Adolescents and

Substance Abuse
Cigarette smoking
Tobacco use in teens is associated with a wide range of
risk taking behavior, including violence, high risk sexual
activity, and drug use. There is a significant risk of
developing a major depression within one year of starting
to smoke. Children with psychiatric disorders are also
more likely to smoke.
Teenage smoking reached a peak in Wisconsin in 1999
(38.1% of seniors) and has declined to 20.9%. Girls
(21.9%) have a slightly higher prevalence rate than boys
(19.8%).
Prevention of Cigarette Smoking

The most effective antidote to smoking is

expensive cigarettes.
Resistance training skills are helpful to reduce
smoking initiation.
75-80% of initially successful quitters resume
smoking within 6 months. If they can stay
abstinent for 5 years, risk of relapse is
negligible.
 Drug and Alcohol Abuse
Drug use increases in adolescents to young
adulthood, then generally declines. In 2005, there
has been a decline in alcohol use, LSD and
cocaine, but an increase in illicit prescription drugs
(oxycodone), marijuana, and club drugs. The use
of inhalants is rising among 8th graders.
Teenage drinking among girls is rising faster than
boys, in large part because they are being targeted
in alcohol related ads in the magazines they read.
 2005 “Monitoring
the Future” Survey
Drinking in last month
8th grade 17%
10th grade 33.2%
12th grade 47%
28% of seniors binge drink
Tried an illicit drug
8th grade 21%
10th grade 38%
12th grade 50%
 Drug Abuse in Children and
Adolescents
1:5 teens has abused Vicodin or OxyContin.
10% have abused a stimulant - Adderall is the
most common. 10% have abused cough
medicines
Most of the time, these prescription drugs are in
the family medicine cabinet. There are Internet
sites devoted to how to get and abuse drugs.
Inhalant abuse can be fatal. Such agents are
commonly found in household - glue, shoe
polish, spray paints, nitrous oxide, correction
fluid, etc.
 Prevention in Children and
Adolescents
The younger the child initiates alcohol and
other drug use, the higher the risk for serious
health consequences and adult substance
abuse and dependence.
Effective prevention and intervention
programs consider cultural context, social
resistance skills, and developmental level of
the child.
 Prevention in Children and
Adolescents
Peers have been successfully used to influence,
teach, and counsel young people. Even though
education about drugs do not contribute greatly
to reducing drug use, the use of peers as
facilitators works for the average student.
Adolescents believe their peers’ attitudes against
drug use. The lower the perceived acceptance
rate, the less frequent the drug use.
DARE works better than non-interactive
programs, but not as well as programs involving
peer delivery of information.
 Prevention in Children and
Adolescents
Most promising preventive measures are:
Assessment and treatment of psychiatric disorders
Education that targets knowledge and attitudes about
substances
Development of proper social and problem solving
skills
Treatment of family problems
Increased opportunities for prosocial activities with
peers
Limited early access to the use of gateway drugs such
as alcohol and nicotine
 Prevention in Children and
Adolescents
Risk factors:
Poor self-image
Low religiosity
Poor school performance
Parental rejection
Family dysfunction
Abuse
Over or under-controlling by parents
Divorce
Externalizing disorders (ADHD has 3x risk substance
use. Those in treatment are at less risk)
 Protective Factors in Children
and Adolescents
 Nurturing home with good communication
 Teacher commitment
 Positive self-esteem
 Self-control
 Assertiveness
 Social competence
 Academic achievement
 Regular church attendance
 Intelligence
 Avoiding delinquent peers
 Depression
Depression is a constellation of symptoms
including social isolation, lack of energy, changes
in sleep and appetite, and an inability to
experience pleasure that appear in addition to a
depressed mood.
Substance Abuse and
Mental Health Services
Administration
Adolescents with depression in
past year (2004)
15%

10%

5%

0%
13-14 14-15 16-17
 SAMHSA - 2004
9% of adolescents experienced a depressive
episode over the last year.
Girls - 13.1% Boys - 5%
No differences in ethnic group, SES in incidence,
but those with health insurance were more likely to
get treatment.
<50% received help for depression.
Those with depression were twice as likely to
smoke, use alcohol and illicit drugs.
 Wisconsin High School Survey
2003

