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- Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders
Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders
- By N.I. D.A.
- Published 01/10/2007
- Dual Diagnosis
- Unrated
N.I. D.A.
The National Institute on Drug Abuse was established in 1974, and in 1992 became part of the National Institutes of Health, Department of Health and Human Services. The Institute includes various programs on drug abuse research.
http://www.nida.nih.gov
By Paula D. Riggs, M.D., University of Colorado School of Medicine, Denver, Colorado
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.
Adolescents who abuse drugs possess special characteristics that include behavioral problems, skills deficits, academic difficulties, family problems, and mental health problems that generally have been shaped by environmental adversities and biological vulnerabilities that began in early childhood.
Developmental studies have yielded an inventory of the risks, difficulties, and typical problems that most often mark the developmental path of adolescents who develop substance use disorder (SUD) (Tarter, 2002; Tims et al., 2002).
Developmental research has also informed the creation of behavioral and family-based interventions that integrate the treatment of adolescent drug abuse with efforts to address other problems associated with adolescent SUD; these interventions have been captured in manuals to guide treatment providers (DrugStrategies, 2002).
A growing research and clinical consensus indicates that treatment for adolescents is most effective when it attends to the patients’ many psychosocial problems and mental health needs in addition to their drug abuse.
There is also evidence that an increasing number of community-based treatment programs are successfully implementing integrated treatment services (Drug Strategies,2002; National Institute on Drug Abuse, 1999).
Despite these advances, integrated treatment of comorbid psychiatric disorders in drug treatment programs for adolescents has trailed other integrated treatment services because of clinical and systemic barriers.
These include a critical shortage of child/adolescent psychiatrists with training in addictions, poor third-party payer coverage for integrated psychiatric services, and the longstanding separation of provider networks for psychiatric and substance abuse treatment (Rotheram-Borus and Duan, 2003).
Another barrier has been the lack of research on adolescents to support the development of integrated “best practice” standards (Weinberg et al., 1998).
Fortunately, recent studies have begun to address this significant research gap. A primary focus of this article is an overview of recent scientific advances, highlighting how research can guide the development of practice standards to improve treatment outcomes for dually diagnosed adolescents.
PATHS TO ADOLESCENT SUD
Adolescents who enter substance abuse treatment programs are more likely than peers who do not abuse drugs to have had a “difficult temperament” as toddlers or preschoolers, characterized by oppositional behavior, aggressiveness, impulsivity, and poor frustration tolerance (Tarter, 2002).
They are also more likely to have experienced abuse or neglect and significant family problems and to have developed a psychiatric disorder during early childhood, such as a learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), or oppositional defiant disorder (ODD).
Behavioral, psychosocial, and mental health problems often have hindered their adjustment to school and led to placement in separate classes for the behaviorally and learning disabled, increasing their association with peers with similar vulnerabilities, including elevated risk for school failure and for developing conduct disorder (CD) (Tarter, 2002).
In youths with such histories, limited experiences of academic success or mastery often lead to demoralization by the end of elementary school and to middle school careers marked by escalating behavior problems, increased social marginalization and associationwith deviant peers, and early onset of substance abuse.
Early substance abuse, coupled with the neurohormonal changes of puberty, impacts the developmentof the brain and neuroendocrine system in ways likely to contribute to the onset or exacerbation of preexisting psychiatric disorders, such as CD, ADHD, and mood or anxiety disorders (Crowley and Riggs, 1995;Rutter et al., 1998).
By the time an adolescent enters substance treatment, he or she often has reaped the cumulative psychological, health, and social consequences of earlier developmental adversities and behavior problems (Rutter et al., 1998; Tims et al., 2002).
Newly presenting adolescent patients are often poorly motivated for treatment and have psychiatric problems; worsening academic, family, and behavior problems; and a limited range of coping and social skills.
They are also likely to lag in important adolescent developmental tasks, including individuation, moral development, and conceptualization of future educational, vocational, and family goals (Rutter et al., 1998; Timset al., 2002).
