Download The Most Vulnerable Victims: Children of Methamphetamine

Oregonian Headline
March 3, 2006
The Most Vulnerable Victims: Children
of Methamphetamine Users
Plus: An Update on Adolescent
Substance Abuse Treatment
OPA Spring Meeting
March 3-4, 2006
Keith Cheng MD
Medical Director, Trillium Family Services
Adjunct Associate Professor
Department of Psychiatry
Oregon Health Sciences University
The Most Vulnerable Victims:
Children of Methamphetamine Users
 In Utero Exposure to Meth Using Parents
 Childhood Exposure Meth Using Parents
 Adolescent Exposure Meth Using Parents
In Utero Exposure
 The effects of prenatal methamphetamine exposure on
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the developing fetus have not been well characterized.
There are conflicting studies, findings are confounded by
the observations that approximately 80% of the
methamphetamine-using women also used nicotine and
alcohol
Methamphetamine use during pregnancy is associated
with an increased incidence of premature delivery, birth
weights, head circumference, and placental abruption.
Cases of cardiovascular collapse and seizures have also
been reported in women using methamphetamine during
pregnancy.
Isolated cases of cardiac defects, cleft lip, and biliary
atresia have been reported in infants exposed to
methamphetamine in utero.
Prenatal Exposure Study
Smith et al: (2003) Effects of Prental Methamphetamine Exposure on growth and withdrawal sxs in infants
born at term. Developmental and Behavioral Pediatrics. 24(1):17-23
 Study done at UCLA Meth Exposed n=134, Meth
Unexposed n=160
 Apgar Scores Birth Weight and Length were not
significantly different from unexposed controls
 Methamphetamine-exposed infants whose
mothers smoked had significantly decreased
growth relative to infants exposed to
methamphetamine alone
 Withdrawal symptoms requiring pharmacologic
intervention were observed in 4% of
methamphetamine exposed infants
Childhood Exposure
“In These Bleak Days: Parent Methamphetamine Abuse and Child
Welfare in the Rural Midwest,” in press Journal of Children and
Youth Services Review
 Profound neglect and abuse
 Physical danger resulting from in-house
manufacture of the drug
 Parents teaching their children criminal
behavior and a paranoid distrust of
authority
Childhood Exposure
 Children becoming surrogate parents to
younger siblings
 Children Exposed to toxic fumes and the
danger of explosions or fires
 Children asked to steal items needed for
making the drug or to stand guard, armed
with a gun, looking out for police or other
authorities
Children in State Care
 Oregon's Meth Epidemic creates thousands of
"orphans," abused and neglected children who fall
into the state's care after their parents are arrested
 Department of Human Services conducted its first
statewide analysis last year, when 5,438 children
entered state foster homes, up from 4,906 in 2003.
 Last year, roughly 2,750 children -- more than half of
all foster cases -- were taken from parents using or
making the potent drug, the study found
 The Children of Meth,”---Joseph Rose, Oregonian,
August 28, 2006
Case Vignette: 3 Admissions for
Residential Placement in 1 Week period
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Ages 7-10 years
All referred from DHS
All came from emergency foster placements
All were abandoned by Meth using mothers
All had previous foster placements
All had become too physically aggressive to be
managed in their emergency foster home
 All had to wait 1-3 months before a new
placement could be found
Adolescent Exposure
 No Specific data or publications in peer
review journals
 Questions: Are they more likely to use
meth themselves? Are they more likely to
drop out of school? Are they more likely to
have a criminal record? Are they more
likely to require long-term care?
Adolescent Case Vignette
 Ryan 17 year old male referred for admission from OYA for
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evaluation of psychosis
Exposed in utero to meth and other drugs
Mother continued to use till he was age 5 yrs, “I was brought up
by my sister till I was 8 years then I took care of my mother.”
Mother had bilateral bka for complications of diabetes
Mother died of diabetes when Ryan was 10 yrs, Father died
from cirrhosis when Ryan was 13
Had ADHD sxs since first grade
Started using tobacco and marijuana at age 7 years, Meth at
age 13. Hasn’t been in school for two years.
