1 Adolescents and Treatment of Alcohol Use Disorders NIAAA Social Work Education Module 10A (revised 3/04) (revised 3/04)

1

Adolescents and Adolescents and Treatment of Alcohol Treatment of Alcohol

Use DisordersUse DisordersNIAAA Social Work EducationNIAAA Social Work Education

Module 10AModule 10A

(revised 3/04)(revised 3/04)

2

OutlineOutline

Prevalence Prevalence Criteria issuesCriteria issues Risk factorsRisk factors Assessment Assessment Treatment & prevention Treatment & prevention

concernsconcerns

Prevalence (8th graders)Monitoring the Future 2000

51.7% have tried alcohol 43.1% have had an alcoholic drink in past year 25.1% have been drunk 15.2% report 1 or more binge drinking episodes 40.5% have tried cigarettes 3.3% smoke ½ pack or more of cigarettes/day 26.8% have tried at least one illicit drug 1.4% report using marijuana daily for at least

one month at some point in their life

3

4

70.6% have tried alcohol 63.7% have had an alcoholic drink in past year 48.9% have been drunk 25.6% report 1 or more binge drinking episodes 1.9% report daily drinking for at least one

month at some point in their lives 46.2% have tried at least one illicit drug 57.6% have tried cigarettes 7.6% smoke ½ pack or more of cigarettes/day

Prevalence (10th graders)

Monitoring the Future 2000 70.6% have tried alcohol

63.7% have had an alcoholic drink in past year 48.9% have been drunk 25.6% report 1 or more binge drinking episodes 1.9% report daily drinking for at least one

month at some point in their lives 46.2% have tried at least one illicit drug 57.6% have tried cigarettes 7.6% smoke ½ pack or more of cigarettes/day

Prevalence (10th graders)

Monitoring the Future 2000

Prevalence (12th graders) Monitoring the Future 2000

80% have tried alcohol

64.6% have tried cigarettes

62.3% have been drunk

54.7% have tried at least one illicit drug

5

6

Prevalence (12th graders) Monitoring the Future 2000

73.8% used alcohol in the past year 30.8% report 1 or more binge drinking

episodes 29.7% binge drank in the past 2 weeks 3.6% reported using alcohol daily 13.2% reported smoking ½ pack or more of

cigarettes per day 41.4% used illicit drugs in the past year 5.8% used marijuana daily for at least one

month at some point in their life

7

Lifetime prevalence 8.30% Point prevalence 2.34% Annual incidence rate 4.00%

Prevalence Prevalence (continued)(continued)

13.8% of ninth graders 22.7% of twelfth graders

Psychoactive Substance Use Disorders: Oregon (Lewinsohn et al 1993)

DSM-IV Criteria Met- Substance Use Problems in Past Year: Minnesota (Harrison et al 1998)

8

CriteriaCriteria

©2002 Microsoft Corporation.

Limitations of DSM-IV Alcohol Use Disorders (AUDs)

Criteria with Adolescents…

Little is known about the validity of Little is known about the validity of criteriacriteria– Several symptoms are atypical of Several symptoms are atypical of

adolescent problem drinkersadolescent problem drinkers– Some symptoms have low Some symptoms have low

specificityspecificity

Source: Martin & Winters, 1998Source: Martin & Winters, 1998

9

Criteria Criteria (continued)(continued)


Criteria with Adolescents… ““One symptom’ threshold for One symptom’ threshold for

abuse produces diagnostic abuse produces diagnostic heterogeneity and “diagnostic heterogeneity and “diagnostic orphans”orphans”

Some symptoms tend to occur Some symptoms tend to occur only in particular subgroupsonly in particular subgroups

Sequencing onset of alcohol Sequencing onset of alcohol abuse and alcohol dependence abuse and alcohol dependence symptomssymptoms

Source: Martin & Winters, 1998Source: Martin & Winters, 1998


10



Criteria with Adolescents… Adult criteria may not apply to Adult criteria may not apply to

adolescentsadolescents Less likely to suffer from progressive Less likely to suffer from progressive

nature, medical complications, other nature, medical complications, other consequences of protracted useconsequences of protracted use

More likely to have polysubstance use More likely to have polysubstance use complicating the picturecomplicating the picture

Difficult to separate effects from Difficult to separate effects from developmental changes/problemsdevelopmental changes/problems