During the last 12 months, have you felt sad or

hopeless for 2 weeks or more so that you
stopped doing social activities?
Total 25.3%
Boys 17.6%
Girls 33.5%
Junior year the worst
 Depression
Depression may manifest itself as irritability and
behavior problems in children and adolescents.
Research now indicates that substance abuse in
boys and girls, and sexual behavior in girls is a
cause for subsequent depression in adolescents.
Depression can then make teens more vulnerable
to substance abuse and other risky behaviors.
The use of antidepressants in children and teens is
controversial.
 Antidepressants and Suicide
In the summer of 2004, two reviews by Columbia
University looked at pharmaceutical industry data
from 22 placebo controlled trials involving 4,250
pediatric patients. They found that young people
given antidepressants were 1.8x more likely to
become suicidal as young people given placebo.
 Antidepressants and Suicide
On October 15, 2004, the FDA issued its strongest
possible warning (black box) for all
antidepressants stating that these medications
may “increase the risk of suicidal thinking and
behavior in children and adolescents with major
depressive or other psychiatric disorders.”
 Antidepressants and Suicide
The best approach is to monitor everyone who is
started on an antidepressant closely for the
appearance of suicidal ideation, agitation, and
irritability, especially during the initial months of
therapy, and be sure that the risk is discussed
during the informed consent process.
 Self-Injurious Behavior
SIB - the deliberate alteration or destruction of
body tissue without conscious suicidal intent
Four types:
Severe - extensive damage (psychotic)
Stereotyped - rhythmic (DD, seizure disorders)
Socially accepted/emblematic - tattooing, piercing,
etc…
Superficial/moderate
 Superficial/Moderate
Compulsive:
Habitual, obsessive/comp rather than impulsive. Urge
is resisted. (Ego-dystonic) Intrusive thoughts about
contamination, inadequacy, bodily shame. Nail biting,
trichotillomania, skin picking
Episodic:
Occasional impulsive burning and cutting in response
to stress or life events.
Repetitive:
Repetitive burning and cutting, rumination about self-
abuse and identification as a cutter or burner. There is
little resistance to the urge. Carefully executed. Has
qualities of addiction.
 Superficial/Moderate
Counter-dissociative:
An attempt to re-associate self with here and now reality
Parasuicidal:
“suicide gesture” reflecting ambivalence about suicide or
as attempt to communicate to others
Impulsive, Superficial/ Moderate
SIB
Skin cutting is the most common, followed by
burning and hitting
Commonly comorbid with personality disorders
Typically includes onset in adolescence, multiple
episodes, chronic, associated with depression,
despair, anger, aggression, anxiety, cognitive
constriction
Predisposing factors include lack of social
support, male homosexuality, AODA, suicidal
ideation in women.
Diagnosed as Impulse Control Dis NOS, or BPD
 Self-Injurious Behavior
 Worldwide, nonfatal deliberate self-harm is more common
in adolescents, especially young females (11.2% girls,
3.2% boys) Boys more frequently need medical attention.
 Self-harm in adolescents increased with consumption of
cigarettes, alcohol and drugs in one large study. Having
friends or family members self-harm was also a risk factor.
Depression, anxiety, and impulsivity was a risk for girls,
who said they were trying to punish themselves or get relief
from a terrible state of mind.
 The Internet may normalize and encourage pre-existing
SIB in adolescents.
 Self-Injurious Behavior
There is disagreement about the meaning of the
injury: symbolic, impulse disorder, serotonin
deficit, endorphin dysregulation.
Adolescents are likely to explain their self-harm
by saying they wanted relief from unpleasant
feelings (depression, anxiety, loneliness, anger)
or that the act was impulsive.
Childhood abuse is a factor in the descriptive
and empirical literature.
There are also associations with AODA, PTSD,
intermittent explosive disorder, dissociative
disorder.
 Summary of Reasons for SIB