The complexity of the problems these youths typically bring to drug abuse treatment underscores their need for multimodal approaches that address a broad range of mental health and psychosocial problems as well as drug abuse.
The following section overviews research-based treatment modalities for adolescent SUD and research on treatments for the comorbid disorders most commonly seen in these youths.
RESEARCH-BASED INTERVENTIONS FORADOLESCENT SUD
Pharmacotherapy
Many medications commonly used to treat adult SUD have not been evalulated in controlled trials with adolescents. Such medications include substitution/replacement therapies (e.g., methadone and buprenorphine), opioid antagonists (e.g., naltrexone), aversive therapies(e.g., disulfiram), or anticraving medications (e.g.,bupropion and naltrexone) (Solhkhah and Wilens,1998).
If these medications are used in treating adolescents, they must be used with caution, careful monitoring, and consideration of the developmental characteristics that distinguish adolescents from adults, such as greater impulsivity and polydrug use (Deas etal., 2000).
Behavioral or Psychosocial InterventionsResearch on behavioral/psychosocial interventions for adolescent SUD has made significant advances in the past decade.
Controlled trials now provide good evidencethat several psychosocial treatment approachescan be effective in treating adolescent SUD and other associated problems.
Some of these interventionsare based on modalities that have been effectively usedwith adults and modified substantially to make them developmentally appropriate for adolescents (Deas etal., 2000; Drug Strategies, 2002; Wagner et al., 1999).
Among the modalities with substantial research support: Family-based interventions include structural strategic family therapy, parent management training (PMT), multisystemic therapy (MST), and multidimensional family therapy (MDFT).
They are based on family systems theory and share the assumption that dysfunctional family dynamics contribute to adolescent SUD and related problems.
In practice, clinicians perform a functional analysis to identify problem behaviors, and relationship patterns that are then targeted with restructuring interventions.
Parents aretaught better monitoring skills and basic behavioral management principles to improve their adolescent’s behavior and reduce drug abuse together with strategies to improve overall family functioning and sustain the gains of treatment (Drug Strategies, 2002; Wagneret al., 1999).
Behavioral therapy approaches are based on operant behavioral principles that include rewarding behaviors or activities that are incompatible with drug use and withholding rewards or applying sanctions when drug use or other targeted behaviors occur.
This provides a constructive reinforcement system to help promote desired behaviors and extinguish those related to drug use. Urine monitoring to detect drug use is indispensable to linking consequences as closely as possible to the targeted behaviors.
Studies of adolescents indicate that it is important both to provide individual behavioral therapy and to involve the family in treatment.
Behavioral therapy has been shown to help adolescents become drug free and to improve problems in other areas, such as employment, school attendance, family relationships, conduct problems, and depression (Azrin et al., 1994; National Institute on Drug Abuse, 1999).
Cognitive-behavioral therapy (CBT), based on learning theory, also has been shown to be effective in treating adolescent SUD (Drug Strategies, 2002;Wagner et al., 1999).
Although there is more empirical support for individual CBT, preliminary studies indicate that group CBT may also reduce adolescent substance use and improve other problem behaviors (Kaminer et al., 1998).
Treatment manuals have been developed for courses of weekly CBT treatment rangingfrom 5 to 16 weeks.
Features common to most CBT models include:
• Employing motivation-enhancing techniques to establish a strong treatment alliance and improve treatment engagement and retention;
• Performing a functional analysis to identify patterns of substance use, skills deficits, and dysfunctional attitudes and thinking that then become specific targets of intervention;
• Enhancing coping strategies to effectively deal with drug craving, negative moods, and anger;
• Strengthening problem solving and communication skills and the ability to anticipate and avoid high risk situations; and
• Identifying enjoyable activities incompatible with drug use. New skills and coping strategies are initially taught and practiced during therapy sessions, then applied to the patient’s daily life in “homework” assignments, with a review of successes and setbacks the following week (Drug Strategies, 2002; Wagner et al., 1999).
