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Substance use in children and adolescent

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Substance use in children and adolescent

  2. 2. OVERVIEW 1. Background and implications for studying adolescent and children substance abuse 2. Epidemiology of substance abuse in children and adolescents 3. Etiology 4. Neurobiology of Adolescent Substance Use and Addictive Behaviors 5. Assessment of Adolescent Substance Use and Problems 6. Diagnosis and Clinical Features 7. Differential Diagnosis and Comorbidity 8. Treatment of adolescent substance abuse 9. Prevention strategies of adolescent substance abuse
  3. 3. SUBSTANCE ABUSE  A maladaptive pattern of substance use leading to clinically significant impairment or distress  Manifested by one or more of the following, occurring within a 12-month period: 1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 2. Recurrent substance use in situations in which it is physically hazardous 3. Recurrent substance-related legal problems 4. Continued substance use despite persistent or recurrent social or interpersonal problems
  4. 4. BACKGROUND AND IMPLICATIONS  Adolescent and children substance abuse can bring immediate and late onset devastating consequences  The acute effects of intoxication can be devastating: 1. Alcohol-related motor vehicle accidents remain leading causes of mortality among youth 2. Sharing needles, I.V drug use lead to transmission of blood borne viruses 3. High risk behaviour like sexual risk taking, sexual victimization and unintentional injury is high
  5. 5.  Age of initiation into substance abuse is progressively falling  Early initiation of alcohol and drug use is associated with 1. Poor prognosis 2. Life long pattern of irresponsible behaviour  Family and the community have to bear the social costs like: 1. Increased morbidity and mortality 2. Increased criminality 3. Decreased productivity and absenteeism
  6. 6.  Physical adverse effects of substance abuse are:  Rare in children and adolescents  Develop only after chronic use over several decades  Understanding of substance abuse problems during adolescence is critical to study any approach aimed at lessening these physical adverse effects  Adolescent substance use has been relatively neglected in clinical practice and in research studies practice (Abrantes, Strong, Ramsey et al., 2005)  The societal costs of this neglect of adolescent substance use are high
  7. 7. EPIDEMIOLOGY 1. Lifetime prevalence of Substance use disorders in children and adolescents is 11.4% 2. More than half of adolescents report alcohol use 3. One fourth report exposure to illicit drugs 4. Prevalence rates of alcohol and drug dependence (1.3% and 1.8% respectively) are one-fourth the magnitude of abuse (5.2% and 7.1%, respectively) [Results from the National Comorbidity Survey Replication- Adolescent Supplement (NCS-A)]
  8. 8. The most important ongoing descriptive study of drug use in youth is the Monitoring the Future (MTF) survey 1. Sponsored by National institute drug abuse (NIDA) since 1975 2. Provides information on annual trends in adolescent substance use 3. Anonymous paper and pencil questionnaire is used 4. Nationally representative cross-sectional school-based samples of 8th, 10th and 12th graders is studied (Johnston et al. 2011)
  9. 9.  The most recent MTF study was conducted in 2010  Key findings of MTF study include: 1. Increase in the overall rate of illicit drug use for all grades 2. Older students in the study showed increase in the use of marijuana and alcohol 3. 19.6% of students have tried an illicit drug by eighth grade 4. 34.1% by 10th grade 5. 47.4% by 12th grade 6. Marijuana remains by far the most commonly used illicit drug
  10. 10. 7. Number of individuals who report misuse of prescription drugs has been increasing in recent years 8. Marked increase in the misuse of prescription opioid medications, such as oxycodone and hydrocodone 9. Overall illicit drug use:  Reached a peak in the late 1970s  Declined during the 1980s  Rose again in the 1990s  Has remained relatively stable during the past several years 10. Illicit drug use remains very common and typically begins during adolescence
  11. 11. EPIDEMIOLOGY IN INDIAN CONTEXT  Extent and pattern of substance abuse among children and adolescent in India is different from the West  Substance abuse among girls is uncommon  Common drugs abused in Indian adolescents are: 1. Alcohol 2. Tobacco 3. Minor tranquillizer 4. Analgesics 5. Cannabis
  12. 12.  A general population survey reported substance use in 0.2-0.3% of children less than 15 years of age  Only a few cases of opioid dependence were reported  A higher prevalence of substance abuse was reported among school students: 1. Alcohol (4-13%) most common 2. Tobacco (3-6%) 3. Minor tranquillizers (1-4%)
