The true measure of a nation’s standing ishow well it attends to its children – theirhealth and safety, their material security,their education and socialization, andtheir sense of being loved, valued, andincluded in the families and societies intowhich they are born.

Unicef (2007) Child Well-Being in Rich Countries. Innocenti Research Centre

http://www.unicef.ca/portal/Secure/Community/502/WCM/PRESS/IRC7/RC7.pdf

dexamphetamine cathinone

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Clark et al 2008.

themesthemes

►chemistrychemistry►mortalitymortality►AetiologyAetiology►NeurobiologyNeurobiology►TerminologyTerminology► Intervention Intervention

Genetic and environmental Genetic and environmental factorsfactors

► Family studies (Marmorstein et al 2008) Family studies (Marmorstein et al 2008) increased risk CD in offspring of parents with increased risk CD in offspring of parents with substance dependencesubstance dependence

► More antisocial behaviour and substance use More antisocial behaviour and substance use in biological children compared to adopted in biological children compared to adopted children of smokers (genetic pathway) children of smokers (genetic pathway) ‘‘disinhibited behavior, including substance disinhibited behavior, including substance use, disruptive behavior disorders, use, disruptive behavior disorders, delinquency, antisocial attitudes, aggressive delinquency, antisocial attitudes, aggressive orientation, and preference for risk taking.’orientation, and preference for risk taking.’

► Keyes et al 2008Keyes et al 2008

‘factor’ refers to disinhibition – scores for impulsive, delinquent, aggressive personality, antisocial attitudes and substance use.

geneticsgenetics

► Adopted away studies (Cadoret et al 1995)Adopted away studies (Cadoret et al 1995)► ‘‘behavioral disinhibition’ (Iacono et al 1999)behavioral disinhibition’ (Iacono et al 1999)► Colorado longitudinal twin study (Button et Colorado longitudinal twin study (Button et

al 2007) al 2007) ‘The common genetic influence on ‘The common genetic influence on all three phenotypes lends further support all three phenotypes lends further support to the hypothesis of a single latent variable, to the hypothesis of a single latent variable, such as behavioral disinhibition, with a such as behavioral disinhibition, with a strong genetic component, underlying a strong genetic component, underlying a wide range of problem behaviors in wide range of problem behaviors in adolescence’adolescence’

Risks for substance abuse Risks for substance abuse ►ADHD/ ‘risk-taking’, conduct problems, ADHD/ ‘risk-taking’, conduct problems,

school difficulties, affective symptomsschool difficulties, affective symptoms► individual/neurodevelopmentalindividual/neurodevelopmental ►Not two biological parents, discord, lack Not two biological parents, discord, lack

of confiding, abuse, local authority careof confiding, abuse, local authority care►Family, (attachmentFamily, (attachment // trauma)trauma)►geography, ‘hanging out’, substance geography, ‘hanging out’, substance

using peers, disorganised using peers, disorganised neighbourhoodsneighbourhoods

► ‘‘deviant peers’deviant peers’

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Outcome ADHDOutcome ADHD

► malesmales 58% reading problems58% reading problems 40% persistent ADHD symptoms [only 4% ADHD]40% persistent ADHD symptoms [only 4% ADHD] 24% alcohol use disorder24% alcohol use disorder 32% any substance use disorder32% any substance use disorder 25% ASPD25% ASPD 12% Autism Spectrum12% Autism Spectrum

► Rasmussen Gillberg (2000) Natural outcome of ADHD Rasmussen Gillberg (2000) Natural outcome of ADHD with DCD at age 22 years: JAACAP 39:1424-1431.with DCD at age 22 years: JAACAP 39:1424-1431.

► Barkley et al (2006) Young adult outcome of Barkley et al (2006) Young adult outcome of hyperactive children: adaptive functioning in major life hyperactive children: adaptive functioning in major life activities JAACAP 45:192-202. activities JAACAP 45:192-202.

► Mannuzza et al (2003) Persistence of ADHD into Mannuzza et al (2003) Persistence of ADHD into adulthood: what have we learned from the prospective adulthood: what have we learned from the prospective follow-up studies? J Att Disfollow-up studies? J Att Dis. 7(2):93-100.. 7(2):93-100.

Effect of cultureEffect of culture

►““in circumstances marked by high levels in circumstances marked by high levels of social control, a large percentage of of social control, a large percentage of the sample – irrespective of their the sample – irrespective of their genetic diversity – exhibits the same genetic diversity – exhibits the same phenotype; in settings marked by low phenotype; in settings marked by low social control, people’s choices and social control, people’s choices and behaviors are more apt to reflect their behaviors are more apt to reflect their genotype.”genotype.”