11

NonuserNonuserExperimenterExperimenter

Recreational UserRecreational User

Regular UserRegular User

AbuserAbuser

Dependent UserDependent User


12

Risk FactorsRisk Factors

A risk factor is defined as:A risk factor is defined as: Occurring before the criterion behavior Occurring before the criterion behavior

(temporally precedes it)(temporally precedes it) Statistically associated with increased Statistically associated with increased

probability of the criterion behavior occurring probability of the criterion behavior occurring

Risk factors are not necessarily:Risk factors are not necessarily: ““Causes” or determinants of the Causes” or determinants of the

behavior/problembehavior/problem Specific or unique to the behavior/problemSpecific or unique to the behavior/problem Always associated with the behavior/problemAlways associated with the behavior/problem

13

Risk Factor TypologyRisk Factor Typology

Source: Hawkins et al., 1992; Petraitis et Source: Hawkins et al., 1992; Petraitis et al., 1995al., 1995

14

Risk Factors: IndividualRisk Factors: Individual

Physiological factorsPhysiological factors– Genetic predispositionGenetic predisposition– Alcohol sensitivityAlcohol sensitivity– NeurochemistryNeurochemistry– Prenatal environmentPrenatal environment

Cognitive impairment, Cognitive impairment, learning difficulties, learning difficulties, school failureschool failure

Temperament/personalityTemperament/personality– Negative mood statesNegative mood states– IrritabilityIrritability– TantrumsTantrums– Social withdrawalSocial withdrawal

AggressivenessAggressivenessEmotional Emotional

distressdistressExtraversion and Extraversion and

sociabilitysociabilityTendencies Tendencies

toward risk toward risk taking and thrill taking and thrill seekingseeking

15

Risk Factors: Individual Risk Factors: Individual (continued)(continued)

External locus of External locus of controlcontrol

Low self-esteemLow self-esteemPoor coping skillsPoor coping skillsDeficient social Deficient social

interaction skillsinteraction skillsAlcohol-specific Alcohol-specific

self-efficacyself-efficacy

Early & Early & persistent persistent problem problem behaviorsbehaviors

Low Low commitment to commitment to school, society, school, society, and/or religionand/or religion

Oriented toward Oriented toward short-term goals short-term goals and hedonistic and hedonistic gratificationgratification

16

Risk Factors: Individual Risk Factors: Individual (continued)(continued)

Little interest in Little interest in success/achievemsuccess/achievementent

Positive attitudes Positive attitudes toward deviant toward deviant behaviorbehavior

Alienation and Alienation and rebelliousnessrebelliousness

Attitudes favorable Attitudes favorable to alcohol useto alcohol use

Early onset of Early onset of alcohol usealcohol use

Beliefs about Beliefs about alcohol use as alcohol use as normativenormative

Alcohol Alcohol expectanciesexpectancies

Co-morbid Co-morbid psychiatric psychiatric problemsproblems

Absence of Absence of resiliency factorsresiliency factors

17Risk Factors: Risk Factors: Social/InterpersonalSocial/Interpersonal

Family alcohol & Family alcohol & drug drug behaviors/attitudesbehaviors/attitudes

Poor/inconsistent Poor/inconsistent family managementfamily management

Limited parental Limited parental monitoringmonitoring

Family Family conflict/home strainconflict/home strain

Peer rejection in Peer rejection in elementary gradeselementary grades

Low bonding to Low bonding to family family

Association with Association with alcohol-involved alcohol-involved peerspeers

Negative Negative evaluations from evaluations from parentsparents

Parent divorce or Parent divorce or separationseparation

Absence of risk Absence of risk reduction/resiliency reduction/resiliency promotionpromotion

18

Risk Factors: Risk Factors: Contextual/CulturalContextual/Cultural

Laws and norms Laws and norms favorable (or favorable (or ambivalent) ambivalent) toward alcohol toward alcohol use; non-use; non-enforcement of enforcement of laws/policieslaws/policies

Availability of Availability of alcoholalcohol

Extreme Extreme economic economic deprivationdeprivation

Neighborhood Neighborhood disorganizationdisorganization

Absence of risk Absence of risk reduction/protectireduction/protective factors?ve factors?