Used Meth for 2 years says he quit for 4 months till present. “I
decided I wanted a future.”
Adolescent Case Vignette #2
 Sheila is 15 in custody of DHS, placed in treatment because of runaway
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behaviors, got caught by police for theft
Been living on the streets, supports meth habit through prostitution, has
been in OYA custody in the past
Uses meth IV, rectally, and thru smoking has been using since age 12
yrs, has also used cocaine, marijuana, and alcohol
Father died when Sheila was 5 yrs old in MVA
Mother recently incarcerated for multiple drug charges
Made suicide attempt by overdose in Nov 2005
Gives history that she used to smoke meth with mother
Ran away from last residential placement has hx of multiple residential
placements
Has not been in school since 7th grade
Has history of sexual and physical abuse, PTSD, MDD, & CD
Trillium Experience
 Psychiatric Residential and Intensive
Community Based Programs--Not a substance
abuse treatment center
 Average Range 350-450 ITS level admissions
per year the past 4 yrs
 Four years ago-admissions for children known to
have “Meth” using parents approximately
relatively uncommon, “Monthly admissions”
 Currently seems that these admissions are more
common, “Weekly”
Trends in Use (from MTF Study)
 Use of amphetamines rose in last half of
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1970s and peaked in 1981 with 26% use
After 1981 there was a steady decline
ended in 1992
Use peaked in the lower grades in 1996
and 1997
There has been a slow drop off since the
mid 1990
No significant Changes in 2004
Trends in Use
 Use of amphetamines rose in last half of
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1970s and peaked in 1981 with 26% use
After 1981 there was a steady decline
ended in 1992
Use peaked in the lower grades in 1996
and 1997
There has been a slow drop off since the
mid 1990
No significant Changes in 2004
Perceived Risk
 Overall changes in perceived risk have
been less strongly correlated with changes
in usage of other drugs
 However the perceived risk has been
rising the past several years possibly
accounting for the decline in use that
occurred in 2003 with 12th graders
Disapproval
 Disapproval rates have been high 70% 87% throughout the life of the study
 From 1981 to 1992 disapproval rose
gradually as use steadily declined
 Disapproval then fell back 6-7 percentage
points for a few years and the use rate
rose slighted
Availability
 In 1975 when MTF started amphetamines had a
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reported high level of availability
The level fell 10% in 1977
Drifted back up in 1980, then jumped sharply in
1981
Declined slowly till 1991, when there was a
modest rise then seem to stabilize during the
late 90s
There has been further decline during the first
year few years of this decade
More Oregon Youth being treated for
Methamphetamine Abuse
 The Oregon Department of Human Services
said that over the past five years the number of
meth treatment admissions for boys under age
17 has grown steadily, and has skyrocketed 57
percent among girls.
 In 2003 the state Office of Mental Health and
Addiction Services reported that more than
1,700 children were treated for
methamphetamine misuse in the state. Of that
number, more than 1,000 were girls, up from
630 in 1999, and 742 were boys, up from 600
An Update on
Adolescent Substance
Abuse Treatment
SUD Assessment
 History & MSE
 SUD Assessment Scales
 Drug Testing
 Risk Factor Analysis
History/MSE/PE
 Because substance-using youth commonly keep their substance-using
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behaviors covert, there is a need to gather information from multiple
sources, including parents, siblings, teachers, caseworkers, peers if
available.
Polysubstance use by adolescents is the rule rather than the
exception; therefore, adolescents often present with multiple SUD
diagnoses. Determine how many psychoactive substances are being
used, and how available they are to the youth.
Determine whether there is substance use or abuse occurring by other
members in the home or whether there is a lack of rules against
substance use by juvenile members of the family.
Determine who are the youth’s peers and associates and whether they
use substances or are involved in conduct-disordered and where the
youth uses substances. Does he or she use alone or tend to be with
groups of certain people and settings?
Be sure to assess for other psychiatric disorders, as there is a high
level of comorbidity, and many symptoms of SUD can mimic psychiatric
symptoms.