  13. 13. HEROIN USE IN INDIA  Initiation to heroin use was before the age of 16 years in 8% of heroin abusers in the north-eastern part of the country  A similar age of initiation of heroin abuse has been reported from other parts of India as well  A country profile documented by the Ministry of Welfare, Government of India reported mean age of initiation to heroin as 14 years
  14. 14. SUBSTANCE USE AMONGST CHILDREN IN INDIA  A high prevalence of tobacco, alcohol and opioid use has been reported amongst street children  Inhalants, sedatives, cough syrups and smokeless tobacco is also common  Most street children are multiple drug users  Alcohol use (75%) is most common followed by charas (50%) and heroin (5-10%)  Drug use in 91% of street children was reported from Madurai
  15. 15.  The Global Youth Tobacco Survey in 2006 showed that in India 1. 3.8% of students smoke 2. 11.9% used smokeless tobacco  A study of 300 street child laborers in slums of Surat in 1993 showed that 135 (45%) used substances
  16. 16. ETIOLOGY  The etiology of adolescent substance abuse lies in factors that predispose an individual to:  Experiment with substances  Progress to regular use  Develop abuse or dependence  A range of risk factors are associated with the development of adolescent Substance abuse
  17. 17. FOUR DIMENSIONS OF RISK FACTORS Predictors of early onset Predictors of heaviness of use Predictors of dependence vulnerability Predictors of desistance i.e., Protective factors
  18. 18. GENETIC AND ENVIRONMENTAL INFLUENCES  Adoption study literature shows that substance dependence in adoptees is: 1. Significantly correlated with alcoholism in biological fathers 2. Uncorrelated or only weakly correlated with alcoholism in adoptive parents 3. A positive family history of substance use disorder is a strong predictor for substance use and dependence
  19. 19.  Genetic influences on the development of adolescent substance abuse may act through: 1. A direct effect on psychophysiological reactions to substances or their metabolism 2. Indirectly through genetic effects on personality traits such as behavioral disinhibition which leads to substance experimentation
  20. 20. PRENATAL SUBSTANCE EXPOSURE  Prenatal exposure to alcohol, cannabis, cocaine is associated with:  Cognitive and behavioral self-regulation difficulties in children (Knopik, Sparrow, Madden et al., 2005)  Increased risk of adolescent substance use and abuse (Biederman, Monuteaux, Mick et al., 2006)
  21. 21. CHILD MALTREATMENT AND ABUSE  Childhood neglect, physical abuse (PA), sexual abuse (CSA) are predictive of: 1. Early onset tobacco, alcohol, marijuana and other illicit drug use 2. Alcohol or other drug problems during adolescence 3. Women are more susceptible (Widom, Ireland, & Glynn, 1995)
  22. 22. Marital Conflict, Parental Divorce and Repartnering  Parental divorce, subsequent repartnering and marital conflicts are associated with increased rates of : 1. Initiation of offspring alcohol, tobacco, marijuana and other illicit drug use 2. Heavier use of these substances 3. Greater risk of problem use (Fergusson, Horwood, & Lynskey, 1994; Hoffman & Johnson, 1998)
  23. 23. PARENTING INFLUENCES Parenting behaviors predictive of early initiation and substance abuse during adolescence :  Inconsistent, ineffective discipline, poor supervision and monitoring  Parent –child conflict  Low levels of parent support and parent– child attachment  Permissive or tolerant attitudes about substance use (Ary, Tildesley, Hops et al., 1993; Brook, Whiteman, Gordon et al.)
  24. 24. PEER INFLUENCES  Deviant peer affiliation is one of the best predictors of early onset substance abuse during the adolescent years  Mechanisms underlying this association remain unknown  Among competing explanations is the possibility that: 1. Deviant peers have a direct influence through peer pressure and socialization 2. Deviant peers provide both modeling and reinforcement for substance use 3. Substance using adolescents seek out peers who also use substances, a form of social homophily (Fergusson, Swain-Campbell, & Horwood, 2002)
  25. 25. EXTERNALIZING DISORDERS  Externalizing disorders are major risk factors predicting the initiation of substance use and the development of abuse and dependence  Risk factors associated with the development of externalizing disorders also predispose to the development of substance use disorders  These disorders are : 1. Conduct disorder 2. Oppositional defiant disorder (ODD) 3. Attention deficit hyperactivity disorder (ADHD) [Review by Crowley and Riggs, 1995]
  26. 26. STAGE THEORY  Stage theory proposes that: 1. There is a temporal ordering of substance experimentation 2. Lower order substances which are more commonly used precede the use of higher order substances  A licit/legal substance such as alcohol or cigarettes is used first  It is followed by marijuana which is usually the first illicit substance  This stage is followed by use of other illicit substances like opioids, cocaine, stimulants etc.
