects of these modalities on rating scale and observational measures in multiple settings. METHOD: Sixteen of 22 children with ADHD and comorbid disruptive disorder completed a randomized, placebo-controlled study examining the separate and incremental effects of 2 doses of MPH and BMOD during a partial hospitalization program. Of the 6 who did not complete the study, 2 children developed significant side effects. For the 16 who did complete the study, effects were examined on measures of symptom ratings, behavioral frequencies, and stimulant side effects across program activities. RESULTS: Based on alpha-adjusted analyses of variance, there were several main effects of MPH and BMOD on ADHD symptoms, oppositional behavior, and positive social behavior, with certain effects unique to each intervention and setting. One incremental effect each was found for MPH (positive mood/behavior) and BMOD (negative behavior). MPH and BMOD were associated with few side effects. Effect sizes for each intervention showed considerable variability in clinical response. CONCLUSIONS: That MPH and BMOD had certain unique main and incremental effects extends findings supporting their combination and suggests that integrated studies evaluate multiple dimensions of functioning and in novel settings (e.g., home, school). The incorporation of other intervention components in combined treatments may be warranted to enhance clinical efficacy.

Effects of methylphenidate on aggressive urban children with attention deficit hyperactivity disorder.

Determined the efficacy of methylphenidate (MPH) in a clinical population of aggressive, urban children diagnosed with attention deficit hyperactivity disorder (ADHD). In previous studies of prepubertal children with ADHD, MPH has been shown to be effective when compared with placebo. Eighteen inner-city children (ages 6 to 12 years), diagnosed with ADHD and attending a summer treatment program for youth with disruptive behavior disorders, participated in a double-blind placebo trial with assessment data obtained from staff in the program and parents at home. Based on staff ratings of the children's behavior in the program and an academic classroom, the children displayed significant improvements in ADHD symptoms and aggressive behavior with low- and high-dose MPH conditions. At home, parents and guardians reported few significant differences between placebo and MPH on behavior ratings. In both settings, MPH was well tolerated with few side effects found during active drug conditions.

Psychopathology in adolescent alcohol abuse and dependence.

Adolescents who abuse or are dependent on alcohol often have coexisting mental disorders. These disorders may both precipitate alcohol use disorders and result from them. In addition, both types of disorders may arise independently in adolescents at high risk. Mental disorders that commonly co-occur with alcohol use disorders in adolescents include antisocial disorders, mood disorders, and anxiety disorders. Treatment programs for adolescents with alcohol use disorders should seek not only to eliminate alcohol and other drug use but also to improve the symptoms of other mental disorders.

Gender and comorbid psychopathology in adolescents with alcohol dependence.

OBJECTIVE: Although several mental disorders have been shown to be common in adolescents with substance use disorders, prior studies have not specifically focused on alcohol dependence and have not had sufficient sample sizes to examine gender effects. This study contrasts mental disorder diagnoses and symptoms between a sample of adolescents with alcohol dependence and a community control sample of adolescents and incorporates gender analyses. METHOD: Adolescents (aged 14 years 0 months to 18 years 0 months) with alcohol dependence (females: n = 55; males: n = 78) and community-dwelling control adolescents without substance use disorders (females: n = 44; males: n = 42) were assessed by means of a semistructured interview for DSM-III-R. RESULTS: While cannabis and hallucinogen use disorders were common in the alcohol dependence group, females and males had similar rates. Conduct disorder (CD), oppositional defiant disorder, attention-deficit hyperactivity disorder, major depression (MD), and posttraumatic stress disorder (PTSD) had significantly higher rates in the alcohol dependence than in the community control group. Depression and PTSD symptoms were more strongly associated with alcohol dependence in females than in males. A configural frequency analysis showed that CD and MD tended to occur together in both female and male adolescents with alcohol dependence. CONCLUSIONS: While alcohol-dependent females and males similarly exhibited more comorbid disorders than control adolescents, gender affects the relationship of alcohol dependence to MD and PTSD. Rather than reflecting distinct types, the comorbid disorders of CD and MD jointly characterize many adolescents with alcohol dependence.

Identifying anxiety disorders in adolescents hospitalized for alcohol abuse or dependence.

In structured clinical interviews of 43 adolescents hospitalized for alcohol abuse or dependence, 17 subjects met criteria for an anxiety disorder, with social phobia (N = 9) and posttraumatic stress disorder (N = 7) most common. Of these 17 subjects, only four were identified in hospital records as having an anxiety disorder. In a comparison of 30 hospitalized adolescents with a matched control group of 30 adolescents from the community, the hospitalized adolescents had a higher rate of anxiety disorders, psychoactive substance use disorders, disruptive behavior disorders, and mood disorders.

