IACAPAP Textbook of Child and Adolescent Mental Health

SUBSTANCE USE DISORDERS

Chapter

G.3

OTHER SUBSTANCE USE
Wai-him Cheung, Anna Kit-sum Lam & Se-fong Hung

Wai-him Cheung MBBS,
MRCPsych (UK), FHKAM(Psychiatry), FHKCPsych
Associate Consultant, Kwai
Chung Hospital, Hong Kong
Conflict of interest: none
declaredAnna Kit-sum Lam MBBS,
MRCPsych (UK), FHKAM(Psychiatry), FHKCPsych
Honorary Clinical AssistantProfessor, Department of
Psychiatry, Li Ka Shing Facultyof Medicine, The University ofHong Kong, Hong Kong
Conflict of interest: none
declaredSe-fong Hung MBBS,
FRCPsych (UK), FHKAM(Psychiatry), FHKCPsych
Consultant of Child andAdolescent Psychiatrist &Honorary Clinical Professor,
Department of Psychiatry, The
Chinese University of Hong
Kong, Hong Kong
Conflict of interest: none
declaredThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Cheung W, Kit-sum Lam A, Hung S. Other substance use. In Rey JM (ed), IACAPAP e-Textbook of Child andAdolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

Other substance use G.3

1

IACAPAP Textbook of Child and Adolescent Mental HealthEpidemiological studies have shown that substance use is common among
adolescents and age of first use is decreasing; a significant proportion ofthem subsequently develop a stereotypic pattern of use. It is well known
that some psychoactive substances have particularly detrimental effects on mental
health and cognitive functions, which increases the burden for child and adolescentmental health services. This chapter focuses mainly on the use of substances
other than alcohol and cannabis: amphetamines, benzodiazepines, cocaine,
codeine, opiates, “club” or “recreational” drugs (GHB, MDMA, Ketamine, andmephedrone), hallucinogens, and inhalants. The terms “substance” and “drug” areused interchangeably.

EPIDEMIOLOGY
The prevalence of substance use in adolescents varies widely in different
epidemiological studies. The Monitoring the Future (MTF) study is an annual
large-scale survey of nationally representative samples of secondary school students
in the US that has been conducted since 1975. In 2010, 16.8% of the participants
had ever used an illicit substance other than marijuana, 11.8% had used in the past
year, and 5.7% in the past 30 days (Johnston et al, 2011). Use of inhalants (glue,
nail polish remover, gasoline, solvents, butane and propellants) is most common
among younger adolescents. Among the 2010 respondents, 7.8% of 8th gradersreported having used inhalants by the end of 6th grade but use tends to decline
as adolescents grow older. Another important finding was that the proportion of
12th graders in 2010 who reported using prescription (psychotropic) drugs (e.g.,amphetamines, sedatives, tranquillizers, and narcotics other than heroin) without
medical supervision was 15%, up slightly from 14.4% in 2009.

Click on the pictures to view
several teenagers talking
about their progression
from experimentation of
cannabis to abusing multiple
substances to addiction( 4:10 and 5:13)

A similar trend of decreasing use of inhalants with increasing age was also
reported among Australian students; while 11% of 12-year-olds had used inhalants
in the last month, only 4% of 17-year-olds had used recently (White & Smith,2009). The survey also found that around 5% of students aged 13 and above had
used tranquillizers in the last month and around 2% of students aged 15 and above
had used amphetamines in the last month. Another annual survey (Fuller, 2011)
to monitor smoking, drinking and drug use among secondary school pupils age
11 to 15 in England found that 18% of students had ever used drugs, 12% had
consumed a drug in the last year and 7% in the last month; while 3.8% had sniffedinhalants in the last year, less than 2% had used other drugs. A survey conductedin three vocational schools (age 15-21) in Thailand in 1999 showed that 29%
of students reported ever having used methamphetamine. The prevalence of
methamphetamine-positive urine test was 10% while opiate-positive urine test waslow (0.2%) (Griensven et al, 2001).
In Hong Kong, a survey of upper primary (aged 9-11) and secondary
school (12-18) students has been conducted every four years. The 2008/09 survey(Narcotics Division of Security Bureau of Hong Kong, 2011) showed that the
proportion of lifetime and 30-day drug-taking among secondary students was
4.3% and 1.5% respectively; the proportion among upper primary school students
was estimated to be 1.6% and 0.5% respectively. Among drug-taking secondary
school students, 15.6% first used drugs at the age of 10 or below. In contrast
to their American or European counterparts, more secondary school students in

Other substance use G.3

2

IACAPAP Textbook of Child and Adolescent Mental HealthHong Kong used Ketamine (49.4%) than cannabis (35.6%) and upper primaryschool students preferred cough medicines (37.5%) and paint thinners (30.7%).