  27. 27. GATEWAY HYPOTHESIS This theory proposes that:  Use of marijuana facilitates the entry into other illicit substance use  This effect can be explained by: 1. Heavy cannabis users have preexisting traits that predispose them to the use of a variety of different substances 2. Marijuana use is a marker for a tendency to use multiple drugs 3. Marijuana use results in socialization into an illicit drug subculture which creates favorable attitudes toward the use of other illicit drugs
  29. 29. Why adolescents are prone to experimenting with drugs and alcohol?
  30. 30. Adolescent Brain Development and Addiction Vulnerability  Adolescent brain is vulnerable  During adolescence dynamic shifts occur in: 1. Brain morphology 2. Fiber architecture 3. Biochemical changes like alterations in dopaminergic and GABAergic neurotransmitter systems 4. Neuroendocrine factors
  31. 31.  Neurodevelopmental morphology studies indicate that: 1. Gray matter volume and cortical thickness follow an inverted parabolic curve across the lifespan 2. Peak occurs in early adolescence (ages 12–14 years) 3. Decline occurs as adult life progresses
  32. 32. Regional brain morphology shows temporal variance:  It follows a caudal-to-rostral pattern  Areas of brain to mature at earlier stage are: 1. Occipital region 2. sensorimotor cortices 3. Striatum  Area of brain to mature last are : 1. PFC 2. Association cortices
  33. 33.  Neurodevelopmental models postulates that :  In adolescent substance abusers there is developmental imbalance between:  Top down cognitive control systems  Bottom up incentive-reward systems
  34. 34. TOP DOWN SYSTEM  Components of a “top-down” executive system are 1. Pre-frontal cortex (PFC) 2. Anterior cingulate cortex (ACC)  Cognitive control is the ability to resist temptation in favor of long-term goal-oriented behavior  Cognitive control is regulated by top down system  Top down system improves in a linear fashion from childhood through adulthood
  35. 35. BOTTOM-UP SYSTEM  A “bottom-up” subcortical system includes: 1. Striatum 2. Midbrain dopaminergic system  Important in reinforcement learning  Matures at an earlier stage of development than a “top-down” system
  36. 36. THE CIRCUIT IMBALANCE During adolescence there is imbalance between:  Immature “top-down” cognitive control processes and  Mature and hyperactive “bottom-up” incentive-reward processes  This allow bottom up system (incentive-reward) system to supersede cognitive control  This leads to increased susceptibility to the (incentive-reward) properties of psychoactive substances
  37. 37. TRIADIC MODEL OF ADOLESCENT ADDICTION It involves the interface of 3 neurobiologic systems: 1. Control /regulatory system involving the medial and ventral PFCs 2. Reward system involving the ventral striatum and midbrain dopaminergic system 3. Threat/harm-avoidance system involving the amygdala Increased engagement in substance use during adolescence takes place due to: 1. An inefficient control/regulatory system 2. A strong reward system 3. A weak harm-avoidance system
  38. 38.  During adolescence 1. Maturational imbalances are the greatest 2. Adolescents are not able to regulate motivational or emotional states in the same way as adults  This explains the early onset and elevated rates of addictive disorders during adolescent period
  39. 39. EFFECT OF ADDICTIVE PROCESSES ON BRAIN STRUCTURE AND FUNCTION 1. Animal models suggest that the brain is more vulnerable to the effects of psychoactive substances during adolescence 2. Among adolescents substance abuse for as few as 1 to 2 years leads to structural and functional deficits in brain  Adolescent substance abuse leads to alterations in: 1. white matter 2. PFC 3. Corpus callosum 4. Cerebellum
  40. 40.  Hippocampal volumes are smaller among adolescents with heavy alcohol use patterns compared to nonsubstance using adolescents  PFC volume seems to vary among adolescents with AUD compared to nondrinking controls  Findings vary by gender: 1. Female adolescents with AUDs had significantly smaller PFC volumes compared to female nondrinkers 2. Male adolescents with AUDs had significantly larger PFC volumes compared to male nondrinkers
  41. 41. Neurocognitive deficits are found in adolescents across the domains of: 1. Attention 2. Visuospatial processing 3. Speeded information processing 4. Memory 5. Executive functioning
