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1. Aladjem M, Wohl R, Boichis H, et al: Desmopressin in nocturnal emesis. Arch Dis Child 57:137-140, 1982. 2. Feeney D, Klykylo W: SSRI treatment of enuresis (letter). J Am Acad Child Ado1 Psycho1 36: 13261327, 1997. 3. Fergusson DM, Horwood LJ, Shannon FT:Factors related to the age of attainment of nocturnal bladder control: An 8-year longitudinal study. Pediatrics 78:884-890, 1986. 4. Foreman D, Thambirajah M: Letter to the Editor. Child Abuse Negl 22:337, 1998. 5. Hoekx L, Wyndaele J, Vermandel A: The role of bladder feedback in the treatment of children with refractory nocturnal enuresis associated with idiopathic detrusor instability and small bladder capacity. J Urol 160:858-860, 1998. 6. Kaplan SL, Breit M, Gauthier B, et al: A comparison of three nocturnal enuresis treatment methods. J Am Acad Child Adolesc Psychiatry 28:282-286, 1989. 7. Levine MD, Bakow H: Children with encopresis: A study of treatment outcome. Pediatrics 58:845-852, 1976. 8. Levine MD: Encopresis: Its potentiation, evaluation and alleviation. Pediatr Clin North Am 29:315-330, 1982. 9. Morrow J, Yeager C, Lewis D: Encopresis and sexual abuse in a sample of boys in residential treatment. ChildAbuseNegl21:11-18, 1997. 10. Schmitt BD: Toilet training refusal: Avoid the battle and win the war. Contemp Pediatr 4(12):32-SO, 1987. 1 I . Schmitt BD: Your Childs Health, 2nd ed. New York, Bantam Books, 1991. 12. Rapoport JL, Mikkelsen EJ, Zavadil A, et al: Childhood enuresis. 11: Psychopathology, tricyclic concentration in plasma, and antienuretic effect. Arch Gen Psychiatry 37:1146-11.52, 1980.

60. ADOLESCENT DRUG ABUSE

Frederick B. HeGert, M.D., and Gordon K. Farley, M.D.

1. How common is adolescent substance abuse? The use and abuse of alcohol and other drugs by adolescents in the United States is a common, serious, and sometimes life-threatening problem. In a study of consecutive appearances at a large city psychiatric emergency room, 35% of the adolescent admissions were for suspected or confirmed drug abuse. About one-third of eighth graders and about two-thirds of twelfth graders use alcohol. Over one-half of twelfth graders report that they drive after drinking. More than 50% of fatal car crashes involving drivers under 20 are alcohol-related. Well over one-half of twelfth graders report marijuana use. Cocaine and crack use are reported to be high among teenagers. It is estimated that 10-15% of all teenagers will develop serious problems with drug and alcohol abuse. With the frequent use of psychoactive substances by adults to change their moods and emotions, it is not surprising that substance abuse is among the most common problems of adolescents. Adults use substances to wake up in the morning, to sleep at night, to enjoy sex more, to improve their alertness, and to self-medicate their psyches. By the time an adolescent is 15, he or she will have had thousands of experiences of seeing respected and admired adults smoking, ingesting, and perhaps even injecting psychoactive substances, both in person and the media.

2. List the most commonly abused drugs.

Commonly abused drugs in rough order of frequency include:

Substance
Alcohol (most commonly used drug by adolescents) Tobacco/Nicotine (second most commonly used drug by adolescents; accounts for more adult deaths than any other drug)
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Street Names

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Substance
Marijuana Stimulants Amphetamines Dexedrine Methylphenidate (Ritalin) Cocaine

Adolescent Drug Abuse

Street Names
Dope, grass, stash, hash, Mary Jane, M.J., pot, reefer Speed, ice, meth, crystal, crank, glass Bennies, white crosses
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Coke, cocoa, paste, snow, powder, crocks, quarter rock, crack

Anorectic drugs either by prescription (Preludin, Tenuate) or over the counter, such as phenylpropanolamine and pseudoephedrine Hallucinogens Lysergic and diethylamide Psilocybin Mescaline Phencyclidine Ketamine Narcotics and Analgesics Morphine Codeine Heroin Volatile Substances (inhaled) Solvents (gasoline, paint thinner, benzene, acetone) Toluene (Rustoleum clear paint, plastic and rubber cement) Aerosol sprays (paint, hair spray, cooking oil) Cryogenic chilling fluids (Freon) Sedative Hypnotics Barbiturates Barbiturate-like drugs Methaqualone Benzodiazepines (e.g., Librium, Valium, Xanax, Halcion) Anticholinergic Drugs Atropine, some antihistamines, antiparkinsonian medications (Artane, Kemadrin) Scopolamine Club Drugs Methylenedioxymethamphetamine (MMDA) Gammahydroxybutyrate (GHB) Reds, yellows, rainbows
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LSD, acid Magic mushroom, boomers, shrooms Peyote, cactus, button Angel dust, PCP Special K, Vitamin K Morf, Miss Emma Smack, stuff, horse, junk, China white