NATURAL HISTORY OF SUBSTANCE ABUSE
A 19-year follow-up of a representative population cohort provides someinsight about the natural history of drug use from adolescence to adulthood (Chen& Kandel, 1995). The major period of risk for initiation into the use of cigarettes,
alcohol, and marijuana is mostly over by age 20. Most of the other drug use
is both initiated and stopped before the late 20s. Both the prevalence of highfrequency use and the quantities consumed during periods of heavy use of most of
the substances (except cigarette smoking) decline in adulthood. The prevalence ofprescribed psychotropics use does not show much change over time and usage rates
are consistently higher for women than for men. For all drugs in general, however,
initiation rates are higher for men while cessation rates are higher for women.

FACTORS INFLUENCING SUBSTANCE USE
Individual factors
Prenatal exposure to substances••

Evidence reveals an elevation of risk for alcohol, cannabis, and cocaineuse during adolescence or early adulthood in people prenatally exposedto these substances (Baer et al, 2003; Day 2006; Delaney-Black et al,
2011)
Risks are not only mediated through a propensity for conduct disorderor other developmental problems but also probably directly related tothe influence on intrauterine neural development.
MarkMark was a skinny teenager brought in by his schoolsocial worker for his irritable mood and aggressive
behaviors in the last year. Mark appeared indifferent; heattended only as a favor to the social worker who had been
caring for him, even though he did not attend school often.
Mark had a rough childhood. His mother was ateenager when Mark and his elder brother were born.
Mark’s father left the family shortly after. The two boys
stayed with their grandmother until she was killed in a
traffic accident seven years later. Childcare arrangements
then became disorganized. As an active, curious andimpulsive boy, Mark had needed extra attention since he
was a toddler. His mother frequently resorted to spanking
despite being aware that it did not work with him. Mark was
sad after the death of his grandmother; he felt he had noone to talk to when his elder brother became increasingly
volatile. In the last few years, he witnessed his older brothersnorting ketamine a few times. At home, Mark particularly
disliked the men who stayed over with his mother. He wasannoyed by the noises they made late at night. Mark was
not happy at school either; lessons were boring and sittingin the classroom was a torture, homework was a gruelingtask every day. He was the class clown; otherwise recesses
and physical education were the only fun time for him. Mark
often got into trouble with teachers; he felt they unfairly

Other substance use G.3

picked on him for trivial matters. In general, teacherscommented that he was a clever but naughty, chatty andunderachieving student. He was at the bottom in all school
examinations except for the first year of elementary school.
In fourth grade, he was considered to suffer from dyslexia.
However, neither the special educational arrangements set
up nor repeating a grade helped him to improve. Regarded
by most as a failing student, Mark was not liked by hisclassmates; nevertheless, he had a few friends outsideschool.
During the final year of elementary school, Markbecame attached to several older teenagers in his
neighborhood. He skipped school to hang out with them,staying out late smoking and drinking; this became worse
once he started secondary school. Confrontations andscrutiny from teachers resulted in defiance and pushed
Mark further away from school. Mark was introduced tosnorting ketamine two years ago. He did not like using
ketamine but found it hard to refuse friends’ offers. He also
tried other illicit drugs; “ice” was Mark’s favorite – it madehim feeling super alert and focused. He noticed he needed
larger amounts to get “high” and often needed sleeping
pills to tide him over the insomnia and the vivid unpleasant
dreams. Lately, his girlfriend complained about him being
oversensitive and irritable.

3

IACAPAP Textbook of Child and Adolescent Mental Health

Genetics•

Although most studies focus on alcohol, evidence from family, twin
and adoption studies demonstrate the important role of genetics on
substance use disorder (Rhee et al, 2003)• Recent studies shed light on the role of gene polymorphism on
individual difference in the response to substance use; a low repeat
MAOA allele may exacerbate the deleterious effects of cocaine in thebrain (Alia-Klein et al, 2011)
Developmental••••

Adolescence is a period of experimentation and risk taking.
Adolescents feel the need to identify with peers to avoid being rejectedby the group.
Stress from the change in roles and expectations at school or at home
Using drugs to “escape” and relieve anxiety and unhappiness.