  42. 42. ASSESSMENT OF ADOLESCENT SUBSTANCE USE  Research suggests that face-to-face interview assessment leads to underreporting of substance use by adolescents  Strategy which should be used in assessment: 1. Use a self-administered questionnaire during an interview 2. Obtain drug use history information 3. Then use a computer self-administered interview to obtain this same information 4. Supplement it by toxicology screens
  43. 43. ADOLESCENT SUBSTANCE ABUSE SCREENING INSTRUMENTS 1. Adolescent Drinking Index (ADI) 2. Drug Use Screening Inventory –Revised (DUSI-R) 3. Problem Oriented Screening Instrument for Teenagers (POSIT) 4. Rutgers Alcohol Problem Index (RAPI) 5. Substance Abuse Subtle Screening Inventory Adolescent Version(SASSI-A) 6. Teen Addiction Severity Index (T-ASI) 7. CRAFFT – a brief screening tool for adolescent substance abuse
  44. 44. DIAGNOSIS AND CLINICAL FEATURES  The diagnosis of substance abuse is made primarily through: 1. Clinical interview with the adolescent 2. Obtaining collateral information from parents and teachers  Adolescents and children are: 1. Likely to be in a precontemplative stage of change 2. Minimize the extent of their substance involvement  Establishing rapport with the adolescent is critical in order to increase the chance of self-disclosure of drug use
  45. 45. INTERVIEWING TECHNIQUES  Parents or caretakers should ideally be present at the initial interview for assessment of adolescents  This allows the establishment of: 1. Rules of confidentiality 2. Threats of harm to self or others
  46. 46. DEALING WITH CONFIDENTIALITY  During assessment adolescent's confidentiality should be honored unless: 1. Specific permission and release is obtained or 2. Patient is clinically judged to be a danger to self or others  Adolescents are usually willing to self-disclose if the rules of confidentiality are clearly established  Exceptions to confidentiality should be specified at the beginning of treatment
  47. 47. The interview with the parents or caretakers should be used to obtain a history of: 1. Presenting complaint 2. Early development history 3. Assess family dynamics Private interview with the adolescent is important in facilitating:  Strong treatment alliance  Eliciting information about substance abuse and behavior problems  Eliciting vital information that patient may not be comfortable disclosing in presence of parents
  48. 48.  History of clinical concern is: 1. Extent or severity of substance involvement 2. Specific substances that the patient is abusing or dependent on 3. Length of time that the pattern has persisted  For each substance clinicians should inquire about: 1. Age of onset of first use or experimentation 2. Age of progression to regular use 3. Peak use 4. Current use 5. Last use
  49. 49.  Other important information includes: 1. Triggers for craving and use 2. Context of use (e.g with particular peers, or at or before school) 3. Perceived motivation for using 4. Positive and negative consequences of use 5. Current motivation 6. Goals for treatment
  50. 50. DIFFERENTIAL DIAGNOSIS  The primary differential diagnosis is establishing whether : 1. Substance abuse or Substance dependence exists for each substance 2. Extent of relevant comorbid psychiatric and medical conditions
  51. 51. COMORBIDITY IN SUBSTANCE USE DISORDERS  Past 6 month prevalence for comorbid psychiatric disorders with an adolescent substance use disorder is: 1. 76% for any comorbid disorder 2. 68% for any disruptive behavior disorder 3. 32% for any mood disorder 4. 20% for any anxiety disorder  Comorbidity is the rule rather than the exception among adolescents with substance use disorders (Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study)
  53. 53. PROBLEMS WITH ADOLESCENT SUBSTANCE ABUSE TREATMENT STRATEGIES  The efficacy of pharmacotherapies for adolescent drug use disorders has not been established  No clear evidence exits for: 1. Specific components of therapy that are critical for successful outcome 2. Therapy particularly efficacious with particular type of substance abuse
  54. 54.  Randomized clinical trials focused on adolescent substance abusers are: 1. Rare 2. Typically single site 3. Cannot be generalized to patient populations across diverse clinical settings 4. Underpowered
  55. 55.  Adolescents with substance abuse: 1. Do not self-refer for treatment 2. Often pressured into treatment by family, school, or court 3. Are defiant 4. Minimize their drug use  Ethical challenges of clinical research with minors include: 1. Requirement to obtain parental consent for participation 2. Potential for confidentiality breach in obtaining parental consent