19

Risk Factors Risk Factors (continued)(continued)

Current state of Current state of knowledge:knowledge:Few data regarding Few data regarding relative importance relative importance & interactions of & interactions of various risk factors various risk factors in etiology of in etiology of alcohol use alcohol use problemsproblems

Do not know Do not know which risk factors which risk factors or combinations or combinations are:are:Most virulentMost virulentModifiableModifiableSpecific to Specific to

alcohol use alcohol use problemsproblems

Adolescent Substance Use

20

AssessmentAssessment

Adolescent assessment for alcohol Adolescent assessment for alcohol use disorders should include:use disorders should include:

Developmental factorsDevelopmental factors Biological factorsBiological factors Psychological factorsPsychological factors Social factorsSocial factors Multiple information sourcesMultiple information sources

21

Assessment Assessment (continued)(continued)

Critical domains/content of assessment:Critical domains/content of assessment:

Actual alcohol/substance use behavior

Type, severity, and temporal sequencing of psychiatric morbidity that may be present

Cognitive processes, neuropsychological functioning

Family organization and interaction patterns

Social skills

22


Critical domains/content of Critical domains/content of assessment:assessment:

School and/or vocational adjustment Recreation and leisure activities Temperament/personality characteristics Peer affiliations Legal status Physical health

23

Assessment Assessment InstrumentsInstruments

Advantages of a valid, standardized, Advantages of a valid, standardized, clinically relevant assessment:clinically relevant assessment:Efficiently and accurately determines Efficiently and accurately determines

treatment needstreatment needsBuilds client motivationBuilds client motivationSupports clinical decision-making as an Supports clinical decision-making as an

ongoing processongoing processReduces clinician bias and inconsistenciesReduces clinician bias and inconsistenciesAffords common language among Affords common language among

professionalsprofessionals

24

Assessment Instruments Assessment Instruments (continued)(continued)

Adolescent Validated Examples:Adolescent Validated Examples:

Personal Experiences InventoryPersonal Experiences Inventory (Winters et al., 1999)(Winters et al., 1999)

Drug Use Screening InventoryDrug Use Screening Inventory (Tarter & Hegedus, 1991)(Tarter & Hegedus, 1991)

Customary Drinking and Drug Use Customary Drinking and Drug Use RecordRecord (Brown et al., 1998) (Brown et al., 1998)

Teen Addiction Severity IndexTeen Addiction Severity Index (Kaminer et al., 1993)(Kaminer et al., 1993)

©2002 Microsoft

Corporation.

25



26

Assessment FeedbackAssessment Feedback

Avoid trying to “prove” things to the Avoid trying to “prove” things to the adolescent and familyadolescent and family

Describe each result and its meaningDescribe each result and its meaning Avoid a “scare tactics” toneAvoid a “scare tactics” tone Solicit and reflect reactions to Solicit and reflect reactions to

assessment informationassessment information Remain open to feedbackRemain open to feedback Be prepared for strong emotional Be prepared for strong emotional

reactionsreactions

Source: Miller & Rollnick, 1991Source: Miller & Rollnick, 1991 ©2002 Microsoft Corporation.

27

Assessment Feedback Assessment Feedback (continued)(continued)

Summary content:Summary content: Risks and problems that emerged Risks and problems that emerged

in the assessment findingsin the assessment findings Reactions to feedback, emphasis Reactions to feedback, emphasis

on readiness to changeon readiness to change Invitation to correct the summaryInvitation to correct the summary Assurance of successful Assurance of successful

treatment availabilitytreatment availability


28

Treatment with Treatment with AdolescentsAdolescents

Limited data exist to address Limited data exist to address treatment effectiveness with treatment effectiveness with

adolescents:adolescents:

““Surprisingly, few clinical studies have Surprisingly, few clinical studies have investigated the effectiveness of treatment investigated the effectiveness of treatment

programs for adolescents” programs for adolescents”

Source: Schinke, Botvin, & Orlandi, 1991; p. 49)Source: Schinke, Botvin, & Orlandi, 1991; p. 49)

29

Treatment Treatment (continued)(continued)

““There is evidence that treatment is There is evidence that treatment is superior to no treatment, but insufficient superior to no treatment, but insufficient evidence to compare the effectiveness of evidence to compare the effectiveness of treatment types. The exception to this is treatment types. The exception to this is that outpatient family therapy appears that outpatient family therapy appears superior to other forms of outpatient superior to other forms of outpatient

therapy.”therapy.”