Click on the picture toaccess Drugscope (UK),an independent center ofexpertise on drugs that seeks
to inform policy development
and reduce drug-related risk.

Family factors•

Ineffective, coercive or hostile parenting, abuse, neglect, and poor
supervision increase the risk of both conduct disorder and substancemisuse (Fergusson & Woodward, 2000; Armstrong & Costello, 2002).
• Parents who use drugs (Haggerty et al, 2007).
Social factors
•
•
•
•
•

Access to substances (e.g., from peers or neighborhood)
Availability
Economic deprivation, homelessness
Exclusion from school and truancy
Delinquency.
AmandaAmanda was a quiet, sensitive and perfectionistic15-year-old girl. Her family had moved frequently fromcountry to country in the last decade as her father
held different positions in a multinational corporation.
They had moved to Hong Kong six months ago. The
school counsellor suggested that Amanda should see a
psychiatrist after she was found cutting herself in a school
toilet.
Although this was the first time she had slashed herself,
Amanda had struggled quietly with every family move.
In the past, talking to her mother helped to relieve thosefeelings but in the last two years she did not want to botherher mother who always looked tired and preoccupied.
Amanda worried about her mother who always stayed up
late unless she had a few sleeping pills or a few drinks,
wondering whether that was related to the frequentarguments with her father.
Leaving the country where she had stayed for three
years and where she had made some good friends wasvery painful for Amanda. She hated listening to her father
saying again and again that things would be alright. She
was frustrated that he treated her as a small child. Despite

Other substance use G.3

trying to study, Amanda could not help ruminating over thefamily moves, crying herself to sleep for weeks after the
move. Waking up not refreshed, she could hardly focus inclass. She seldom talked, her new classmates didn’t lookfriendly and her old friends were often offline when she
looked for them. Amanda felt nobody could understandher. School became increasingly burdensome; she did nothave the energy to finish assignments let alone picking up
her guitar, which she previously enjoyed. On weekends,
she’d rather stay home munching. She felt unhappy anddisappointed with her deteriorating school performance andfeared that her predicament had no end. Amanda began
stealing sleeping pills from her mother, which made her feelgroggy but also relaxed. She soon realized that a few of
those pills plus a few hours of privacy made her bedroom ahaven, her mind free from all the troubles. She then began
taking these pills even during the day. However, outside
her bedroom, her situation did not improve, things actually
got worse. On the morning in which she received the term
results, Amanda felt absolutely defeated having failed
two subjects. She locked herself in a toilet, wept and cut
herself.

4

IACAPAP Textbook of Child and Adolescent Mental Health

Table G.3.1

Characteristics of commonly misused substances

Substance

Physical form

Preferredmode ofconsumption

Detection
time(Urine)1

Benzodiazepines

TabletIngested or
injected

3 days

CocaineBase (less water
insoluble)
Salt (highly watersoluble)CodeineLiquid, capsule, tablet

Ingested

24 – 72 hrs

Morphine

Capsule, tablets,
liquidIngested, injected

24 – 72 hrs

Dextromethorphan

Tablet, syrup

Ingested(3-5 days)

GHB(γ-hydroxybutyrate)

Liquid or white
powderIngested

5 – 12 hrs

HeroinPowderSmoked, inhaled,
injected

24 – 72 hrs

Ketamine

Crystalline powder or
liquidSnorted, ingested,injected

24 – 72 hrs

MDMA (ecstasy)

TabletIngested

24 – 72 hrs

Mephedrone

Powder or capsule

Snorted, ingested

24 – 96 hrs

Methamphetamine

Crystal (”ice”),
powderInhaled fromwater pipe,
smoked, injected

24 – 72 hrs

Volatile alkyl nitrites(popper)

Volatile liquid in
ampulesInhaled24 – 48 hrs

Organic Solvent

Gases or clear liquid

Sniffed, inhaled

24 – 72 hrs

PCP (phencyclidine)

Powder, tablet, liquid

Ingested,smoked, injected

14 – 30 days

LSD (Lysergic acid
diethylamide)

Tablet, capsule,liquid, licked off
paper, injected

Ingested, inhaled,snorted, smoked

1.5 – 5 days

Zopiclone

TabletIngested

24 – 72 hrs

SmokedSnorted or
injected

24 – 96 hrs

Click on the pictures to view
“Facts about Drug Addiction”
a clip that explains how drugs
work (2:00)

The duration of detection is variable and depends on the route, dosage, duration and patternof administration, individual metabolism and laboratory essay cutoff.