Soapers (even though now only illegally manufactured)

Scope Ecstasy, XTC, clarity, lovers speed G, liquid ecstasy

3. What are the general concerns in treating acute intoxication with any drug? The major concern in the acutely intoxicated is to maintain life-support systems until it is known what specific drug has been ingested. The acute treatment of intoxication or acute drug abuse is a highly specialized activity and best done in inpatient medical or psychiatric settings where medical support is readily and immediately available.

4. What makes alcohol intoxication dangerous? Alcohol intoxication is extremely common and often occurs in combination with other substances, most frequently sedative hypnotics. The symptoms vary with route of administration,

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amount used, specific substance, previous history of use and addiction, and period of time over which the substance has been consumed. Alcohol intoxication should be suspected with a history of rapid change in mental status, because alcohol is rapidly absorbed through the gastric mucosa. Laboratory confirmation of alcohol use is easily obtained; however, behavioral symptoms correspond only roughly to blood alcohol levels. Nystagmus on extreme lateral gaze, mild dysarthria, and mild ataxia are relatively early signs. The most important part of treatment is to follow the patient carefully to avoid coma. Some adolescents have died from high alcohol blood levels when their breathing stopped, apparently because levels were high enough to block the medullary breathing centers. Social risks include impulsive and unprotected sex, fighting, and automobile accidents.

5. What about hallucinogens?

Psychomimetics include marijuana, LSD, psilocybin, and phencyclidine (PCP). These agents cause a cognitive disorder with illusions (trails with marijuana), frank visual hallucinations (color and shape changes with LSD), and disordered thinking (body image changes progressing to thought blocking and delirium with PCP). What is not generally known is that all hallucinogens produce anxiety, ranging from mild transient dysphoria with marijuana to anxious irritability with PCP and genuine panic with LSD (bad trips). Physical changes include injected conjunctivae with marijuana, and dilated but reactive pupils with LSD and psilocybin. PCP, however, produces more prominent physical signs. Paresthesias in the limbs, initially or at low doses, progress to analgesias (cigarette bums are common), then muscular rigidity, myoclonus, or even convulsions or coma. When seen in the emergency department, the patient taking PCP may be mute and amnestic with catatonic posturing. Ptosis and nystagmus may be the only clues to diagnosis. Lab tests may be helpful, but most hallucinogens are cleared quickly; hence negative drug screens are common. However, urine screens for marijuana may be positive for several days after a single dose.

6. Is sniffing glue dangerous?

Solvents produce a giddy delirium that may progress to coma with prolonged inhalation. Despite newspaper reports, few youths have died from acute inhalation, but many have suffered long-term brain damage by repeated use. Usually this damage takes the form of dementia, but sometimes presents as pure cerebellar degeneration. The diagnosis is suspected when a patient has a ketone breath and body odor, and swollen mucous membranes but no other cold symptoms. Poverty and depression frequently are associated with solvent abuse. Initial medical treatment is supportive.

7. Why is abuse of stimulant drugs harder to treat? Stimulants are known as body drugs for their ability to produce physiologic changes. Cocaine in its many forms is now the best known illicit stimulant, but even caffeine produces many symptoms if sufficient amounts are taken. Symptoms include dilated but reactive pupils with a host of Ts: tremor, tachycardia, tachypnea, talkativeness, temperature (elevated), and tension (muscular and nervous). Grand ma1 convulsions and a high temperature may lead to shock. Deaths have been related to strokes, cardiac irregularities, and delirium. Initial euphoria is followed by anxiety and irritability, then anger and rage with higher doses. Speeded-up thinking may become maniacal acutely or paranoid over prolonged periods. In this case a urine toxicology screen or hospitalization for longer term observation is the only method for distinguishing chronic stimulant abuse from schizophrenia. Acute treatment for mild reactions requires only general support, or, at most, single-dose neuroleptics (e.g., haloperidol [Haldol], 5 mg intramuscularly) to calm the patient. Serious toxicity requires major supportive measures in a structured medical setting, with ice packs and diazepam (Valium) to control temperature and seizures. Physical and mental depression frequently follow withdrawal; thus the tendency to increase the dose of the drug is high. With the advent of lower melting point cocaines through freebasing and high-tech marketing (pagers, cell phones, and crack houses), the drug has come into widespread use. Cocaine, particularly in its newer form as cocoa paste, is a highly concentrated and dangerous drug.