►Shanahan & Hofer cited in Button T. et al (2009)Shanahan & Hofer cited in Button T. et al (2009)

In summaryIn summary► increased risk of conduct disorder, ADHD, major increased risk of conduct disorder, ADHD, major

depressive and anxiety disorders in the children of depressive and anxiety disorders in the children of parents with alcohol problems compared to the parents with alcohol problems compared to the children of parents without alcohol problems children of parents without alcohol problems

► ‘ ‘a common diathesis’: this increases risk for a common diathesis’: this increases risk for ► ‘‘psychopathologies that interfere with social psychopathologies that interfere with social

functioning’ but also for substance misuse and a functioning’ but also for substance misuse and a range of risky behaviours including alcohol use range of risky behaviours including alcohol use disorders [46]. disorders [46].

► abnormalities in the myelinisation associated with abnormalities in the myelinisation associated with maturation of frontal cortical networks maturation of frontal cortical networks

► a potential ‘parsimonious…organising concept’, a potential ‘parsimonious…organising concept’, perhaps best characterised as ‘psychological perhaps best characterised as ‘psychological dysregulation’ or ‘neurobehavioural disinhibition’. dysregulation’ or ‘neurobehavioural disinhibition’.

► Clark et al (2002, 2008) cited in Newbury-Birch et al (2009)Clark et al (2002, 2008) cited in Newbury-Birch et al (2009)

outcomeoutcome

► FemalesFemales 75% depression/anxiety disorder75% depression/anxiety disorder 75% conduct disorder 75% conduct disorder 50% substance 50% substance dependencedependence 5% eating disorder5% eating disorder

► Beiderman et al 2006 Psychopathology in females Beiderman et al 2006 Psychopathology in females with ADHD: a controlled five year prospective study with ADHD: a controlled five year prospective study Biological Psychiatry 60:1098-1105Biological Psychiatry 60:1098-1105

30% Borderline PD30% Borderline PD► Anckarsater, Gillberg C. et al.Anckarsater, Gillberg C. et al. The impact of ADHD and The impact of ADHD and

autism spectrum disorders on temperament, autism spectrum disorders on temperament, character, and personality development.character, and personality development. AJP AJP 163(7):1239-44, 2006 163(7):1239-44, 2006

► More stds and teenage pregnancyMore stds and teenage pregnancy► Barkley et al 2006Barkley et al 2006

Family Family s.e.c.s.e.c.

UnresponsivUnresponsive mother/ e mother/ parental parental conflictconflict

Child abuseChild abuse

Parental Parental substance substance misuse misuse (smoking)(smoking)

Conduct Conduct disorder disorder symptoms symptoms 10 year 10 year

Weak/ strong final predictors deviant peer associations age 15

•“…adolescent peer affiliations reflect the endpoint of a complex social process in which the individual's peer choices are likely to be shaped by his or her social environment, family and parental factors, and preexisting temperamental or behavioural characteristics…”

Fergusson DM & Horwood L. (1999) Prospective childhood predictors of deviant peer affiliations in adolescence. JCPP 44:581-92

Terminological debatesTerminological debates

► addiction, which refers to the loss of control addiction, which refers to the loss of control over the intense urges to take the drug even over the intense urges to take the drug even at the expense of adverse consequencesat the expense of adverse consequences

► The term “dependence” has traditionally The term “dependence” has traditionally been used to describe “physical been used to describe “physical dependence,” which refers to the dependence,” which refers to the adaptations that result in withdrawal adaptations that result in withdrawal symptoms when drugs, such as alcohol and symptoms when drugs, such as alcohol and heroin, are discontinued. Physical heroin, are discontinued. Physical dependence is also observed with certain dependence is also observed with certain psychoactive medications, such as psychoactive medications, such as antidepressants and beta-blockers.antidepressants and beta-blockers.

► OBrien et al 2008 Am. J. PsychiatOBrien et al 2008 Am. J. Psychiat

Altered white matter in adolescent binge drinkers. McQueeny et al 2009

Principles:Principles:Person-centred carePerson-centred care

►People who misuse drugs should be People who misuse drugs should be given the same care, respect and given the same care, respect and privacy as any other person.privacy as any other person.

►Ensure that there are clear plans to Ensure that there are clear plans to facilitate effective facilitate effective transfer of transfer of people who misuse drugs between people who misuse drugs between services, to reduce loss of contactservices, to reduce loss of contact

►Use biological testing as part of a Use biological testing as part of a comprehensive assessment of drug usecomprehensive assessment of drug use

Copyright restrictions may apply.

