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Drugs and Child's

23

Few illnesses bring more fear to a parent than alcoholism and drug abuse. But unlike other disorders that can also be devastating to a child and his or her family, addiction feels particularly confusing - and somehow personal.

Where did we go wrong? How did she use all this time without us knowing? Where did he even get the drugs?

Okay, I’m ready to accept that what happened; so can I help, or am I going to make things even worse?

For other physical and mental illnesses, parents routinely turn to medical specialists for advice and expect guidance and typically follow the experts’ recommendations. The very process of charting a course of action with a doctor has significant therapeutic effects for both the child and the parents. Unfortunately, we have come to expect much less from the medical community when it comes to the prevention, diagnosis, and treatment of substance use disorders.

On one hand, we don’t trust that we know all that much about the illness itself. Both science and popular culture keep shifting their opinion on the “true” cause of addiction. In the 1960s and the 1970s, it was all about parenting; in the 1980 and the 1990s, we woke up to the monumental discoveries of genetics; and during the past decade, we have

been greatly attracted to co-occurring psychiatric disorders including posttraumatic stress disorder, bipolar disorder, attention-deficit hyperactivity disorder, and autism. Recently, family system considerations for both prevention and treatment have resurfaced, bringing us full circle to the world of our parents. Scientists now know that what causes one kid to get drunk and another to stay sober is rather complex. A number of interrelated biological, psychological, and social determinants affect the pleasure, reward, motivation, and memory brain neuronal circuitry leading to impairment in behavioral control, craving, and diminished recognition of significant problems in one’s life.

On the other hand, there are very few medical doctors with the appropriate training to address substance use among children and adolescents. The American Board of Psychiatry and Neurology has certified less than 250 psychiatrists in the subspecialty of addiction psychiatry over the past 10 years. Our texts will be straightforward answers to every parent’s questions about preventing, identifying, and treating substance abuse and dependence.

 

 

(21) Drugs & Child’s

Drug Addicted Children Documentary

DC21

When should we consider residential programs for our daughter?

In cases where an adolescent needs long-term treatment, residential programs employing the principles of a therapeutic community (TC) can be considered. These are individuals with long-standing history of drug use, failed intensive programs, and those with legal problems. A number of adolescents are also court mandated to complete residential programs. There are also certain TC programs that incorporate psychiatric consultations to deal with treatment and diagnostic issues and also for medication evaluations. Some TCs are modified to meet the needs of special populations like mentally ill chemical abusers in community residences, adolescent substance abusers in residential TCs, and criminal offenders in corrections facilities.

The TC consists of staff with or without recovery experiences and provides a constellation of services including medical and mental health and vocational and educational services. Work and assigned job responsibilities are a means to therapy and improving interpersonal skills with both peers and authorities. Peers act as role models to expected behaviors. Staff members play the role of rational authority figures, providing feedback and direction.

Those in the program are expected to work with the “program,” which refers to following the structure and communication lines of the community and the “family” (clients and staff). The program follows a strict schedule of therapeutic, recreational, and educational activities.

Encounters are the cornerstone of treatment. These are peer led, and participants are made aware of the behaviors that need to be modified. Probes, on the other hand, are staff led, with the goal of further understanding the individual’s background for treatment planning purposes and also for fostering trust, openness, and support. Some have even claimed that residential treatment does not work. To simply view residential treatment as a failure is to overlook a number of factors that have been identified that affect long-term outcomes, both positive and negative, and the corrective actions that have been incorporated by providers to directly address this gap.

Because 60% of individuals relapse within 90 days of discharge from residential treatment, case management, coupled with assertive interventions, was designed to provide rapid initiation of continuing care in the community. This is part of the discharge planning that is done while still in treatment.