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8. Do adolescents who take drugs have other problems? Most of these youngsters were breaking rules before they began using substances. There are only three methods of supporting an expensive drug habit-theft, prostitution, or distribution-and none is legal. Current methods of distribution emphasize use of youngsters on the front lines, because they face less severe penalties when caught. Although most adolescents do not become addicts, the U.S. leads all industrialized nations in percentage of young people involved with illicit drugs. 9. Can drugs be detected without blood or urine tests? Cocaine recently has been shown to be excreted in saliva at levels parallel to plasma levels. It may be possible to develop a saliva screening test using a dipstick method.
10. What are the basics of long-term treatment for drug abuse? No one method is more effective than others; thus, treatment reflects a plethora of methods. Basic approaches emphasize the goals of acceptance, education, and usually abstinence. More recent approaches have emphasized addiction as a family disease and focused on sexual abuse as a common theme. Inpatient programs emphasize a stepwise approach, last 4-6 weeks, and make frequent use of videos and films. Patients are taught to increase self-esteem and to recognize their individuality; return to the community is gradual. When in denial and/or uninformed, the familys attitude toward substance abuse (Dont talk, dont trust, dont feel) can lead to specialized roles in the family as well as emotional abuse and passage of substance abuse to the next generation. Multisystemic and multimodal treatment programs that attend to individual, family, peer, school, and community factors associated with drug abuse have achieved recent prominence. These programs are especially effective for the treatment of juvenile offenders who also have a drug abuse problem. All comprehensive treatment programs should attend to comorbid psychiatric conditions. Note that Alcoholics Anonymous and Narcotics Anonymous are helpful, long-term support systems.

11. What can the physician do to help the cessation and prevention of tobacco use? From the standpoint of lifetime mortality and morbidity, tobacco use is undoubtedly the most serious addiction. More than 450,000 Americans die each year because of tobacco use, and a much larger number suffer chronic illness. There is evidence that maternal smoking during pregnancy may put the offspring at additional risk for specific psychopathology (e.g., attention deficit-hyperactivity disorder [ADHD]). For most smokers, tobacco use begins during the juvenile years. The National Cancer Institute recommends that physicians use a five-step program when treating adolescents. All steps begin with the letter A. The steps are: 1. Anticipatory guidance. 2. Ask. 3. Advise. 4. Assist. 5. Arrange follow-up. These steps have been described in great detail by the American Academy of Pediatrics. Nicotine addiction treatment using nicotine-containing gum and transdermal patches as a substitute for cigarettes has had some success. The use of medications such as bupropion (Wellbutrin, Zyban) to decrease nicotine craving also has been useful.

12. What factors predict adolescent drug abuse? A number of contributors to adolescent drug abuse have been identified by workers in the field:
Social sanction Previous risk-taking behavior Abuser personality characteristics Economic feasibility Family history, genetic loading Poverty Psychiatric co-morbidity, e.g., ADHD, bipolar mood disorder, depression, anxiety, conduct disorder) Environmental reinforcement (family, societal, and media influences) Cultural and ethnic factors Family patterns Family dysfunction Modeling Peer influences Alienation Reinforcing chemical properties of the substance

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13. What stages of drug abuse have been identified? The National Commission on Marijuana and Drug Abuse describes these patterns or stages: 1. Experimental drug use 4. Intensified drug use 2. Social or recreational use 5. Compulsive drug use 3 . Circumstantial or situational drug use The American Medical Association describes the following patterns of drug use: 1. Drug experimentation 3. Drug abuse 2. Drug use, first recreational, then regular 4. Drug dependency A common pattern of cocaine use and abuse by groups includes the following steps: 1. Curiosity 7. Psychopathic behavior 2. Initiation 8. Ritualistic behavior 3. Pleasure 9. Dependency tolerance 4. Group identification 10. General physical deterioration 5. Group prestige 11. Severe sociopathic personality destruction 6. Family isolation Despite the different labels, each of these progressions notes a movement from curiosity and controlled casual use to uncontrolled obligatory use (addiction).
14. How can the stages help to identify at-risk adolescents? To treat adolescent drug abuse effectively, many experts believe that the stage of the abuser or potential abuser must be recognized. Many questionnaires purportedly reveal adolescents who are at risk for or already in the early stages of abuse. The questions revolve around parent and peer relations, school adjustment, and observed drug use. Drug abuse by teenagers is believed by many to be seriously underestimated because of numerous factors, including denial by physicians,mental health professionals,and family members, as well as the often episodic nature of drug abuse. The use of routine questions about family and individual patterns of drug abuse and use can aid in detection.
15. Can treatment during early stages be helpful? During the early stages of drug curiosity and experimentation, parental and peer attitudes are crucial. Parents must present appropriate questions and expectations to the adolescent and let the adolescent know what their actions will be if drug use is observed. Group sessions to explore attitudes toward drug use and anticipated consequences and alternatives may be helpful, because adolescents are susceptible to peer influences.