Anton, R. F. et al. JAMA 2006;295:2003-2017.

Time to First Heavy Drinking Day by Naltrexone and Combined Behavioral Intervention (CBI) Interaction

A new class of untouchablesA new class of untouchables

► ‘‘A new class of untouchables is emerging in our A new class of untouchables is emerging in our inner cities, on the social fringes of suburbia, and inner cities, on the social fringes of suburbia, and in some rural areas; young people who are in some rural areas; young people who are functionally illiterate, disconnected from school, functionally illiterate, disconnected from school, depressed, prone to drug abuse and early depressed, prone to drug abuse and early criminal activity, and eventually, parents of criminal activity, and eventually, parents of unplanned or unwanted babies. These are the unplanned or unwanted babies. These are the children at high risk of never becoming children at high risk of never becoming responsible adults.’responsible adults.’

Dryfoos J.G. (1990) Adolescents at risk: prevalence and Dryfoos J.G. (1990) Adolescents at risk: prevalence and prevention. Oxford University Press: New York. Quoted in Liddle prevention. Oxford University Press: New York. Quoted in Liddle HA., Dakof G., Parker K., Diamond G., Barrett K., Tejeda M. (2001) HA., Dakof G., Parker K., Diamond G., Barrett K., Tejeda M. (2001) Multidimensional family therapy for adolescent drug abuse: Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial. The American Journal of Drug results of a randomized clinical trial. The American Journal of Drug and Alcohol Abuse 27:651-688.and Alcohol Abuse 27:651-688.

Long termLong term effect effect interventionintervention

► 14-year follow-up MST v individual therapy 14-year follow-up MST v individual therapy for adolescent offendersfor adolescent offenders

► All arrests 81 v 50%, All arrests 81 v 50%, Drug arrests 33 v Drug arrests 33 v 13%13%

► ‘‘improved family support and decreased improved family support and decreased deviant peer involvement may have deviant peer involvement may have allowed…(participants) to succeed in … allowed…(participants) to succeed in … developmental tasks (e.g. normal romantic developmental tasks (e.g. normal romantic relationships)…’relationships)…’

► Schaeffer et al (2005) Long-term follow-up of a RCT of Schaeffer et al (2005) Long-term follow-up of a RCT of MST with serious and violent juvenile offenders. J. MST with serious and violent juvenile offenders. J. Consulting and Clinical Psychology 73(3):445-453Consulting and Clinical Psychology 73(3):445-453

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MST/CMLittell J (2005) Cochrane Review - No evidence that MST superior to usual services

Sundell et al (2008) J. Fam. Psychology – no differences from usual services

Medical interventionMedical intervention

►The percentage of patients receiving The percentage of patients receiving CBI only who had a good global clinical CBI only who had a good global clinical outcome (60.6%) was intermediate outcome (60.6%) was intermediate between those receiving placebo and between those receiving placebo and medical management (58.2%) and medical management (58.2%) and those receiving placebo medical those receiving placebo medical management and CBI (71.3%). Overall, management and CBI (71.3%). Overall, the differences among these 3 groups the differences among these 3 groups were not significant (were not significant (PP = .07).  = .07).

Figure 2. Effect Size Estimates and Hazard Ratios for Primary Outcomes Effect size estimates for percent days abstinent are reported as Cohen d values.

Anton, R. F. et al. JAMA 2006;295:2003-2017

Copyright restrictions may apply.

Medical interventionMedical intervention

►N = 1400 ‘alcoholics’N = 1400 ‘alcoholics’►All improved, best outcomes:All improved, best outcomes:

medical management plus naltrexonemedical management plus naltrexone Medical management plus CBIMedical management plus CBI

►at end treatment: MM with placebo = CBIat end treatment: MM with placebo = CBI►At 12 mo.: CBI>MMP=MM naltrexoneAt 12 mo.: CBI>MMP=MM naltrexone

► Anton RF. Et al Anton RF. Et al Combined pharmacotherapies Combined pharmacotherapies and behavioral interventions for alcohol and behavioral interventions for alcohol dependence: the COMBINE study: a dependence: the COMBINE study: a randomized controlled trial.randomized controlled trial. JAMA. 295(17):2003-JAMA. 295(17):2003-17, 200617, 2006

NICE PHG – targeted prevention NICE PHG – targeted prevention

► ““In young people with aggressive and behavioural In young people with aggressive and behavioural disorders one two year multicomponent family disorders one two year multicomponent family based programme, Coping Power (targeted at 9-11 based programme, Coping Power (targeted at 9-11 year olds), was effective in reducing use of alcohol, year olds), was effective in reducing use of alcohol, tobacco, and cannabis and this was associated with tobacco, and cannabis and this was associated with a reduction in problem behaviours. In contrast, a a reduction in problem behaviours. In contrast, a single component approach, LST, had no effect on single component approach, LST, had no effect on substance use behaviours.”substance use behaviours.”

