All might have won, but not all have the prize: optimal treatment for substance abuse among adolescents with conduct problems

Treating Mental Health and Substance Use Disorders in Adolescents: What Is on the Menu?

Specific treatments targeting adolescents with substance use disorders (SUDs) have been developed over the last couple of decades. Despite these developmentally tailored treatments, long-term abstinence rates remain relatively low among adolescents receiving care. Research over the last decade has increasingly focused on adolescents with comorbid substance use and psychiatric disorders, in recognition of the barriers caused by inadequate treatment of co-occurring psychiatric disorders. Treatments targeting dually diagnosed youth are now regarded as essential to improving SUD treatment outcomes, but remain underutilized. A variety of treatment modalities such as behavioral therapy, family therapy, 12-step groups, motivational interviewing, contingency management, and combinations of these interventions have been modified for adolescents. In this article, we review the research on these treatments, as they apply to dually diagnosed youth. Furthermore, we explore the evidence for various treatments targeting comorbid SUD, specific to the presence of externalizing or internalizing disorders. The current evidence base supports the importance of integrated treatment targeting both SUD and psychiatric disorders simultaneously. High-quality treatment programs offering combinations of behavioral and family therapy, particularly with motivational interviewing and contingency management, are particularly well supported. In addition, we review various psychotropic medication treatments that have also been studied in conjunction with adolescent SUD treatment. Finally, we review research on post-treatment, supportive care that has been shown to improve long-term SUD outcomes. Recently conceptualized modular treatments, which offer personalized combinations of evidence-based treatments for specific disorders, have been proposed as a means of improving outcomes. Future research on modular programs must test the efficacy of individualized treatments when applied to combinations of psychiatric and SUDs in adolescents.

A randomized controlled trial of a group motivational interviewing intervention for adolescents with a first time alcohol or drug offense

Group motivational interviewing (MI) interventions that target youth at-risk for alcohol and other drug (AOD) use may prevent future negative consequences. Youth in a teen court setting [n=193; 67% male, 45% Hispanic; mean age 16.6 (SD=1.05)] were randomized to receive either a group MI intervention, Free Talk, or usual care (UC). We examined client acceptance, and intervention feasibility and conducted a preliminary outcome evaluation. Free Talk teens reported higher quality and satisfaction ratings, and MI integrity scores were higher for Free Talk groups. AOD use and delinquency decreased for both groups at 3 months, and 12-month recidivism rates were lower but not significantly different for the Free Talk group compared to UC. Results contribute to emerging literature on MI in a group setting. A longer term follow-up is warranted.

Adolescent substance use in the multimodal treatment study of attention-deficit/hyperactivity disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication

OBJECTIVE

To determine long-term effects on substance use and substance use disorder (SUD), up to 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA; n = 436); to test whether medication at follow-up, cumulative psychostimulant treatment over time, or both relate to substance use/SUD; and to compare substance use/SUD in the ADHD sample to the non-ADHD childhood classmate comparison group (n = 261).

METHOD

Mixed-effects regression models with planned contrasts were used for all tests except the important cumulative stimulant treatment question, for which propensity score matching analysis was used.

RESULTS

The originally randomized treatment groups did not differ significantly on substance use/SUD by the 8-year follow-up or earlier (mean age = 17 years). Neither medication at follow-up (mostly stimulants) nor cumulative stimulant treatment was associated with adolescent substance use/SUD. Substance use at all time points, including use of two or more substances and SUD, were each greater in the ADHD than in the non-ADHD samples, regardless of sex.

CONCLUSIONS

Medication for ADHD did not protect from, or contribute to, visible risk of substance use or SUD by adolescence, whether analyzed as randomized treatment assignment in childhood, as medication at follow-up, or as cumulative stimulant treatment over an 8-year follow-up from childhood. These results suggest the need to identify alternative or adjunctive adolescent-focused approaches to substance abuse prevention and treatment for boys and girls with ADHD, especially given their increased risk for use and abuse of multiple substances that is not improved with stimulant medication. Clinical trial registration information-Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder (MTA); http://clinical trials.gov/; NCT00000388.