  56. 56. TREATMENT STRATEGIES  Treatment for adolescent with substance involves recognizing that these are chronic relapsing conditions  Patients may need multiple episodes of treatment over time  Treatment typically involves: 1. Initial attempts to create abstinence or markedly reduce drug use 2. Addressing the biopsychosocial aspects of substance use 3. Maintenance or relapse prevention•phase
  57. 57. PHARMACOTHERAPY TOBACCO  An early open-label trial using nicotine patch with adolescent smokers desiring to quit reported no benefit (5% abstinence rate at 6 months) (Hurt, Croghan, Beede et al., 2000)  Single underpowered clinical trial failed to find a significant improvement in abstinence rates at 6 months using the nicotine patch (Grimshaw & Stanton, 2006)  Efficacy for pharmacological treatment of adolescent smokers remains to be established
  58. 58. ALCOHOL  There have been no multisite randomized clinical trials of pharmacotherapies for alcoholism in adolescents  Most recent findings from large US multisite trials with adults suggest that behavioral interventions should remain the treatment of choice for adolescents with alcohol problems
  59. 59. OPIOIDS  Relatively little research has been conducted on the effectiveness of treatment of opioid abuse in children and adolescents  Findings from the limited adolescent-focused research suggest that methadone is likely to be effective in reducing long-term use of heroin and other illicit opioids in those adolescents who have developed severe dependence (Kellogg, Melia, Khuri et al., 2006)
  60. 60.  There is little research evaluating pharmacological treatments for adolescent substance abuse  Available evidence is based almost entirely on adult, rather than adolescent samples  Evaluations of the efficacy of pharmacotherapies have produced equivocal results regarding their efficacy in adolescents (DeLima, Soares, Reisser et al.,2002)
  61. 61. SPECIFIC THERAPEUTIC APPROACHES Motivational Interviewing: 1. Motivational interviewing techniques have been demonstrated to promote:  Treatment engagement  Strong treatment alliance  Patient generated treatment goals 2. Motivational interviewing principles can be effectively used in conjunction with another empirically supported treatment modalities such as individual and/or family-based treatment
  62. 62. COGNITIVE-BEHAVIORAL THERAPY  Cognitive-behavioral therapy (CBT) is effective in treating adolescent substance use disorders  In CBT following characteristics need to be identified: 1. Reinforcers of substance use 2. Skills deficits 3. Specific cognitive distortions associated with substance use  CBT should be provided to: 1. Enhance coping strategies to deal effectively with drug cravings and negative affects 2. Strengthen problem solving and communication skills 3. Identify and avoid high-risk situations
  63. 63.  An important feature of CBT is its emphasis on developing new behaviors that are:  Enjoyable  Incompatible with drug use Riggs et al. (2005) demonstrated that  When treatment was free or incentivized, many adolescents voluntarily entered treatment when referred by counselors, teachers, friends, or family  Thus, individual CBT is a viable therapeutic option for youth with SUDs
  64. 64. CONTINGENCY MANAGEMENT  This approach encourages healthy changes in behavior by rewarding adolescents for objective evidence of abstinence such as negative urinalyses  It regards substance use as operant behaviors that are reinforced by the effects of the drugs involved  Following the operant conditioning model, the adolescent’s drug use will subside when tangible incentives are offered for abstinence
  65. 65. TWELVE-STEP PROGRAMS  These programs incorporate a self-help approach centered within the context of reciprocal support  They are organized around the basic tenets of Alcoholics Anonymous (AA)  In this approach individuals support each other’s sobriety through encouragement of mental and spiritual health via a lifelong spiritual journey through 12 steps
  66. 66. MULTISYSTEMIC THERAPIES Multisystemic therapies:  Treat adolescents within the context of their environment  Try to modify multiple environmental factors contributing to SUDs  Multisystemic therapy is an approach that addresses 1. Social and family influences of drug use 2. Associated antisocial behaviors  Therapists make frequent home visits and are available on a full time basis to families  Henngeler et al. (1996) demonstrated that over 98% of youth receiving MST remained in treatment, compared to very few youth in a control group