16. How successful is treatment during the middle stages? During middle stages of adolescent drug use and abuse, traditional mental health approaches have been relatively unsuccessful. By contrast, many different kinds of self-help and peer-support groups claim remarkable success. Some of these groups include: Parents, Peers, and Pot; Palmer Drug Abuse Program (PDAP); Channel One; Alcoholics Anonymous (AA); Al-Anon Family Groups; Families Anonymous; Narcanon Family Groups; and Narcotics Anonymous. Often, a traditional psychotherapeutic approach combined with chemically enforced abstinence and a self-help peer-support group leads to the best results. Note that treatment of co-morbid psychiatric illness is important at any stage of abuse.
BIBLIOGRAPHY
1. American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. J Am Acad Child Adolesc Psychiatry 36(suppl): 140s-156s. 2. Brook JS, Cohen P, Brook DW: Longitudinal study of co-occurring psychiatric disorders and substance use. J Am Acad Child Adolesc Psychiatry 37:322-330, 1998. 3 . Epps RP, Manley MW, Glynn TJ: Tobacco use among adolescents: Strategies for prevention. Pediatr Clin North Am 42:389402, 1995.

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4. Galanter M, Gleaton T, Marcus CE, McMillen J: Self-help groups for parents of young drug and alcohol abusers. Am J Psychiatry 141:889-891, 1984. 5. Henggler SW, Borduin CM: Family Therapy and Beyond: A MultisystemicApproach to Treating the Behavior Problems of Children and Adolescents. Pacific Grove, CA, Brooks/Cole, 1990. 6 . Kaminer Y: Adolescent Substance Abuse: A Comprehensive Guide to Theory and Practice. New York, Plenum, 1994. 7. Kandel DB, Chen K, Warner LA, Kessler RC, Grant B: Prevalence and demographic correlates of symptoms of last year dependence on alcohol, nicotine, marijuana and cocaine in the US population. Drug Alcohol Depend 44:ll-29, 1997. 8. Kandel DB, Johnson JG, Bird HR, et al: Psychiatric disorders associated with substance use among children and adolescents: findings from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. J Abnonn Child Psycho1 25:121-132, 1997. 9. Riggs DD: Depression in substance-dependent delinquents. J Am Acad Child Adolesc Psychiatry 34:764771, 1995. 10. Weissman MM, Warner V, Wickramaratne PJ, Kandel DB: Mental smoking during pregnancy and psychopathology in offspring followed to adulthood. J Am Acad Child Adolesc Psychiatry 38392-899, 1999. 1 1. Zoccolillo M, Vitaro F, Tremblay RE: Problem drug and alcohol use in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry 38:900-907, 1999.

6 1. PRINCIPLES OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY

Frederick B. HeGert, M.D.

1. Why are physicians concerned about child and adolescent medications?

Practitioners sometimes avoid giving medications to children and adolescents because they are concerned about unusual responses or dosage requirements. However, except for the lack of a euphoric response to stimulants in children, there are few qualitative differences between children and adults in their response to medication. Childrens younger organs frequently clear medications more quickly, whereas adolescents generally need adult doses.

2. What are major issues for the family practitioner?

Families sometimes focus all difficulties on unlikely medical causes or past injuries and expect that medications either will not work at all or will work miracles. Medications may allow a seriously ill child to be treated as an outpatient; this is an important point, but hardly a miracle. Medications are part of a total treatment plan. Parents and practitioners need to be supportive, never using medications as a punishment. Children and adolescents need to remember that medications do not excuse them from the need to work on their problems. Below are specific principles for treatment of attention deficit-hyperactivity disorder, depression, psychosis, conduct disorders, and anxiety disorders.

ATTENTION DEFICIT-HYPERACTIVITY DISORDER

3. Why is so much attention paid to attention deficit-hyperactivity disorder (ADHD)?
ADHD is a common and well-researched childhood disorder. The central notion of a short attention span and hyperactivity has been around since a German poet wrote about Fidgety Phil a hundred years ago. In the ensuing years, over 10,000 articles have been published in the scientific literature. Although stimulant medications have been used for over 50 years, from time to time splinter groups have raised questions about their use. From the standpoint of the scientific community, stimulants remain one of the safest and most effective of all psychotropic medications. The increase in use of stimulants is probably the result of an increased recognition that 15% of patients with