SUD Assessment Instruments
 Substance Abuse Rating Instruments can
be helpful in screening for SUDs and for
monitoring treatment response. “Lie
scales” can be especially helpful in
identifying youths that deny their
substance use
 There are now several adolescent
assessment instruments such as:
CRAFFT, SASSI, PESQ, and ADI
CRAFFT Questions
(2 or more “yes” answers suggests a serious
problem & warrants further evaluation)
 Have you ever ridden in a Car driven by someone
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who was high or had been using alcohol or drugs
Do you drink or take drugs to Relax
Do you ever drink or take drugs while you are
Alone?
Do you ever Forget things you did while using
alcohol or drugs
Do you Family and Friends ever tell you that you
should cut down on your use?
Have you gotten into Trouble from drinking or
taking drugs?
Kay DL: (2004) Office recognition and management of adolescent substance
abuse. Curr Opin Pedia 16:532-541
Drug Testing
 Use of urine drug screens can be helpful
in identifying SUDs in youth that are skilled
in hiding their drug use from adults.
However, a single negative drug screen
does not rule out drug use, abuse, or
dependence; and a single positive drug
screen does not establish an SUD
Urine Drug Screen
Detection
Alcohol
Marijuana & Hashish
Amphetamines
Cocaine
Codeine, Morphine, Heroin,
Opium
LSD
Phencyclidine
Oral Anabolic Steroids
Injected Anabolic Steroids
6-10 hours
1 day Π 5 weeks
1-2 days
1-4 days
1-2 days
8 hours
2-8 days
Up to 3 weeks
Up to 3 month s
Risk Factor Analysis
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Chaotic home environment
Parental Substance Abuse
Parental Mental Illness
Ineffective Parenting
Lack of Parental involvement/supervision
Failing School Performance
Poor Social Coping Skills
Association with Conduct Disordered Peers
Perceived parental/peer/community approval of
drug use
SUD Treatment
 Traditional Treatments
 Peer Deviancy Training
 Limitations of Psychoeducational
Interventions
 Medications
 Community Based Interventions
Traditional Treatments
 Alateen
 Narcotics Anonymous
 Group Therapy
 Individual Therapy/Counseling
Peer Deviancy Training
Dishion, T.J., McCord, J., & Poulin, F. (1999). When interventions harm:
Peer groups and problem behavior. American Psychologist, 54, 755-764
 Dishion: at Oregon Social Learning Center @ UO
 158 youth grades 6 to 8 studied 83 boys, 75 girls in 12 week
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program to reduce problem behaviors
Three study groups: peer only, parent and peer groups, self
study, and no intervention control group
All study group showed improvement after 12 weeks
Peer only groups exhibited significantly worse behaviors after
one year, and three year followup, than similar at risk youths
who were given prevention materials to study on their own or
who had no interventions at all
For peer only group a 75% higher rate of delinquency
Medications
 Evidence for use in children specifically for
SUDs: Meager to date, mostly case
reports of small sample size studies
 Treatment of comorbid disorders can help
prevent development of SUD
 Needs to be in combination with other
interventions
The Evidence with ADHD Treatment
 Biederman, J., et al. Pharmacotherapy of attention-
deficit/hyperactivity disorder reduces risk for substance use
disorder. Pediatrics 104(2):e20, 1999
 56 boys with ADHD who were being treated with either stimulants
or TCAs at the beginning of the study, 19 boys with ADHD who were
not receiving any medications, and 137 boys without ADHD. All boys
were Caucasian and were followed for 4 years and then evaluated
for abuse of or dependence on marijuana, alcohol, hallucinogens,
stimulants, or cocaine. At the time of evaluation, the boys were at
least 15 years old.
 Treating ADHD with medications appeared to reduce the tendency to
abuse drugs and alcohol. While 75 percent of the unmedicated
ADHD boys had started abusing these substances in the previous 4
years, this was true of only 25 percent of the medicated ADHD boys
and 18 percent of the boys without ADHD. The researchers
calculated that treating ADHD with medications reduced the risk of
substance abuse or dependence by 84 percent.