  68. 68. School Based Prevention  School-based efforts are efficient as they offer access to large numbers of students  Contemporary approaches to school-based prevention of substance use are: 1. Social resistance skills training 2. Normative education 3. Competence enhancement skills training
  69. 69. Social Resistance Skills  These interventions are designed with the goal of: 1. Increasing adolescent’s awareness of various social influences that support substance use 2. Teaching them specific skills for effectively resisting both peer and media pressures to smoke, drink, or use drugs
  70. 70. Normative Education  Normative education approaches include content and activities to correct inaccurate perceptions regarding the high prevalence of substance use  Many adolescents overestimate the prevalence of smoking, drinking, and the use of certain drugs, which can make substance use seem to be normative behavior  Educating youth about actual rates of use, which are almost always lower than the perceived rates of use, can reduce perceptions regarding the social acceptability of drug use
  71. 71. COMPETENCE ENHANCEMENT PROGRAMS  Competence-enhancement programs recognize that youth with poor personal and social skills are more susceptible to substance abuse  Competence enhancement approaches teach following life skills: 1. General problem-solving and decision-making skills 2. General cognitive skills for resisting interpersonal or media influences 3. Skills for increasing self control and self-esteem 4. Adaptive coping strategies for relieving stress and anxiety
  72. 72. LIFE SKILLS TRAINING  The Life Skills Training (LST) program seeks to influence major social and psychological factors that promote substance use  Separate curricula have been developed for: 1. Elementary school students (grades three to six) 2. Middle or junior high students (grades six to eight, or grades seven to nine) 3. High school students (grades nine or ten)  The program content is delivered using cognitive-behavioral skills training techniques
  73. 73. LST COMPONENTS  The LST program consists of three major components that address critical domains found to promote substance use  Each component focuses on a different set of skills 1. Drug Resistance Skills enable young people to:  Recognize and challenge common misconceptions about substance use  Deal with peer and media pressure to engage in substance use
  74. 74. 2. Personal Self-Management Skills help students to:  Examine their self-image and its effects on behavior  Identify everyday decisions and how they may be influenced by others  Consider the consequences of alternative solutions before making decisions 3. General Social Skills give students the necessary skills to:  Overcome shyness  Communicate effectively and avoid misunderstandings  Use both verbal and nonverbal assertiveness skills to make or refuse requests
  75. 75. PROJECT TOWARDS NO DRUG ABUSE  Project Towards No Drug Abuse (TND) is designed to help high risk students (14 to 19 years old) resist substance use and abuse  It is based on an underlying framework that young people at risk for substance abuse will not use substances if they:  Are aware of misconceptions and myths about drug use  Have adequate coping skills and self-control  Know about negative consequences of substance use  Are aware of cessation strategies for all forms of substance use  Have good decision-making skills
  76. 76. BRIEF ALCOHOL SCREENING AND INTERVENTION FOR COLLEGE STUDENTS (BASICS) (BASICS) is a program for college students who drink alcohol heavily and are at risk for alcohol-related problems like:  Poor class attendance  Missed assignments  Accidents  Sexual assault  Violent behavior  It is not designed for students who are alcohol dependent  The goal of BASICS is to motivate students to reduce their alcohol use in order to decrease the negative consequences of drinking
  77. 77. Family Based Prevention Programs  Family based substance abuse prevention programs for adolescents are: 1. Family Matters 2. Creating Lasting Family Connections 3. Brief Strategic Family Therapy
  78. 78. FAMILY MATTERS  Family Matters is a universal prevention program  It is designed to prevent tobacco and alcohol use in children 12 to 14 years old  The program is implemented at home by parents with the help of four instructional booklets