Affect regulation
 Reconnection with the body
 Calming the body during periods of arousal (exhibit decreases in
respiration, skin conductance, heart rate in response to the behavior (like
concentration)
 Validating inner pain
 Avoiding suicide
Communication
 Express things which cannot be said out loud
Control/punishment
 Trauma re-enactment
 Bargaining and magical thinking
 Self-control
 Control of others
 Children and Suicide
Suicide attempts are statistically insignificant
until the age of 12., but higher in the US in the
last 20 years.
Suicidal children have a history of impulsive,
aggressive behavior, are taller and physically
more mature than their classmates, more were
more likely to be involved with conflict with
parents, and be in a disciplinary crisis. Families
must be involved in assessment, prevention and
treatment.
 Warning Signs
 Past suicide attempts or threats
 Past violent or aggressive behavior
 Mental illness or alcohol use
 Bringing weapons to school
 Recent experience of humiliation, shame loss
 Bullying as victim or perpetrator
 Victim of abuse/neglect
 Themes of depression, death
 Vandalism, cruelty to animals, setting fires
 Poor peer relationships, cults, no supervision
Suicide first arises as a public
health problem at 12 years
old.
Suicide Rates per 100,000

12

1.3

10yrs - 14 15yrs-19 20yrs-24

 Suicide Rates: 1981-2001

30

25

20
Female
15
Male
10

0
Adolescent Suicidal Behavior:

2001 U.S. Data

20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Ideation Plan Attempt Complete
 Wisconsin Suicides
Suicide is the second leading cause of death in
adolescents.
From 2000-2002, there were 323 suicides (262
homicides.)
The annual rate is 5.7/100,000 - 36% higher than
the national average. The highest incidence is in
northern Wisconsin.
Guns are involved in 52%.
27% tested positive for alcohol.
 Suicidal Ideation
In teens, suicidal ideation more strongly indicates
antisocial behavior than it does risk of suicide.
Features that may separate those who attempt
from those who don’t:
AODA
Severe and enduring hopelessness
Isolation
Reluctance to discuss suicidal thoughts
Psychopathology
 Gender Issues
Girls
Attempts to completions 4,000:1
A suicide attempt is not a risk factor for suicide. Having
a depressive episode is, often with no precipitating
event
Panic attacks are a risk factor for girls
Boys
Attempts to completions 500:1
Rate increased 3x since 1955 - Increased AODA?
Dropped since 1995 - Increased antidepressants?
Usually within hours of event, before consequences,
when anticipatory anxiety is highest. Events include
legal problems, relationship problems, humiliation.
Aggression is a risk factor for boys
 Risk Factors for Adolescents
Mental illness
90% have depression, anxiety, AODA a year before
suicide. It is estimated that 1 million youths suffer from
depression, but 60-80% do not receive help. Fewer than
10% of completed suicides were on antidepressants or in
AODA treatment.
50% of teen suicides involve alcohol use.
Parents frequently do not recognize signs of suicidal
behavior. Most lay people justify depressive symptoms in
themselves and others, blaming it on stress. Stressors
can mislead. It may be the mental illness that is causing
the stress.
 Risk Factors for Adolescents
Imitation
Family history
Sexual orientation issues
Sexual abuse
Other stressors
Interpersonal losses
Bullying (perpetrator or victim)
Lack of affiliation
Males after romantic breakup
 Suicide Attempts (cont)
Girls attempt mostly by ingestion (55%) or cutting
(31%). Boys by cutting (25%), ingestion (20%),
firearms (15%), hanging(11%).
Greatest difference in mental state between an
ideater and attempter is the presence of AODA.
Suicidal teens who abuse substances are 12.8x
more likely to make an attempt.
 Risk Factors
Incarceration
The suicide rate for adolescents in detention centers is
57/100,000. For adolescents housed in adult facilities is
2,041/100,000!!
Risk Assessment in Adolescents
Although suicidal ideation is very common in this
population, suicide should be asked about and
evaluated in the context of an accompanying
mental illness. Depressed adolescents should
always be assessed for suicidality. It is important to
include data from many sources, including parents,
school, or other significant relationships.
Risk Assessment in Adolescents
Consider the following:
Predictability of the youngster
Circumstances of suicidal behavior
Intent to die
Psychopathology
Coping mechanisms
Communication
Family support
Environmental stress
Risk Assessment in Adolescents
Precipitating factors in vulnerable youth may
increase immediate risk.
Opportunity
• Access to lethal means, lack of supervision
Altered states of mind
• Hopelessness, rage, intoxication, mental illness
Undesirable life events
• Losses, loss of esteem, humiliation, pregnancy, abuse
 Prevention Strategies
Suicide awareness programs