An important aspect of any treatment is to establish support that such interventions do in fact work when using clearly defined outcome measures. In the substance abuse field, there are a number of evidence-based interventions including Cognitive Behavior Therapy (CBT), Motivational Enhancement Therapy (MET), Community Reinforcement

Approach (CRA, adapted for adolescents), and Contingency Management (CM). CRA is a comprehensive behavioral approach aimed at identifying factors in the environment that promote sobriety. It also involves skill building and developing pro social skills that compete with drug-seeking behaviors. CM is differentially rewarding desired behaviors (sobriety) while punishing or withholding reinforcement for undesired behaviors (drug use). Positive reinforces can include receiving vouchers or tokens if abstinence is exhibited and being placed on contract, bracelet monitoring, or house arrest for drug relapse. The challenge is for these proven treatments to be provided at varying levels of care from the traditional out patient to day programming to levels as intensive as an inpatient setting or a residential program.

In a recent study (Garner et al., 2009), the Washington Circle (WC) continuity of care after long-term residential treatment performance measure was studied as well as the effect of assertive continuing care interventions in achieving continuity of care. The WC, which has been previously shown to be reliable with patients, was now tested to see if it can be generalized to a program level (residential treatment facility) whose treatment is reimbursed through public funding. Three hundred and forty-two adolescents who were admitted to long-term residential treatment were randomly assigned to either standard continuing care or an assertive continuing care condition (CRA, CM, or both). Because the study utilizes a randomized design, it experimentally tested the ability of the WC performance measure to predict outcome.

The following were measured: degree of substance related problem, length of residential treatment, type of intervention, whether the intervention was with or without assertive conditions, presence or absence of follow-up within a two-week period after discharge from residential treatment, and recovery status (whether sober or not) while in the community.

Individuals included in the study were mostly adolescent Caucasians between 15 and 16 years old with significant legal involvement, high levels of dependence (mostly to cannabis and alcohol), and high co-occurring psychological problems and involvement in risky behaviors (multiple sexual partners and unprotected sex).

Those adolescents involved with WC have a significantly higher continuity of care treatment. Greater severity of the substance problem at baseline decreases the likelihood of recovery at three months. This emphasizes the need to provide ongoing effective substance abuse interventions by qualified and trained clinicians. Because there is a high degree of co-occurring psychological conditions, treatment also has to address these. Adolescents achieving continuity of care criteria had approximately a 92% chance of being sober at three-month follow-up compared with adolescents who did not achieve these criteria.

There are component treatments that do work. What is important is to provide these services concurrently in a coordinated manner from a multimodal and multidisciplinary approach and where case management is also provided. Meeting the needs of the adolescent should be guided by what can minimally meet his or her needs given a particular set of circumstances. Residential treatment may well be the least restrictive level meeting the youngster’s needs at a particular time and this certainly needs to be periodically reviewed and revised accordingly as to whether criteria for this level of care are continually met.

I’ve heard about 12-steps programs. Are they for adults only?

Most Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups are for adults, and adolescents may be unable to identify with what is going on in the meetings. Parents have even expressed concern that their sons and daughters will be influenced by hard-core drug addicts there. While these concerns can be valid, they illustrate that it is all the more important that parents help find the right fit for their children. The utility of these support groups can be more meaningful for adolescents who have already been introduced to them in prior treatments. Most of the interventions are provided in longer term treatments. The 12-steps programs are rooted in the belief that recovery from addiction is only possible if one recognizes his problem with alcohol or drugs and admits that use of drugs in moderation is impossible without significant psychosocial consequences.

The most widely used approach is based on the principle and philosophy of AA and NA. Treatment programs based on NA/AA models are also known as the Minnesota model or self-help programs. Adolescents are expected to finish the first three

to five steps during inpatient or residential treatment. Concepts of acceptance, surrender, spirituality, and powerlessness may be difficult for adolescents to handle. The Step Workbook for Adolescent Chemical Dependency Treatment (Jaffe, 1990) offers a developmentally appropriate guide to the first five steps. Step 1 is the acknowledgment of inability to control substance use and is a confrontation of denial as well as developing motivation to participate in treatment. Steps 2 and 3 are also motivational in nature, emphasizing the need for help from someone other than the addict himself or herself. Adolescents are encouraged to look outside of themselves for guidance, structure, and meaning. Step 4 is the development of moral inventory involving a description of past behaviors. This lays the groundwork for subsequently dealing with issues identified. Step 5 explicitly asks for verbal disclosure and implicitly letting the adolescent deal with a helping individual. This modified approach still needs to be empirically tested.