1

Other substance use G.3

5

IACAPAP Textbook of Child and Adolescent Mental Health

SCREENING
There are several well validated screening tools to evaluate whether a youth
may or may not have a drug problem; the results help to determine whether further
assessment is needed:•

CRAFFT (see Appendix G.3.1) is a 6-item self-report tool that screensfor use of both alcohol and drugs in adolescents. In one study, a cutoff score of 2 or more “yes” answers has a sensitivity of 92.3% andspecificity of 82.1% (Knight et al, 1999). It appears to be a valid meansof screening adolescents for substance-related disorders in adolescentclinics and in multi-ethnic adolescent populations (Knight et al, 2002;
Subramaniam et al, 2010).

•

The Drug Abuse Screening Test for Adolescents (DAST-A) is a 27-item
self-report instrument that directly queries adolescents about adverse
consequences experienced as a result of drug use. DAST-A scores greaterthan 6 yielded sensitivity, specificity, and positive predictive power of
79%, 85%, and 82%, respectively (Martino et al, 2000). DAST-A has
good reliability and validity for screening psychiatrically ill adolescentinpatients for substance abuse problems.

•

The Assessment of Substance Misuse in Adolescence (ASMA) is an 8-item
questionnaire for adolescents not known to treatment services. Two
cut-off scores have been suggested: a rating of “at risk” (score greaterthan 8) detected weekly or daily drug use with 85% sensitivity and95% specificity; a rating of “problem drug use” (score greater than12) detected daily drug use with 36% sensitivity and 99% specificity(Willner, 2000).

Click on the picture to accessthe monograph “Identifying
Mental Health and SubstanceUse Problems of Children
and Adolescents: A Guide forChild-Serving Organizations”

CLINICAL ASSESSMENT
Good assessment is a key aspect of the management of substance use
disorders. Apart from information collection, it offers an opportunity to engage,educate and motivate the young person for change, even in the first encounter.
Gaining an understanding of how patients conduct their lives, their aspirations
and unmet needs, together with the pattern and impact of drug use are importantin formulating the management plan.
General issues•

Be vigilant; look for signs of drug use•

Develop good rapport by maintaining an empathic and non-judgmental
attitude to encourage disclosure of the drug misuse problems•

The goals and process of assessment must be made clear to the young
people and their parents•

Be familiar with the local laws governing confidentiality about
substance abuse and explain them to patient and parents•

Parents’ involvement should be encouraged•

Because of the relatively short history and the developmental context(e.g., living with family) substance use disorders may manifest indifferent ways in adolescents than in adults

Other substance use G.3

Click on the picture to accessthe US National Institute ofDrug Abuse (NIDA), one of
the best sites for substancemisuse: it is reliable andcontains many useful
resources. NIDA supports
and conducts researchacross a range of disciplines.

6Other substance use G.3
Insomnia, anxiety, tremor, tachycardia, hypertension,
diaphoresis.
Transient visual, tactile, or auditory hallucinations orillusions; headache.
Seizures.
Fatigue, difficulty concentrating, craving, anhedonia,
vivid unpleasant dreams, myalgia, psychomotor
retardation-agitation, hyperphagia-anorexia,
insomnia or hypersomnia.
Irritability, agitation, insomnia, lethargy, depressedmood, suicidal ideation, lacrimation, diarrhea.
Irritability, agitation, anxiety, insomnia, tremor, chills,
runny nose, dilated pupils, pilo-erection, bone pain,
abdominal pain, loss of appetite, vomiting, diarrhea.
Insomnia, nausea, hyperhidrosis, depression,difficulties with thinking and memory.
Insomnia, anxiety, agitation, delirium, hallucinations,muscular cramps, autonomic instability.
Insomnia, anxiety, agitation, tremor, chills, runnynose, dilated pupils, increased heart rate and bloodpressure, bone pain, cramps, abdominal pain, lossof appetite, vomiting, diarrhea.