Popular with normal teens, but they don’t seem to
increase self-referrals, help-seeking, or help-giving in
adolescents. They may activate suicidal ideation in
disturbed adolescents, whose identity is usually not
known by the instructor. They may contribute to
clustering. They also tend to minimize the role of
mental illness.
 Prevention Strategies
Screening
Assessments of depression, AODA, recent or frequent
suicidal ideation, past suicide attempts. They identify a
number of unknown, untreated cases of depression.
Screening programs that do not include procedures to
evaluate and refer should not be used.
Gatekeeper training
Teachers, counselors, MD’s, youth workers trained to
recognize teens at risk. This may work, but there is no
clear research.
 Prevention Strategies
Crisis centers and hotlines
There is little research about the effectiveness of these
centers. Few teenagers use them, and those that do
are not at highest risk (boys).
Restriction of lethal means/alcohol
A modest but statistically significant decrease in teen
firearm suicides has been associated with child access
prevention laws.
Even adolescents without a mental disorder have 13x
greater suicide risk if there is a gun in the home and a
32x greater risk if it is loaded.
 Restriction of Lethal Means
Firearms
17% of households purchase new guns after a child’s
suicide attempt. But if they are educated, they are 3x
more likely to remove them.
The following reduce suicide risk in an additive
manner:
• Unloading guns
• Locking guns
• Storing ammunition separately
• Locking ammunition
Alcohol
States that have increased the minimum drinking age
have seen a 7% suicide reduction in teens.
 Prevention Strategies
 Skills training
 Teaching the problem solving and coping skills in the skills. Some
evidence of efficacy.
 Follow-up appointments
 A nighttime phone contact and next day follow-up assures 90% of
teens will stay in treatment after an ER visit.
 Antidepressants
 Caregivers need to be alert for decreasing inhibition, irritability,
change in sleep, agitation in the first weeks after an antidepressant
has been started.
 Bipolar Disorder
Bipolar disorder is a disorder of mood swings, out
of proportion with events in a person’s life. These
swings include mania and depression.
Bipolar disorder in children is enormously
controversial! Depending on who you listen to,
there is either an epidemic, or it is virtually non-
existent.
The diagnosis has increased 26% from 2002 to
2004!
 Dr. Biederman,
Mass Gen, Boston
Irritability is the determinant, even in the absence
of depression, elevated mood, grandiosity, or
cycles of behavior.
These irritable episodes are not just tantrums, but
explosive, long-lasting, and often without triggers.
This is the “Broad Phenotype” - Bipolar NOS
Supported by parents, insurance companies, and
by the observation that many of these children
respond to medication.
 Dr. Geller
Washington U, St. Louis
Children must have alternating episodes of mania
and depression. The cycling can be complex and
very short.
This is the “Narrow Phenotype.”
Children exhibit:
Excessive giddiness
Severe irritability
Grandiosity
Fragmented thought
Aggression
 Making a Diagnosis
Besides symptoms, we generally require three
important validators of a diagnosis:
Family history
Course of illness
• The first presentation of Bipolar Disorder is depression
• 33-50% of depressed children develop mania in 10-15 yrs.
Treatment response
• Bad reaction to antidepressant
 Bipolar vs. ADHD
Most children diagnosed with bipolar disorder
appear to also meet ADHD criteria.
It is rare that children with ADHD meet bipolar
criteria.
In adults with bipolar disorder, 33% can be
diagnosed retrospectively with ADHD, with about
10% having current ADHD symptoms.
 Bipolar vs. ADHD?
It may be that these represent different
developmental presentations of the same
condition:
Childhood ADHD
Adolescent anxiety and depression
Young adult bipolar disorder (mania)
 Problems
Children who get amphetamines may have an
earlier age of onset of mania than those who don’t!
Amphetamines can be harmful neurobiologically,
especially after adolescent exposure, with
hippocampal atrophy, disturbed dopaminergic
activity, enhanced corticosteroid response to
stress, and increased long-term depressive and
anxiety behaviors.
 Distinguishing Bipolar Disorder
from ADHD
Sleep problems are more common in bipolar.
Irritability, frustration intolerance and aggression
are present in both.
Attention problems can be the same.
Mood symptoms distinguish the bipolar group, but
not until 7 years old.
Hallucinations, delusions, suicidal and homicidal
behavior is more common in bipolar
 Bipolar Disorder
Treatment is usually with the mood stabilizer
Depakote. ADHD symptoms usually do not
respond to Depakote.
The best evidence is for lithium.
Antipsychotics are frequently used, but with very
limited data.