Adolescents are encouraged to look outside of themselves for guidance, structure, and meaning.

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(22) Drugs & Child’s

Dramatic rise in substance abuse in America - Teen Drug Use Number One Health Problem

DC22

Have the 12 steps been studied in adolescents?

Several studies on 12-step approaches were associated with positive treatment outcomes. Fiorentine found that adolescents with prior 12-step involvement remained in a substance abuse treatment program longer and were also more likely to complete treatment than those without such prior involvement. Both pretreatment 12-step meeting experience and longer duration of participation in drug treatment were positively associated with subsequent 12-step involvement. Adolescents who were involved in a combination of formal drug treatment and 12-step approaches were more likely to have high rates of abstinence than those who participated in either drug treatment or in a 12-step approach alone. Weekly or more frequent 12-step attendance was also associated with drug and alcohol abstinence. A 12-step recovery support group combined with Relapse Prevention treatment resulted in an earlier decrease in drug use.

Adolescents who attended AA/NA meetings after substance abuse treatment have higher rates of abstinence and productivity compared with those who did not attend such meetings. For adolescents who received inpatient substance abuse treatment, 12-step attendance was the most powerful predictor of drug abstinence at 6- and 12-month follow-up.

In another study, adolescent in patients who had a prior history of substance abuse treatment, more feelings of hopelessness, friends who did not use drugs, and less parental involvement while in treatment were more likely to attend AA than other adolescent inpatients. Three spirituality-related characteristics-feeling connected to others, frequency of meditation and prayer, and spiritual orientation to life-distinguished the subjects who expressed preference for both spirituality and 12-step approaches being integrated in TC treatment.

How effective are group therapies?

Group therapy can be nonstructured or process-oriented groups aiming to break denial. Other goals include expressing and clarifying feelings, especially painful affective states, developing relationships, and confronting negative characteristics or behaviors impeding recovery. This is often confrontational. It seems that the adolescents with whom I work are more likely to believe other adolescents sharing similar experiences than the treating staff. A major hurdle for adolescents is the degree with which they will risk trusting others and disclosing personal information that they hold on to strongly.

How can I be a part of my child’s treatment?

In previous questions, I have repeatedly touched on this. Family interventions are key components of adolescent substance abuse treatment as a number of family-related risk and protective factors have been identified. Commonalties in family treatment include psychoeducation about drug use, assisting families to initiate and maintain treatment of adolescents, and providing parent training to improve communication.

Goals of family treatment include:

1. Decreasing the family’s resistance to treatment

2. Redefining substance use as a family problem

3. Reestablishing parental influence

4. Interrupting dysfunctional sequences of family behavior

5. Assessing the interpersonal function of drug abuse

6. Implementing change strategies consistent with the family’s interpersonal functioning

7. Providing assertive training skills for the adolescent and any high-risk sibling

It can be difficult to find programs that specifically provide these services. It is important to find those programs that can address these goals as described. A review of combined data on family literature showed its superiority over other modalities and also noted that it can enhance the effectiveness of other approaches. Treatment can involve all family members, as drug use is related to family dysfunctional relationships and interactional patterns. Examples of family treatment within this include multidimensional family therapy, multisystemic family therapy, and structural strategic family therapy. It is important to continue being a part of your child’s treatment.

You need to empower yourselves to learn about drug use, how to monitor your children, know the early warning signs, and participate in scheduled family meetings and therapies. It may well be that you need to take a proactive role in pursuing family meetings with providers. To merely expect the provider to do the work and come back when your child has been “fixed” will not be beneficial to your child.

Jo’s comments:

I realize that I have to be part of my child’s treatment for it to work. I got angry after finding out that my son John was using. I gave him everything, and being a single mother,

it has been tough for me to provide the things he needs and wants. I feel betrayed. When I decided to bring him for treatment, my attitude was like “Fix him. I’ve been there for him; this time, he needs to do this on his own.” I now realize that as the parent, I also undergo adjustment. If anything, he now needs me more than ever. I have to heal with him.