Sedation, relaxation, euphoria, impaired
concentration, disorientation, drowsiness, confusion,
incoordination, tremor, amnesia
Euphoria, enhanced concentration, sense of power
and alertness, talkativeness, reduced appetite,anxiety, restlessness, panic attacks, irritability,
paranoia, delusions, hallucinations.
Cough suppressant, analgesia, euphoria, drowsiness,depression, constricted pupils.
Euphoria, sense of well-being, drowsiness,
respiratory depression, constricted pupils, analgesia,
decreased awareness.
Euphoria, dissociation and dream-like experiences,hallucinations, drowsiness, dizziness, slurred speech,
vomiting, diarrhea, pruritus.
Euphoria, disinhibition, drowsiness, slurred speech,
loss of motor control, enhanced empathy and sexualintimacy.
Euphoria, lethargy, sense of well-being, drowsiness,
constricted pupils, hypoactive state.
Analgesia, numbness, amnesia, dissociation,
disorientation, hallucinations.

GABAa receptor agonist; increase
postsynaptic Cl- influx

Presynaptic dopamine, norepinephrine,
serotonin reuptake blockade; release(mild) Na channel blockade.

Opioid analogue, mu-opioid receptor
agonist.

mu-opioid receptor agonist.

Opioid analogue, NMDA receptor
antagonist increasing the synthesis andrelease of serotonin, as well as inhibiting
the reuptake of serotonin

Activates GABAb receptor, and a distinct
GHB receptor.

mu-opioid receptor agonist

NMDA receptor antagonism, enhancing
glutamate release.

Benzodiazepines

CocaineCodeineMorphine

Dextromethorphan

GHB (gammahydroxybutyrate)

HeroinKetamine

GABA: gamma-aminobutyric acid; 5-HT: 5-hydroxytryptamine (serotonin); MDMA: 3,4-methylenedioxy-N-methylamphetamine; NMDA: N-Methyl-D-aspartic acid.

Fatigue, insomnia, irritability, depression.

Withdrawal syndrome

Acute effectPharmacology

Effects of commonly misused substances

Substance

Table G.3.2

IACAPAP Textbook of Child and Adolescent Mental Health7

Other substance use G.3
Depression, anxiety, impaired concentration.

Tiredness, insomnia, nasal congestion, impaired
concentration, irritability, blackouts, depression,anxiety, unusual sweat odor, increased appetite andcraving.

Craving, tachycardia, diaphoresis.
Headaches, nosebleeds, dry cough, anxiety attacks,
poor appetite, tension, nausea and vomiting, chest
pains, dizziness, depression, insomnia.
Vocalizations, bruxism, diarrhea, oculomotor
hyperactivity, tremor, pilo-erection, somnolence,
seizures.
Not documented

Empathy-enhancing, heightened confidence & senseof well-being, mild depersonalization and derealization,
jaw clenching, thirst, dry mouth, restlessness, impairedbalance, poor concentration, reduced appetite, dizziness,
bruxism, diaphoresis.
Euphoria, increased concentration, talkativeness, urge
to move, empathy, jaw clenching, reduced appetite,
insomnia, headache, nausea, palpitations, increased sex
drive, excessive sweating and cold blue finger/toes.
Euphoria, enhanced wakefulness, anxiety, reduced
appetite, increased physical activity, excitement, anger,
hallucination and paranoid delusion, impaired judgment.
Heat sensation and excitement
Excitation, disinhibition, drowsiness, light-headedness,agitation, anesthesia and poorly coordinated movements.
Agitation, euphoria, nystagmus, ataxia, slurred speech,
confusion, delirium, psychosis.
Heightened sense, vivid hallucinations, synesthesia,
derealization, panic reactions, autonomic hyperactivity(pupil dilation, pilo-erection, diaphoresis, tachycardia,
hyper-reflexia, tremor), impaired coordination.
Reduces sleep latency, increases the slow-wave sleep.

Post-synaptic serotonin receptors
agonist.

Stimulate the release and theninhibit the reuptake of monoamine
neurotransmitters.

Low dose: dopamine andnorepinephrine reuptake blockade.
High dose: increases dopamine,
norepinephrine and serotonin release.

Potent vasodilator and relaxation ofsmooth muscles.

Unknown.

NMDA receptor antagonist, enhancing
glutamate release.

5-HT2A agonist.