► A review of community-based interventions to reduce A review of community-based interventions to reduce substance misuse among vulnerable and disadvantaged substance misuse among vulnerable and disadvantaged young people young people

► Lochman & Wells (2004) the Coping Power Program for Lochman & Wells (2004) the Coping Power Program for preadolescent boys and their parents: 1 year follow-up. J Cons preadolescent boys and their parents: 1 year follow-up. J Cons Clin Psychol 72:571-578 Clin Psychol 72:571-578

Other interventionsOther interventions

► ‘‘aftercare’ by phone reduced relapse aftercare’ by phone reduced relapse compared to no aftercare compared to no aftercare

►Kaminer 2008Kaminer 2008

Outcomes according to NTA Outcomes according to NTA

► ““The proportion of young people who complete an The proportion of young people who complete an intervention according to the goals set out in their intervention according to the goals set out in their care plans is 57%...care plans is 57%...

► interventions tend to be more successful when they interventions tend to be more successful when they involve the young person’s parents and siblings, involve the young person’s parents and siblings, grandparents or foster carers…grandparents or foster carers…

► In reaching out to more young people with drug In reaching out to more young people with drug and alcohol misuse problems, specialist services and alcohol misuse problems, specialist services have established much closer links with other have established much closer links with other children’s serviceschildren’s services

► NTA Young Peoples report 2009NTA Young Peoples report 2009

In summaryIn summary

► Psychoactive drugs have a degree of shared Psychoactive drugs have a degree of shared chemical structurechemical structure

► All work through the same subcortical reward All work through the same subcortical reward mechanismsmechanisms

► Disproportionately impact vulnerable children, all of Disproportionately impact vulnerable children, all of whom have mental disorderswhom have mental disorders

► Vulnerability is substantially genetically determinedVulnerability is substantially genetically determined► Affected children and young people require a full Affected children and young people require a full

assessment and multimodal treatment assessment and multimodal treatment ► Treatment is partially effective and needs to be Treatment is partially effective and needs to be

longer term.longer term.

Parental illicit drug Parental illicit drug useuse

** 00

Childhood sexual Childhood sexual abuseabuse

** 00

Female genderFemale gender ** 00

Novelty Novelty seeking/conduct seeking/conduct problemsproblems

** **

Cannabis use 16-25Cannabis use 16-25 **

Affiliation 16-25Affiliation 16-25 **

Alcohol use 16-25Alcohol use 16-25 **

cigarettescigarettes **

1 year lagged 1 year lagged measure illicit drug measure illicit drug useuse

**

Age x cannabis useAge x cannabis use **

Fergusson et al (2008) The developmental antecedents of illicit drug use. Drug Alc Dep 96:165-77

Child predictors

Adolescent/ young adult predictors

Parental illicit drug Parental illicit drug useuse

** 00

Childhood sexual Childhood sexual abuseabuse

** 00

Female genderFemale gender ** 00

Novelty Novelty seeking/conduct seeking/conduct problemsproblems

** **

Cannabis use 16-25Cannabis use 16-25 **

Affiliation 16-25Affiliation 16-25 **

Alcohol use 16-25Alcohol use 16-25 **

cigarettescigarettes **

1 year lagged 1 year lagged measure illicit drug measure illicit drug useuse

**

Age x cannabis useAge x cannabis use **

Child predictors

Adolescent/ young adult predictors

“…cannabis use mediated the effects of childhood factors on later illicit drug abuse…”

Fergusson et al (2008) The developmental antecedents of illicit drug use. Drug Alc Dep 96:165-77

m/f motivations for drug usem/f motivations for drug use► RelaxRelax► intoxicatedintoxicated► Keep goingKeep going► Enhance activityEnhance activity► Keep goingKeep going► Enjoy companyEnjoy company► Decrease boredomDecrease boredom► Increase confidenceIncrease confidence► Stay awakeStay awake► Feel elated/euphoricFeel elated/euphoric► SleepSleep► After effectsAfter effects► Lose inhibitionsLose inhibitions► Enhance sexEnhance sex► Improve effectsImprove effects► Work Work ► Lose weightLose weight

Boys et al 2001