What is multisystemic family therapy?

Multisystemic family therapy t akes i nto a ccount broader social relationships including teachers, neighbors, and other social units interacting with the drug-dependent adolescent. It is often incorporated in outpatient community-based settings and also includes case management. Treatment is made accessible to the families and is provided where they live. Case managers work with the families and other involved individuals like probation and parole officers and school officials. Adolescents are also provided with vocational services. The goal is to keep the adolescent in the community in which he lives and keep him in school. This family intervention has been most successfully applied among juvenile legal offenders and has not been routinely applied in traditional outpatient settings.

Terms:

Multisystemic family therapy - Treatment that takes into account broader social relationships including teachers, neighbors, and other social units interacting with the drug-dependent adolescent. The goal is to keep the adolescent in the community in which he lives and keep him in school. This is a very intensive treatment that has been supported to meet the needs of youngsters with multiple issues and legal problems.

Cognitive behavior Therapy - Therapy that uses cognitive and behavioral interventions to improve skills and change maladaptive behaviors, which hinder cessation of drug use.

 

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(23) Drugs & Child’s

Cognitive Behavior Therapy for Substance Abuse

DC23

What is Cognitive Behavior Therapy?

Cognitive Behavior Therapy uses cognitive and behavioral interventions in changing faulty cognitions, which hinder cessation of drug use and improving skills.

Social skills training address the following:

1. Consequential thinking to identify the antecedents and consequences of substance use behavior

2. Self-control in resisting impulse to use substances and peer pressure and to develop drug refusal skills

3. Avoiding trouble by identifying and avoiding high-risk situations for substance use and associated problem behaviors

4. Social networking by identifying prosocial activities and new, nonsubstance-using friends

5. Coping with authority by using negotiation and compliance skills

6. Problem solving for effective and prosocial solutions in difficult situations

7. Relapse coping by developing strategies for dealing with subsequent substance use behavior

What is Relapse Prevention?

Relapse Prevention is a cognitive behavioral approach aimed at developing self-control; identifying triggers in the environment leading to use and relapse; and developing coping skills in dealing with stressors, triggers, and lapses into substance use.

The individualized Relapse Prevention plan incorporates family responsibilities in supporting the child’s sobriety.

What is a harm-reduction approach?

Harm reduction is a comprehensive philosophy used to decrease the negative effects of drug use on society. It presupposes that a society has to deal with the presence of drug use because it can never be totally eradicated. Some may even see harm reduction as the end of or a means to abstinence and by no means should be viewed as a tool of drug legalization.

Principles of harm reduction have been applied in situations that have generated responses ranging from endorsement to protest and controversy. Harm reduction approaches include the Methadone Maintenance Treatment Program’s aim at decreasing opioid use, delinquency, criminality and health problems; exchange needle programs to decrease HIV transmission; decriminalization of cannabis use in certain states and countries like the Netherlands to address illicit use and its legal consequences; and education and outreach on opioid overdose preventions.

Does harm reduction make drug use acceptable?

It would seem so, but only temporarily. Harm reduction can be seen as a means to the goal of full abstinence. If adolescents can achieve one goal at a time, starting with a decrease in drug use, then a decrease rather than cessation itself will be a step to the goal. This approach will allow adolescents to set realistic goals that they are able to achieve with concrete results.

What is Motivational Enhancement Therapy?

Motivational Enhancement Therapy (MET) as a means to further engage adolescents in treatment and retain them. MET is aprinciples of motivational psychology, that is designed to produce rapid change whose underlying motivation comes from within the individual. Rather than being therapist driven, motivational strategies are used to facilitate an individual’s own change. Motivational Enhancement Therapy arose from practical issues raised by clinicians in dealing with substance use, especially with people who are reluctant or ambivalent to change. Strategies are persuasive rather than coercive. It creates dissonance that is conducive to change. The overall goal is to increase intrinsic motivation.