α1,2,3 and 5 of GABAA receptors
agonistMDMA (ecstasy)

Mephedrone

Methamphetamine

Volatile alkyl
nitrites (popper)

Organic solvents

PCP(Phencyclidine)

LSD (lysergic acid
diethylamide)

Zopiclone

GABA: gamma-aminobutyric acid; 5-HT: 5-hydroxytryptamine (serotonin); MDMA: 3,4-methylenedioxy-N-methylamphetamine; NMDA: N-Methyl-D-aspartic acid.

Similar to benzodiazepines.

Fatigue, insomnia or hypersomnia, vivid unpleasant
dreams, mood lability, anxiety, depression, irritability,
violence, paranoid psychosis, suicidality, motorstereotypies.

Withdrawal syndrome

Acute effectPharmacology

Substance

Table G.3.2 (continuation)

IACAPAP Textbook of Child and Adolescent Mental Health8IACAPAP Textbook of Child and Adolescent Mental Health•Clarify the young person’s understanding of symptoms•

Care for the general health needs and drug related problems, whether
or not the patient is ready to stop using drugs

History
The following information needs to be obtained (see also Chapter A.5):
•

•
•
•
•
•
•
•

•
•

•

Substances used (current and past), for each type:− Age at first use− Frequency− Duration− Minimum, maximum and usual quantity consumed− Route of administration− Substances taken in combination
Binging, memory loss and overdose episodes
Accidents and injuries related to substance use
Previous attempts to stop using
Withdrawal symptoms
Presence of psychotic symptoms and their association with drug
consumption
Symptoms of psychological or physical dependence
Immediate risk factors:− Overdoses, deliberate self-harm and attempted suicide− Injecting behavior− Multiple substance use
Co-existing psychiatric problems (e.g., depression, conduct disorder,
psychosis, ADHD)
Substance use in risky contexts− Substance use in the presence of family members− Sexual exploitation or risky sexual behavior− Criminal behavior
Physical problems− Infections (e.g., hepatitis B/C, HIV, venereal disease)− Urological problems related to ketamine use.

Click on the picture to access
Street Drugs, a website withinformation specifically forstudents, parents, teachers,
and health professionals.
The site also has research
reports, frequently asked
questions and materials suchas posters and interactive
media.

It is necessary to also obtain information about patients’ understanding of
their substance use by enquiring about:
•
•
•
•
•
•
•
•

Level of knowledge of substances and associated risks
Where, how and with whom they take substances
Who else among their friends and family uses drugs
Whether, according to the patient, substances are being used to control
mood, thoughts or behavior
Their understanding about how substance use affects their lives
Hopes and fears in relation to substance use and being drug free;previous experiences of being drug and alcohol free
Family’s views on substance abuse
Available supports if changing substance use behavior

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9IACAPAP Textbook of Child and Adolescent Mental Health

Becky
Becky was 16 when first admitted to the psychiatricunit of a general hospital after being brought by the police.
According to the admission notes, she was “hysterical” andattempted to jump from the roof of a building after a fightwith her boyfriend. Becky was quiet and settled after thesecond day of her admission remaining cooperative during
the ten days of her hospital stay. Assessment revealed that
Becky had quit school a year earlier and done nothing sincethen. She had a poor relationship with her family and they
got used to her being absent for days at a time. For a week
before the admission, Becky was upset about her boyfriend
dating one of her close friends. She confronted them a
few times but they never admitted it. She felt depressed,
angry and betrayed but denied intending to kill herself. She
described herself as unusually “out of control” when she
threatened to jump from the roof. Physical examinationand laboratory investigations, including urine toxicology
screening, did not reveal abnormal findings; pregnancy
test was negative. Becky was mostly quiet in the ward. Her
mood improved gradually. No abnormal behaviors were•observed throughout her admission. Becky was diagnosed
with adjustment disorder.
She was expected to attend a clinic for follow up two
weeks later but turned up one month later. In that visit,
Becky disclosed that she had been hearing voices talking
to her for many weeks until several days after her hospital
admission. She concealed that because she believed shewould be kept in hospital longer. She stressed again that
she had not taken any illicit drugs but had been taking
slimming pills for several weeks before the incident. Whenshe stopped taking those the voices also stopped. Becky
appeared calm and friendly in the following two clinic visits
but the service subsequently lost contact with her. She
reappeared in the clinic five months later disclosing she
had been smoking “ice” with her friends for nearly a year.
Throughout this period, she heard voices talking to her fromtime to time. She was uncertain whether her hallucinatory
experiences were related to her drug use because
sometimes those voices were exceptionally long lasting;
she was 3-months-pregnant.