Long-term Stimulant Treatment
and Brain Size
 Individuals with ADHD had significantly smaller
brain volumes in all regions
 Compared with controls, previously unmedicated
children with ADHD demonstrated significantly
smaller total cerebral volumes and cerebellar
volume
 Unmedicated children with ADHD also exhibited
smaller total white matter volumes compared
with controls and with medicated children with
ADHD
 Castellanos FX, Lee PP, Sharp W et al. (2002), Developmental trajectories
of brain volume abnormalities in children and adolescents with attentiondeficit/hyperactivity disorder. JAMA 288(14):1740-1748.
Difference in amounts used
between addict and patient
 Desoxyn
 “Eightball”
(methamphetamine)
(eighth of an ounce) =
3.5 grams
 10 - 40 mg/day
 “Baggie or Teena”
 50 - 100 x’s larger
(sixteenth of an
Dose difference
ounce) = 1.75 grams
between Meth
Addict and Patient
being treated for
ADHD
Long-term effects
of Amphetamines on the Brain
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Descriptions from NIDA Website
Intense paranoia
Visual and auditory hallucinations, and
Out-of-control rages that can be coupled
with
Extremely violent behavior
Withdrawal syndrome sxs include:
depression, anxiety, fatigue, paranoia,
aggression, and an intense craving for the
drug.
Case Vignettes: Antabuse
 17 year old Asian female
 Drinking not part of the
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family culture
History of success in
academically
Many in peer group used
drugs and etoh
Wanted to stop after
psychiatric admission for
suicide attempt
Did not want parents
involved in treatment
 17 year old Hispanic
 Drinking part of the
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culture of some family
members
Marignally engaged in
school
Many in peer group used
drugs and etoh
Wanted to stop etoh after
psychiatric admission for
suicide attempt
Allowed parents to be
involved in treatment
Prevention
Psychoeducational Limitations
 The DARE Story
 School programs should also enhance
academic and social competence
 Education should focus on self-control,
emotional awareness, communication,
social problem-solving, and drug
resistance skills
Prevention Programs
Examples of evidence based practice:
 Multisystemic Therapy (MST),
 Incredible Years,
 Strengthening Families Program
 Project Chrysalis
Scott Henggler’s MST
 Developed in the late 1970s to address several limitations of
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existing mental health services for serious juvenile offender
MST interventions aim to attenuate risk factors by building youth and
family strengths (protective factors) on a highly individualized and
comprehensive basis
MST is a family-based treatment model. The treatment plan is
designed in collaboration with family members and is, therefore,
family driven rather than therapist driven
MST services are delivered in the natural environment (e.g., home,
school, community)
The typical duration of home-based MST services is approximately 4
months, with multiple therapist-family contacts occurring each week
Local MST program offered through “Options” 503.335.5975
NIDA Focus on Prevention
 Analysis of Risk Factors
 Prevention programs should enhance
protective factors and reverse or reduce
risk factors
 An emphasis on Family Interventions and
Parental Management Training
NIDA Prevention Principles
Programs Should:
 Enhance protective factors and reverse or
reduce risk factors
 Address all forms of drug abuse, alone or in
combination
 Address the type of drug abuse problem in the
local community, target modifiable risk factors
and strengthen identifiable protective factors
 Be tailored to address risks specific to
population or audience characteristics like age,
gender, or ethnicity
NIDA Prevention Principles for Family &
School Prevention Programs Should Also:
 In family based prevention programs, enhance
family bonding, relationships & include parenting
skills training and enforcement of family rules
 Be designed to intervene as early as preschool
to address risk factors such as aggression, poor
social skills & academics
 In school age children target academic and
social emotion learning and self control skills
 In adolescent school programs enhance
academic and social competence and drug
resistance skills
NIDA Prevention Principles for
Community Programs Should:
 Be aimed at key transition points
 Combine two or more effective programs
 Reach populations in multiple settings
 Adapt to match community norms or
differing cultural elements
 Be long-term with repeated interventions.
Research shows that benefits from early
programs diminish without followup
programs at a later age