Five general principles are:

1. Express empathy as the adolescents do not see any problem with using

2. Develop discrepancy; present the pros and cons of drug use and tilt the arguments against use

3. Avoid argumentation- avoid direct confrontation and challenges

4. Roll with resistance, accepting the current level of resistance to treatment and lack of motivation thereof

5. Support self- efficacy; the adolescent will have the final say to make the change

 I am opposed to medications. When should I consider medication for my child?

Very frequently, parents express opposition to medication in general. There is limited success in the use of medication to affect abstinence. This is especially the case when dealing with adolescents. In addition, most studies are based on adults. Even fewer case studies mentioned the use of medications to decrease craving. Medications are clearly helpful in treating symptoms of withdrawal from certain drugs like alcohol, opioids, and benzodiazepines, and use of methadone or buprenorphine (Suboxone) is helpful as a detoxification medication or for maintenance. Medications can also be very helpful if drug use is also co morbid with moderate to severe depression, anxiety, psychosis, and ADHD. In fact, to resist aggressively treating these co morbid conditions can result in continued drug use. These conditions have to be treated aggressively and concurrently, and the adolescent will likely need a combination of treatments (medications and psychotherapy) on a long term.

Physicians make use of medications for the following reasons:

1. To treat comorbid psychiatric disorders (stimulants for ADHD)

2. To take advantage of drug- aversive agents (like disulfiram for alcoholism)

3. To treat withdrawal effects (methadone for heroin or opioids)

4. To block reinforcing effect of drugs (buprenorphine for opioids)

5. To substitute a similar drug for prolonged maintenance (methadone for opioids)

6. To treat craving (modafinil for cocaine)

Substitution therapies and aversive agents are infrequently used in adolescents. However, if these medications can increase the likelihood of treatment success or at least prevent further problems, parents should discuss these options with the physician. Parents are hesitant about considering medications to treat substance abuse without coexisting psychiatric conditions in their children. While studies are limited, use of medications to treat substance abuse without coexisting psychiatric worked and have few side effects. Bupropion (Wellbutrin) has been used for adolescent nicotine addiction, ADHD, and depression. Buprenorphine (with or without naltrexone [Subutex or Suboxone]) has been studied and found to be safe and effective for adolescents who abuse opioids. Other medications that have been used and studied include medications that decrease craving for alcohol like disulfiram (Antabuse), naltrexone (Revia), acamprosate (Campral), and topiramate (Topamax), a medication used for seizures and bipolar disorder.

There are experimental drugs that are currently being investigated, including rimonabant and ondansetron for marijuana abuse.

Edith’s comments:

I see that my son really needs his bipolar medication. John goes through ups and downs and he would smoke weed to bring himself down. He also experimented with cocaine.

With Lithium, his mood became stable and he stopped using. Hopefully, it will be longer this time.

 Terms:

Cognitive behavior Therapy - Therapy that uses cognitive and behavioral interventions to improve skills and change maladaptive behaviors, which hinder cessation of drug use.

Relapse Prevention - A cognitive behavioral treatment approach aimed at developing self-control; identifying triggers in the environment leading to use and relapse; and developing coping skills in dealing with stressors, triggers, and lapses into substance use.

Harm-reduction approach - Treatment approach that consists of strategies in minimizing the impact of alcohol use and other high-risk behaviors. It operates on the theory that abstinence and minimal harm are goals, but proponents also recognize that any behavior changes that reduce harm are, by themselves, positive outcomes.

Motivational Enhancement Therapy - A type of evidence based, non-coercive, and self-centered psychotherapy aimed at increasing the likelihood to change behaviors. As it applies to addiction.  Motivational Enhancement Therapy increases the imbalance toward accepting the need to change from drug-seeking to nonusing behaviors

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(24) Drugs & Child’s

Causes of Substance Abuse & Addiction

DC24

Are stimulants considered drugs?