Source: Williams, Chang, & Addiction Centre Source: Williams, Chang, & Addiction Centre Adolescent Research Group, 2000Adolescent Research Group, 2000

30


““...multiple psychosocial intervention approaches ...multiple psychosocial intervention approaches have been developed during the past two have been developed during the past two decades. Unfortunately, little is currently decades. Unfortunately, little is currently

known about which of these many approaches known about which of these many approaches is most effective for which individuals.” is most effective for which individuals.”

Source: Wagner, Brown, Monti, Myers, & Waldron, 1999Source: Wagner, Brown, Monti, Myers, & Waldron, 1999

31

Intervention can Intervention can succeed with succeed with adolescentsadolescents

Outcomes with Outcomes with adolescents are adolescents are similar to those with similar to those with adultsadults

Improvement varies Improvement varies across domainsacross domains



32

“…“…some treatment is better than some treatment is better than none; no particular treatment none; no particular treatment

method has emerged as superior method has emerged as superior to any other.” to any other.”

Source: Catalano, Hawkins, Wells et al., 1990-1991Source: Catalano, Hawkins, Wells et al., 1990-1991


33

Treatment as Treatment as AdolescentsAdolescents

Many existing treatment approaches Many existing treatment approaches mirror adult-centered strategiesmirror adult-centered strategies

Adolescent alcohol and substance use Adolescent alcohol and substance use problems may be markedly different problems may be markedly different from those experienced by adults in from those experienced by adults in terms of:terms of:Behavioral manifestationsBehavioral manifestationsUnderlying motivationsUnderlying motivationsAssociated factorsAssociated factors


34

Treatment as Adolescents Treatment as Adolescents (continued)(continued)

Compared to adult substance abusers, Compared to adult substance abusers, adolescent substance abusers:adolescent substance abusers:Have a briefer history of substance useHave a briefer history of substance useAre more likely to demonstrate episodic Are more likely to demonstrate episodic

consumption. Chronic, daily use is less likelyconsumption. Chronic, daily use is less likelyAre less likely to have consequences of Are less likely to have consequences of

protracted use protracted use Use a greater number and types of Use a greater number and types of

substancessubstancesAre undergoing rapid developmental changes Are undergoing rapid developmental changes

that may mimic or exacerbate substance that may mimic or exacerbate substance effectseffects

35

Compared to adult substance abusers, Compared to adult substance abusers, adolescent substance abusers:adolescent substance abusers:Are more likely to have co-occurring problems Are more likely to have co-occurring problems

(e.g., depression, family disruption, academic (e.g., depression, family disruption, academic problems, problem behavior/deviance, low problems, problem behavior/deviance, low level conventionality, peer drug use)level conventionality, peer drug use)

““Outgrow” patterns of use/abuse without Outgrow” patterns of use/abuse without intervention more oftenintervention more often

May be less amenable to confrontation-of-May be less amenable to confrontation-of-denial approaches (due to developmental denial approaches (due to developmental independence and autonomy issues)independence and autonomy issues)


36


Heterogeneity of population:Heterogeneity of population:– Individual differencesIndividual differences– Amenability to treatmentAmenability to treatment– Matching factorsMatching factors


37

Treatment ApproachesTreatment Approaches

Evidence-based, developmentally Evidence-based, developmentally sensitive:sensitive:

Family system approachesFamily system approaches Brief motivational interventionsBrief motivational interventions Guided personal change programsGuided personal change programs Cognitive-behavioral skills buildingCognitive-behavioral skills building Assertive aftercare programsAssertive aftercare programs Community-based treatment modelsCommunity-based treatment models Pharmacological agentsPharmacological agents

38

Treatment Approaches Treatment Approaches (continued)(continued)

Cautions about treatment (group, AA)

Need for interventions suited to range of settings, contexts where adolescents are encountered


39

Diversity ConcernsDiversity Concerns

Inadequate research attention directed Inadequate research attention directed to issues of ethnicity, culture, to issues of ethnicity, culture, discrimination, mistrust, and discrimination, mistrust, and acculturation in adolescent treatment acculturation in adolescent treatment effectiveness studieseffectiveness studies

Need for culturally specific programs?Need for culturally specific programs? Effects of cultural sensitivity, Effects of cultural sensitivity,

appropriateness, competence?appropriateness, competence?