  79. 79. CREATING LASTING FAMILY CONNECTIONS (CLFC)  (CLFC) is a selective intervention  It is designed to prevent substance abuse and violence among adolescents and families in high-risk environments  CLFC is designed to:  Enhance family bonding and communication skills among parents and youth  Promote healthy beliefs and attitudes that are inconsistent with drug use and violence
  80. 80. BRIEF STRATEGIC FAMILY THERAPY  BSFT is an indicated family-based prevention program  It aims to decrease individual and family risk factors through skills building and by improving and strengthening family relationships  BSFT targets children and adolescents (6 to 17 years of age) who engage in: 1. Rebellious , truant, or delinquent behaviors 2. Substance use 3. Peers exhibiting these behaviors
  81. 81. MODEL COMMUNITY BASED PREVENTION PROGRAM  Community Trials Intervention to Reduce High-Risk Drinking (RHRD) is a universal intervention  RHRD aims to alter community-wide alcohol use patterns such as: 1. Drinking and driving 2. Underage drinking 3. Binge drinking and related problems
  82. 82.  The RHRD program uses five prevention components: 1) Reducing alcohol access by helping communities use zoning and municipal regulations to control the density of bars, liquor stores, etc. 2) Responsible beverage service by training alcohol beverage servers and assisting retailers develop policies and procedures to reduce drunkenness 3) Reduce drinking and driving through increased law enforcement 4) Reduce underage alcohol access by training alcohol retailers to avoid selling to minors and increased enforcement of laws regarding alcohol sales to minors 5) Provide communities with tools to form the coalitions needed to implement and support the interventions
  83. 83. HARM REDUCTION INITIATIVES  These interventions aim at limiting or reducing the harm caused by substance use even if substance use itself continues  These include: 1. Campaigns that aim to reduce alcohol related harm by reducing driving under the influence 2. Needle and syringe exchange programs that help in reducing transmission of blood borne viruses without reducing drug use per se  There is no evidence indicating that such programs increase either the prevalence of drug use or the frequency of drug use among users
  84. 84. CONCLUSION  Understanding of substance abuse problems during adolescence is critical  Prevalence rates of alcohol, tobacco, and other drug use increase rapidly from early to late adolescence and typically peak during young adulthood  Deviant peer affiliation is one of the best predictors of early onset substance abuse during the adolescent years  Currently the research on adolescent SUD treatment is dominated by psychosocial-based modalities  Family systems based treatments and motivational enhancement therapy/BI approaches have received the most empiric support compared with other modalities
  85. 85. REFERENCES 1. Rutter’s Child and Adolescent Psychiatry, 5th Edition, Edited by M. Rutter, D. V. M. Bishop D. S. Pine, S. Scott, J. Stevenson, E. Taylor and A. Thapar © 2008 Blackwell Publishing Limited. ISBN: 978-1-405-14549-7 2. Lewis's Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th Edition 3. Neurobiology of Adolescent Substance Use and Addictive Behaviors: Prevention and Treatment Implications:Christopher J. Hammond, MD1,2, Linda C. Mayes, MD1, and Marc N. Potenza, MD, PhD; Adolesc Med State Art Rev. 2014 April ; 25(1): 15–32. 4. Evidence-Based Interventions for Preventing Substance Use Disorders in Adolescents; Kenneth W. Griffin, Gilbert J. Botvin, Ph.D; Child Adolesc Psychiatr Clin N Am. 2010 July ; 19(3): 505–526. doi:10.1016/j.chc.2010.03.005
  86. 86. 5. Evidence for Optimism: Behavior Therapies and Motivational Interviewing in Adolescent Substance Abuse Treatment; Mark J. Macgowan, PhD, LCSW, Bretton Engle, PhD, LCSW; Child Adolesc Psychiatr Clin N Am. 2010 July ; 19(3): 527–545. doi:10.1016/j.chc.2010.03.006. 6. Advances in Adolescent Substance Abuse Treatment; Ken C. Winters, Andria M. Botzet, and Tamara Fahnhorst; Curr Psychiatry Rep. 2011 October ; 13(5): 416–421. doi:10.1007/s11920-011-0214-2 7. Substance Abuse in Children and Adolescents; B.M. Tripathi, Rakesh Lal; Indian J Pediatr 1999; 66 : 569-575 8. Substance use and addiction research in India; Pratima Murthy, N. Manjunatha, B. N. Subodh, Prabhat Kumar Chand, Vivek Benegal; Indian J Psychiatry 2010;52:S189-99.
  87. 87. THANK YOU