Parents have commented that using stimulants to treat ADHD with drugs is using one addictive medication to treat another addiction. On the contrary, studies have shown that the use of stimulants to treat ADHD decreases risk of subsequent drug abuse or if abuse has already occurred, that it decreases relapse. There are anecdotal reports of kids misusing and abusing their stimulant medications. In my practice, we consider using nonstimulant medications to treat ADHD comorbid with drug use to address these concerns. This includesatomoxetine (Strattera, a nonstimulant medication approved for ADHD) and bupropion (Wellbutrin, an antidepressant medication with some evidence of efficacy for ADHD). If stimulants have to be tried for lack of response to these medications, we consider Concerta (methylphenidate). Its preparation (in capsule OROS form) makes it difficult to pulverize and snort it.

There is a new medication called lisdexamfetamine, a prostimulant, that is converted to its active form, d-amphetamine, in the gut, and it has low abuse potential if taken intranasally or intravenously.

Stimulant misuse and diversion occurs in about 10–20% of college students surveyed. Stimulants are usually diverted from friends and used primarily to improve concentration and alertness in class rather than to get high.

 I have heard that Subutex (buprenorphine) is used to treat heroin addiction. Does this method work?

Yes, and an additional benefit is that physicians with the proper training and authorization are now allowed to treat individuals with opioid addiction in an office setting. These individuals are usually able to keep their jobs and stay in school and can be seen monthly on a regular basis. We have treated youngsters with this medication. Buprenorphine, a partial agonist, can be used for detoxification (treatment of withdrawal symptoms), as an anticraving agent, and as a maintenance medication (to prevent relapse). Buprenorphine is also combined with naloxone (Suboxone) to decrease abuse and diversion.

These medications are administered by placing them under the tongue. Being on buprenorphine is similar to being on methadone (methadone maintenance treatment program), which also prevents relapse to drug use.

Is disulfiram (Antabuse) safe to use in adolescents?

Disulfiram has been used in adolescents and was found to be safe and effective. When someone takes disulfiram and then consumes alcohol, he or she experiences uncomfortable body reactions, thus encouraging one to abstain from the consumption of alcohol to avoid these effects. Disulfiram produces symptoms of headache, flushing, nausea or vomiting, diarrhea, and blood pressure changes after consuming alcohol. There has been one good study that established that disulfiram has few side effects and those who received active treatment had longer duration of sobriety. It is usually given at 250 mg daily orally. Disulfiram should not be taken by those with liver problems.

How long will my child stay on medication? How long should my child be in treatment?

This is based on a number of factors, including need for maintenance medication (for example, recurrent depression or chronic psychosis) and presence of a stable support system to effect longer-term sobriety, transition to school, or going back to school after a longer term treatment.

For those who have coexisting psychiatric conditions, it is best to continue on maintenance medications. In cases of depression, the following conditions favor use of medications for more than a year: recurrent depression (two depressive episodes or more), double depression (those with dysthymia and major depression, as reported by youngsters that they have been depressed “for as long as we can remember”), disordered thinking (psychosis), suicidal behavior, and ongoing family dysfunction. The goal of treatment is to gain full remission of symptoms and functioning and is no longer improvement of symptoms alone.

Parents should keep in mind that drug dependence is a chronic condition, so their child’s use of maintenance medications is akin to those one might take for diabetes, asthma, or psychiatric conditions like recurrent depression, ADHD, and bipolar disorder. Part of medication monitoring is looking for long-term side effects of prescribed medications. Of note, some medications used to maintain remission of psychosis and bipolar disorder can cause weight gain, difficulties in managing sugar in the body, or increase in fats. Parents, families, and treating physicians should continue to discuss the need for these medications. I always encourage people to look for answers and questions so that active discussion and collaboration will continue

 What are the common side effects of medications?

The side effects are based on classes of medications such as those used for depression, psychosis, anxiety, and ADHD. The FDA has approved some medications for certain conditions in adults, and child psychiatrists use these medications to treat similar conditions in adolescents.

These medications have few side effects and are effective. These are acceptable practices known as off labeling. Premedication evaluations and workups are done to make sure that these medications are safe. Also, your child’s physician will closely monitor your child. Your child’s psychiatrist, who is preferably a child and adolescent psychiatrist with training in addiction, is best suited to answer your questions and concerns.