40

Motivation to ChangeMotivation to Change

Pretreatment motivation Pretreatment motivation predicts treatment success predicts treatment success among adolescentsamong adolescents

Choices, self-selection bolster Choices, self-selection bolster commitmentcommitment

Problem Recognition Problem Recognition QuestionnaireQuestionnaire measures measures readiness to change, problem readiness to change, problem recognitionrecognition

41

Prevention & Early Prevention & Early InterventionIntervention

Goal = Reduce number of new cases and Goal = Reduce number of new cases and enhance positive functioning by:enhance positive functioning by: Reducing vulnerability and risk factorsReducing vulnerability and risk factors Promoting protective and resilience factorsPromoting protective and resilience factors

Most effective when: Most effective when: Contexts support the intervention messages Contexts support the intervention messages Interventions are developmentally appropriateInterventions are developmentally appropriateMultiple “boosters” are delivered over a long time Multiple “boosters” are delivered over a long time frameframeMultiple contexts/domains are engagedMultiple contexts/domains are engagedBegin youngBegin young

42

Summary IssuesSummary Issues

Controlled use of substances?Controlled use of substances?What is success?What is success?Coexisting problemsCoexisting problemsFamily estrangementFamily estrangementMatchingMatching““Outgrowing” problemsOutgrowing” problemsDiagnostic criteriaDiagnostic criteria


43

Summary Summary (continued)(continued)

Majority try alcohol/drugs by 12Majority try alcohol/drugs by 12thth grade grade Some develop diagnosable problemsSome develop diagnosable problems Vulnerability, risk, resilience, protective Vulnerability, risk, resilience, protective

factors are knownfactors are known Intervention is usually better than no Intervention is usually better than no

interventionintervention

What we know…

44

Summary Summary (continued)(continued)

Which factors are most important and how do Which factors are most important and how do they interact with one another?they interact with one another?

Which interventions are best for which Which interventions are best for which adolescents?adolescents?

How does the interaction between individual How does the interaction between individual and treatment factors affect outcomes?and treatment factors affect outcomes?

What diagnostic criteria and instruments are What diagnostic criteria and instruments are most appropriate for adolescents?most appropriate for adolescents?

What we don’t know…

45

AppendicesAppendices

Comparisons with RussiaComparisons with Russia

46

Project HOPE (May, 1997) Northern Moscow

55th th (n = 422)(n = 422) 77thth

(n = 324)(n = 324) 99thth (n = 353)(n = 353)

Alcohol 31.8% 69.4% 91.2%

Tobacco 22.1% 49.3% 71.1%

Inhalants 6.6% 8.3% 12.8%

Marijuana 2.1% 3.3% 17.3%

Been Drunk - - 54.1%


47


Project HOPE, 1997—5th graders

32% have tried alcohol32% have tried alcohol21% have had an alcoholic drink in the 21% have had an alcoholic drink in the

past yearpast year11% have had an alcoholic drink in the 11% have had an alcoholic drink in the

past monthpast month6.6% have tried inhalants6.6% have tried inhalants2% have tried marijuana2% have tried marijuana22% have tried cigarettes22% have tried cigarettes

48


Project HOPE, 1997—7th graders 69% have tried alcohol69% have tried alcohol 49% have had an alcoholic drink in the 49% have had an alcoholic drink in the

past yearpast year 25% have had an alcoholic drink in the 25% have had an alcoholic drink in the

past monthpast month 8% have tried inhalants8% have tried inhalants 3% have tried marijuana3% have tried marijuana 49% have tried cigarettes49% have tried cigarettes

49

Project HOPE, 1997—9th graders

91% have tried alcohol91% have tried alcohol81% have had an alcoholic drink in the 81% have had an alcoholic drink in the

past yearpast year50% have had an alcoholic drink in the 50% have had an alcoholic drink in the

past monthpast month54% have been drunk54% have been drunk12.8% have tried inhalants12.8% have tried inhalants17% have tried marijuana17% have tried marijuana71% have tried cigarettes71% have tried cigarettes


Documents

1 Adolescents and Treatment of Alcohol Use Disorders NIAAA Social Work Education Module 10A (revised 3/04) (revised 3/04)