{Continued on source document page:
http://www.nida.nih.gov/PDF/Perspectives/vol2no1/03Perspectives-Treating.pdf
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.
Adolescents who abuse drugs possess special characteristics that include behavioral problems, skills deficits, academic difficulties, family problems, and mental health problems that generally have been shaped by environmental adversities and biological vulnerabilities that began in early childhood.
Developmental studies have yielded an inventory of the risks, difficulties, and typical problems that most often mark the developmental path of adolescents who develop substance use disorder (SUD) (Tarter, 2002; Tims et al., 2002).
Developmental research has also informed the creation of behavioral and family-based interventions that integrate the treatment of adolescent drug abuse with efforts to address other problems associated with adolescent SUD; these interventions have been captured in manuals to guide treatment providers (DrugStrategies, 2002).
A growing research and clinical consensus indicates that treatment for adolescents is most effective when it attends to the patients’ many psychosocial problems and mental health needs in addition to their drug abuse.
There is also evidence that an increasing number of community-based treatment programs are successfully implementing integrated treatment services (Drug Strategies,2002; National Institute on Drug Abuse, 1999).
Despite these advances, integrated treatment of comorbid psychiatric disorders in drug treatment programs for adolescents has trailed other integrated treatment services because of clinical and systemic barriers.
These include a critical shortage of child/adolescent psychiatrists with training in addictions, poor third-party payer coverage for integrated psychiatric services, and the longstanding separation of provider networks for psychiatric and substance abuse treatment (Rotheram-Borus and Duan, 2003).
Another barrier has been the lack of research on adolescents to support the development of integrated “best practice” standards (Weinberg et al., 1998).
Fortunately, recent studies have begun to address this significant research gap. A primary focus of this article is an overview of recent scientific advances, highlighting how research can guide the development of practice standards to improve treatment outcomes for dually diagnosed adolescents.
PATHS TO ADOLESCENT SUD
Adolescents who enter substance abuse treatment programs are more likely than peers who do not abuse drugs to have had a “difficult temperament” as toddlers or preschoolers, characterized by oppositional behavior, aggressiveness, impulsivity, and poor frustration tolerance (Tarter, 2002).
They are also more likely to have experienced abuse or neglect and significant family problems and to have developed a psychiatric disorder during early childhood, such as a learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), or oppositional defiant disorder (ODD).
Behavioral, psychosocial, and mental health problems often have hindered their adjustment to school and led to placement in separate classes for the behaviorally and learning disabled, increasing their association with peers with similar vulnerabilities, including elevated risk for school failure and for developing conduct disorder (CD) (Tarter, 2002).
In youths with such histories, limited experiences of academic success or mastery often lead to demoralization by the end of elementary school and to middle school careers marked by escalating behavior problems, increased social marginalization and associationwith deviant peers, and early onset of substance abuse.
Early substance abuse, coupled with the neurohormonal changes of puberty, impacts the developmentof the brain and neuroendocrine system in ways likely to contribute to the onset or exacerbation of preexisting psychiatric disorders, such as CD, ADHD, and mood or anxiety disorders (Crowley and Riggs, 1995;Rutter et al., 1998).
By the time an adolescent enters substance treatment, he or she often has reaped the cumulative psychological, health, and social consequences of earlier developmental adversities and behavior problems (Rutter et al., 1998; Tims et al., 2002).
Newly presenting adolescent patients are often poorly motivated for treatment and have psychiatric problems; worsening academic, family, and behavior problems; and a limited range of coping and social skills.
They are also likely to lag in important adolescent developmental tasks, including individuation, moral development, and conceptualization of future educational, vocational, and family goals (Rutter et al., 1998; Timset al., 2002).
The complexity of the problems these youths typically bring to drug abuse treatment underscores their need for multimodal approaches that address a broad range of mental health and psychosocial problems as well as drug abuse.