In order to ensure that medications are safe, the following are usually requested before trying a medication: a physical examination (usually done by the child’s own physician) to identify any problems, and a laboratory examination involving the kidneys, blood, and liver, and in cases where stimulants are being considered, heart tracing or electrocardiogram. Studies have shown that stimulant use is correlated with (but not established as causing) sudden cardiac death in children and adolescents.

The risk is increased if your child has structural heart abnormalities (enlarged or small heart, holes, or irregular heartbeat). Your child’s physician will ask you if any risk factors are present, such as family history of heart disease, rhythm abnormalities (irregular heartbeat), or sudden death from heart attacks.

 Is my son at risk for suicide while taking antidepressants?

The FDA has mandated drug manufacturers to issue a black box warning on antidepressants to monitor for suicidal behavior. A black box warning appears on the prescription label of a medication, indicating the significant, serious, or even potentially life threatening side effect(s) of that medication. This is the most serious warning required by the FDA, and it has also been applied to medications other than antidepressants. Certain antibiotics, such as ciprofloxacin, had a black box warning for swelling of tendons and rupture as a side effect resulting in permanent disability; and the diabetes medication rosiglitazone can cause significant heart problems.

The black box warning for antidepressants has created considerable concern for parents, who do not want to give their child a medication that will worsen his or her depression. This warning was initially considered for antidepressants in 2004 after the FDA reviewed 23 studies involving more than 4300 children who received nine types of antidepressants and reported general characteristics of suicidal thinking and behavior. In 17 out of the 23 studies, asking about suicidal thoughts and behaviors was specifically included. In these data, medication did not worsen preexisting suicidal thoughts nor result in emergence of suicidal thoughts after treatment, and none of these individuals committed suicide (Parents Medguide for Depression). American studies have been done to further investigate this issue. One study (Simon, Savarino, Operskalski, & Wang, 2006) found that the risk for suicide was highest before medication treatment and significantly declined thereafter. Another study (Gibbons , Hur, Bhaumik, & Mann, 2006) found an association between higher SSRI prescription rates and lower suicide rates in children and adolescents.

Before the warning was given, there was an increasing trend in pediatric diagnosis of depression from 1993 to 2004. After that, there was a decrease in the diagnosis of depression, which deviated from what could have been predicted from the trend established in previous years. Pediatricians and nonpediatrician primary care doctors accounted for a reduction of these diagnoses. In 2002, 260 deaths from suicide occurred between the ages of 10 to 14 years, ranked third after accidents and malignancy as the leading cause of death in this age group.

From 1990 to 2003, the combined suicide rate among those aged 10 to 24 years declined 28.5%. However, from 2003 to 2004, the rate increased by 8.0%, the largest increase in a single year from 1990 to 2004 (CDC, 2007). Some believe this observation was correlated with a decrease in antidepressant prescription during that period. Treatment of pediatric depression with antidepressants declined significantly two years after this warning was given without any concomitant increase in the use of other treatments like counseling or use of other medication (Libby et al., 2007). In another follow-up study published two years later (Libby, Orton, & Valuck, 2009), under diagnosis of depression persisted for both pediatric and adult patients, suggesting that the effects were persistent, significant, and covered not only minors but adult patients as well.

It is important to be informed about these issues; to be involved with your child’s treatment; and to discuss these concerns with his or her psychiatrist, preferably a child and adolescent psychiatrist, who is best able to address these questions with you.

 Terms:

 Diversion - Occurs when prescribed medications with addictive potential are made available to individuals for the sole purpose of getting high.

Detoxification - Treatment of drug withdrawal symptoms, of which the level of medical supervision varies with the presence of life-threatening conditions or coexisting medical conditions

Off labeling - Use of medications under one of the following conditions:

1) Prescription of an FDA-approved medication outside of its recommended dosage (a physician prescribes higher doses that what is recommended for an approved antidepressant),

2) Prescription to an individual in a group for whom the drug was not studied (an approved antidepressant for adults being prescribed to adolescents), or

3) Prescription of an approved medication for something other than what is was originally intended for (use of antidepressants for anger control instead of depression). This is an acceptable medical practice that requires full disclosure from physicians to parents to ensure that informed consent is obtained.