Self-reported health problems and physical symptomatology in adolescent alcohol abusers.

PURPOSE: Few studies have examined the impact of alcohol abuse on the health status of adolescents. The purpose of this investigation was to determine whether adolescents with a diagnosis of alcohol abuse differed from controls on the frequency of self-reported health problems, clinical signs and symptoms detected upon clinical examination, and liver injury test results. METHODS: Cases were ascertained from in-patient drug and alcohol treatment centers. Age- and sex-matched controls were recruited from community sources. The Health Problems Checklist (HPC) was used to measure self-reported problems; the clinical examination was performed by a physician or a physician's assistant. RESULTS: Alcohol-abusing adolescents reported significantly more physical symptoms than did controls as measured by the HPC. The results of the clinical examination revealed a low prevalence of overt abnormalities in both groups, however, alcohol-abusing adolescents reported a higher frequency of appetite changes, weight loss, eczema, headaches and episodes of loss of consciousness than did controls. As expected, alcohol-abusing adolescents had significantly higher levels of ALT, AST and GGTP as compared to controls. CONCLUSIONS: The findings of this study are generalizable only to in-patient adolescent alcohol abusers. In this study, alcohol abuse was also associated frequently with psychiatric disorders, drug abuse, cigarette smoking, and low parental education. Future studies using larger sample sizes should address the importance of social environmental and behavioral variables in moderating the relationship between alcohol abuse and decreased health status in adolescents.

Cognitive distortions and adolescent affective disorder. Validity of the CNCEQ in an inpatient sample. Children's Negative Cognitive Error Questionnaire.

Despite a proliferation of recent research examining childhood and adolescent depression, the area still lags behind the adult depression field, particularly in the investigation of cognitive correlates of affective psychopathology. To advance cognitive research with youth, the Children's Negative Cognitive Error Questionnaire (CNCEQ) was developed to provide a measure of cognitive distortions or errors in children and adolescents. Yet, few studies have employed the CNCEQ and no evidence exists supporting the validity of its four component cognitive error scales. The purpose of the present study was to examine the construct validity of the CNCEQ and its constituent scales through the use of factor analysis and criterion-group comparisons. Groups of adolescent psychiatric inpatients, diagnosed as affective or disruptive disordered, completed the CNCEQ following admission. Results failed to support the implicit four-factor structure of the CNCEQ, instead suggesting the appropriateness of a single-factor solution labeled "negative thinking." Despite no diagnostic group differences on the CNCEQ total or other scale scores, affective disordered patients evinced more cognitive errors on the Overgeneralizing scale. Findings suggest that the CNCEQ in its current stage of development holds promise, yet requires refinement to produce a valid measure of cognitive functioning in youth.

Cognitive distortions and psychiatric diagnosis in dually diagnosed adolescents.

OBJECTIVE: The purpose of this study was to examine the characteristics and patterns of cognitive distortions among psychiatrically hospitalized adolescents. METHOD: Measures of cognitive distortions, depression, and hopelessness were administered to 135 adolescents on two psychiatric inpatient units. Subjects were grouped according to their Axis I diagnoses: depression only, conduct disorder only, depression and substance abuse, conduct disorder and substance abuse, all three diagnoses, and none of the three diagnoses. RESULTS: Multivariate analyses of covariance indicated that differently diagnosed adolescents exhibited varying levels of cognitive distorting as measured by the Children's Negative Cognitive Errors Questionnaire (CNCEQ). In particular, adolescents with multiple Axis I diagnoses tended to score highest. On all but one of four CNCEQ subscales, the depression only group evidenced as much cognitive distortion as did the group with multiple diagnoses. However, each diagnostic grouping demonstrated its own somewhat distinct distortions based on CNCEQ subscales. CONCLUSIONS: Findings are discussed in terms of the utility of differentiating cognitive styles for subsequent treatment. It is suggested that disparate cognitive interventions could be matched with adolescents displaying particular problems.

Risk factors for completed suicide among adolescents with a lifetime history of substance abuse: a case-control study.

The risk factors for suicide in adolescents with substance abuse were assessed by comparing 23 adolescent suicide victims and 12 community controls with a lifetime history of definite or probable DSM-III substance abuse. Suicide victims were more likely than controls to show the following risk factors: active substance abuse, comorbid major depression, suicidal ideation within the past week, family history of depression and substance abuse, legal problems and presence of a handgun in the home. Recommendations for the identification and prevention of suicide among substance-abusing youth on the basis of these findings are presented.