The following section overviews research-based treatment modalities for adolescent SUD and research on treatments for the comorbid disorders most commonly seen in these youths.
RESEARCH-BASED INTERVENTIONS FORADOLESCENT SUD
Pharmacotherapy
Many medications commonly used to treat adult SUD have not been evalulated in controlled trials with adolescents. Such medications include substitution/replacement therapies (e.g., methadone and buprenorphine), opioid antagonists (e.g., naltrexone), aversive therapies(e.g., disulfiram), or anticraving medications (e.g.,bupropion and naltrexone) (Solhkhah and Wilens,1998).
If these medications are used in treating adolescents, they must be used with caution, careful monitoring, and consideration of the developmental characteristics that distinguish adolescents from adults, such as greater impulsivity and polydrug use (Deas etal., 2000).
Behavioral or Psychosocial InterventionsResearch on behavioral/psychosocial interventions for adolescent SUD has made significant advances in the past decade.
Controlled trials now provide good evidencethat several psychosocial treatment approachescan be effective in treating adolescent SUD and other associated problems.
Some of these interventionsare based on modalities that have been effectively usedwith adults and modified substantially to make them developmentally appropriate for adolescents (Deas etal., 2000; Drug Strategies, 2002; Wagner et al., 1999).
Among the modalities with substantial research support: Family-based interventions include structural strategic family therapy, parent management training (PMT), multisystemic therapy (MST), and multidimensional family therapy (MDFT).
They are based on family systems theory and share the assumption that dysfunctional family dynamics contribute to adolescent SUD and related problems.
In practice, clinicians perform a functional analysis to identify problem behaviors, and relationship patterns that are then targeted with restructuring interventions.
Parents aretaught better monitoring skills and basic behavioral management principles to improve their adolescent’s behavior and reduce drug abuse together with strategies to improve overall family functioning and sustain the gains of treatment (Drug Strategies, 2002; Wagneret al., 1999).
Behavioral therapy approaches are based on operant behavioral principles that include rewarding behaviors or activities that are incompatible with drug use and withholding rewards or applying sanctions when drug use or other targeted behaviors occur.
This provides a constructive reinforcement system to help promote desired behaviors and extinguish those related to drug use. Urine monitoring to detect drug use is indispensable to linking consequences as closely as possible to the targeted behaviors.
Studies of adolescents indicate that it is important both to provide individual behavioral therapy and to involve the family in treatment.
Behavioral therapy has been shown to help adolescents become drug free and to improve problems in other areas, such as employment, school attendance, family relationships, conduct problems, and depression (Azrin et al., 1994; National Institute on Drug Abuse, 1999).
Cognitive-behavioral therapy (CBT), based on learning theory, also has been shown to be effective in treating adolescent SUD (Drug Strategies, 2002;Wagner et al., 1999).
Although there is more empirical support for individual CBT, preliminary studies indicate that group CBT may also reduce adolescent substance use and improve other problem behaviors (Kaminer et al., 1998).
Treatment manuals have been developed for courses of weekly CBT treatment rangingfrom 5 to 16 weeks.
Features common to most CBT models include:
• Employing motivation-enhancing techniques to establish a strong treatment alliance and improve treatment engagement and retention;
• Performing a functional analysis to identify patterns of substance use, skills deficits, and dysfunctional attitudes and thinking that then become specific targets of intervention;
• Enhancing coping strategies to effectively deal with drug craving, negative moods, and anger;
• Strengthening problem solving and communication skills and the ability to anticipate and avoid high risk situations; and
• Identifying enjoyable activities incompatible with drug use. New skills and coping strategies are initially taught and practiced during therapy sessions, then applied to the patient’s daily life in “homework” assignments, with a review of successes and setbacks the following week (Drug Strategies, 2002; Wagner et al., 1999).
{Continued on source document page:
http://www.nida.nih.gov/PDF/Perspectives/vol2no1/03Perspectives-Treating.pdf