Parents have commented that using stimulants to treat ADHD with drugs is using one addictive medication to treat another addiction.

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(25) Drugs & Child’s

Adolescent Substance Abuse Risk Factors - Child Psychology

DC25

My son refuses to go into treatment. What should I do?

Adolescents who refuse treatment usually do not see their drug use as a problem and see no need to stop. Also, they may still have yet to see the negative consequences of drug use. There are certain interventions that deal with improving the motivation to change, called Motivational Enhancement Therapy. In certain cases, external leverage may need to come from concerned agencies to make them receive treatment. Some parents may even see these as counterproductive. The idea of getting adolescents into treatment is to work on improving their motivation.

Engagement in treatment also allows disrupting the cycle of continued use. Adolescents will often continue to deny problems resulting from drug use. In these cases, it can be necessary to ask for additional external leverage by referring them to agencies like the Youth Services Bureau (YSB). The YSB is a government social services agency that provides prevention programs and treatment to families and youth at risk for delinquent behavior. The YSB may compel the youngster to get into treatment to avoid having to go to court or being placed in detention. Recalcitrant and persistent drug use is an indication for inpatient admission. As parents, you may sign in your minor for treatment. This is where the family can rally together. That family member whom the youngster has identified to be most supportive of him or her can reinforce this decision. I have seen time and again adolescents who were admitted after vehemently refusing treatment say that this experience has helped them. Admission disrupted the cycle of use. It also allowed for providing necessary family interventions and increasing readiness for continuing aftercare treatment.

I have used drugs before and I’m using them again; I’m at a loss about what to do. Where can I get help?

This is one of the sensitive things that will have to be dealt with at some point during counseling. Parents will inevitably blame themselves once they find out that their children have used drugs. It is best to deal with family issues in a straightforward and honest way, and at the same time, also work with your child in dealing with his treatment. Partnership for a Drug-Free America has very good tips on how to talk to your kids about this. It is important for parents to receive concurrent help to deal with their own sobriety. For parents who do not live with their substance-abusing adolescent, it is a bigger challenge to get them help. In this case, responsibility falls heavily on working with the adolescent in strengthening his or her self efficacy. It is doubly difficult to expect kids to stop using when their parents are not sober.

Eleanor’s comments:

Having information about drugs has been helpful. Kush, haze, E, L, purple haze-words that come straight from kids. The Web sites are helpful in separating facts from myths.

Resources for parents who have children abusing drugs or for those who suspect as much include the Substance Abuse and Mental Health Services Administration’s A Family Guide to Keeping Youth Mentally Healthy and Drug-Free Web site (available at:http://family.samhsa.gov). The Substance Abuse and Mental Health Services Administration also has a telephone hotline and Web site to assist in identifying drug treatment programs throughout the United States. By reading our texts, you should have recognized that drug abuse should be treated as a disorder with onset during adolescence, and it needs to be treated aggressively and early. Remember, drug use causes lasting negative effects with serious psychosocial and legal consequences for your developing child. Receiving treatment now will make a difference in your child’s life and yours, and it can be done!

American Academy of Addiction Psychiatry (AAAP)

www.aaap.org

American Academy of Child and Adolescent Psychiatry (AACAP)

www.aacap.org

American Society of Addiction Medicine (ASAM)

www.asam.org

Cocaine Anonymous World Services

www.ca.org

Drug Enforcement Administration (DEA)

www.justice.gov/dea/contactinfo.htm

National Institute on Alcohol Abuse and Alcoholism

www.niaaa.nih.gov

 National Institute on Drug Abuse (NIDA)

www.nida.nih.gov

 Office of National Drug Control Policy

www.whitehousedrugpolicy.gov

 Partnership for a Drug-Free America

www.drugfree.org

 Substance Abuse and Mental Health Services

Administration (SAMHSA)

SAMHSA’s Health Information Network

www.samhsa.gov

 US Screening Source, Inc.

www.usscreeningsource.com/druginformation.htm

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