Drug abuse prevention for high-risk African American children and their families: a review and model program.

In this article we are specifically concerned with the familial and socioeconomic factors that contribute to the exceedingly high prevalence rates of drug abuse in African-American children. In addition to detailing the impact of drug abuse in African-American children and their families, we consider how this critical health problem can be prevented using existing knowledge and strategies known to mental health professionals. A model program entitled Project for a Substance Abuse-Free Environment (SAFE) is outlined. Its objectives are to implement: (a) a broad-spectrum family intervention to empower disadvantaged and high-risk families in their communities: (b) a competency-based skills intervention to increase resilience and decrease drug use and other maladaptive behaviors in at-risk children; (c) alternative activities that will promote self-efficacy, achievement, and self-esteem; (d) a culturally-relevant evaluation plan that includes both formative (process) and summative (outcome) evaluation; (e) a comprehensive approach for assessing project impact; (e) systematic procedures for enhancing the maintenance and generalization of gains in participating children and families.

Social skills and depression in adolescent substance abusers.

The present study provided an assessment of social skills and depression in adolescent substance abusers hospitalized in an inpatient psychiatric setting. Level of social skill was evaluated using the Adolescent Assertion Expression Scale and the Loneliness Scale. Depression and related problems were examined through administration of the Beck Depression Inventory. Beck Hopelessness Scale, and the Rosenberg Self-Esteem Scale. Comparisons with normative values and clinical cut-offs (by gender) indicated that female adolescent substance abusers were less submissive and more aggressive than normative counterparts; male substance abusers exhibited less assertiveness. In addition, mild to moderate levels of depression were evident in both female and male substance abusers. Further, results of correlational analyses revealed several significant relationships between measures of social skills and depression. Results are discussed in terms of: (a) the need for finer grained analyses of social functioning in adolescent substance abusers, (b) the potential value of skills intervention for a subgroup of these individuals, and (c) the need for longitudinal data to more clearly explicate patterns and sequencing of social (mal)adjustment, affective disorder, and onset of substance abuse in this population.

Patterns of polydrug use in adolescent alcohol abusers.

It is clear that alcohol abuse by adolescents rarely exists today without the concurrent use of other drugs. Little is known, however, about the extent and patterns of polydrug use in clinical samples of adolescent alcohol abusers. The present study examined patterns and correlates of polydrug use in 72 adolescents admitted to an inpatient treatment unit with a diagnosis of alcohol abuse. The degree of lifetime involvement with 10 different drug classes was assessed in a clinical interview. Ninety-six percent of subjects reported use of drugs other than alcohol, and there were substantial rates of use for most drug classes. Males and females did not differ in the percentage of subjects who used different drug classes or in severity of involvement ratings for these drug classes. The data suggest a consistent ordering of drug classes, such that the use of drug classes later in this order was rare in the absence of the use of drug classes earlier in the order. The data suggest that polydrug use characterizes the large majority of adolescent alcohol abusers, and that such use is often quite extensive. Implications for assessment and treatment are discussed.

Patterns of affective comorbidity in a clinical population of dually diagnosed adolescent substance abusers.

Patterns of affective comorbidity with substance abuse are examined in a sample of 156 adolescent psychiatric inpatients, ages 13 to 18 years old. Affective disorders, including adjustment disorder with depressed mood, were observed in 51.3% of patients. A total of 30.7% of patients had comorbid major depression. In both males and females, secondary major depressive disorder was more common than its primary form. In this population, the primary-secondary paradigm did not predict either acute remission for depressive symptoms or distinct family history of comorbid disorders. Consistent with previous studies of adults, significantly more females had comorbid affective disorder and significantly more males had conduct disorder.

Comparison between treatment completers and noncompleters among dually diagnosed substance-abusing adolescents.

The psychiatric and demographic characteristics that may distinguish treatment completers from noncompleters among hospitalized adolescents with substance abuse and comorbid psychiatric disorders were examined. Affective and adjustment disorders were more prevalent among treatment completers whereas non-completers were more likely to be assigned a conduct disorder diagnosis. There were no differences between the groups with respect to demographic and legal status, education level and lifetime psychiatric diagnosis in the parents or caretakers, living arrangements, treatment history, and perception of treatment benefits. A higher percentage of treatment completers than noncompleters received psychotropic medications. The factors contributing to treatment termination as well as the clinical and research implications of the findings are discussed.