Expectations of treatments and motivation – according to the stages-ofchange model (Prochaska & DiClemente, 1992).

A good understanding of the psychosocial impact of substance use is also
necessary for diagnosis and to plan treatment, this would include a thorough graspof young people’s lives:
•
•
•
•
•
•
•
•

How they conduct their lives
In what activities they engage
Who has an influence on them
How they perceive their lives
What aspirations they have
What are their unmet needs
What are the consequences of their substance abuse for them
What are their goals and aspirations.

Abuse

DIAGNOSISTo establish a diagnosis of substance abuse in DSM-IV (American Psychiatric
Association, 1994), there should be a pattern of recurrent use resulting in failure
to fulfil major role obligations at home, work or school; legal problems; social orinterpersonal problems; and physically hazardous situations within a 12-month
period. The parallel category in ICD-10 (World Health Organization, 1992)
is termed as “harmful use” and emphasizes actual damage caused to mental or
physical health, but not to adverse social consequences for the substance user.
Dependence
Making a diagnosis of substance dependence according to DSM-IV requires
meeting within a 12-month period three of seven criteria: tolerance, withdrawal
symptoms, compulsive nature of use, failure to quit, amount of time spent seeking

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10

IACAPAP Textbook of Child and Adolescent Mental Healthdrugs, giving up on other more appropriate activities, and use despite adverse
consequences. Similar criteria are required according to ICD-10. For further
discussion of the validity of the distinction between abuse and dependence see
section on DSM-5 below.
Despite diagnostic criteria in both classification systems having been used
for many years, there are still problems when applying them to adolescents. The
criteria for tolerance, withdrawal and medical complications may not be applicable
to adolescents because of the relatively short history of substance use.
Proposed changes for DSM-5
In the proposed changes for DSM-5, the overall section is to be labelled“addiction and related disorders,” which would include gambling – a nonsubstance or behavioural addiction. A new category of “substance use disorder” is
proposed, which would combine the two current diagnoses of “substance abuse”
and “dependence” (on the basis that this historical distinction is not supported byempirical evidence), with severity rated according to the number of symptoms.
The criterion “legal difficulties” is to be eliminated while “drug craving” is to be
added. Tolerance and withdrawal symptoms are not to be counted towards thediagnosis when patients are involved in an appropriate medical treatment programfor a problem such as pain, anxiety or depression unless they have other symptomsof aberrant behavior demonstrating compulsive drug seeking (O’Brien, 2011).
The makers of DSM-5 hope this would clear misconceptions and avoid patientswith other psychiatric disorders having their successful treatment discontinued toaddress their “dependence” (Heilig, 2011).
Whether the proposed changes for DSM-5 are clinically useful in separating
patients with patterns of substance use that would respond to brief psychologicalinterventions from those needing more substantial treatment requires further
exploration (Poznyak et al, 2011). Criticisms include that with no other alternative
than acute intoxication, individuals who use psychoactive substances infrequently
without major indications of dependence are unlikely to have their substancerelated problems diagnosed in emergency rooms, hospital wards and out-patient
clinics, thus unlikely to receive early intervention – proven effective with nondependent substance users (Babor, 2011). Furthermore, by collapsing thediagnosis of abuse and dependence into a single disorder, it is possible to makea diagnosis of substance use disorder with as few as two psychosocial criteria andthe subjective judgment of the clinician (Meyer, 2011). Despite some positivechanges, the proposed DSM-5 criteria for substance use disorders do not go very
far in improving their diagnosis in youth; targeted developmental adjustments,
including clearer operational symptom definitions, are needed to ensure that
DSM-5 validly identifies substance use disorders across all developmental periods(Winters et al, 2011).

Click on the picture to access
Erowid, a useful website withinformation about everything
to do with drugs

Drug testing in adolescents
Current practice parameters (Bukstein et al, 2005) state that toxicology“should be a routine part of the formal evaluation and ongoing assessmentof substance use both during and after treatment”. Self-reports by drug using
adolescents are often unreliable, especially in the community, school and legal
settings. Denial, social desirability responses, concern over legal or other perceived
consequences are likely to result in an under-reporting of drug use in this age

Other substance use G.3

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IACAPAP Textbook of Child and Adolescent Mental Healthgroup. Drug testing could provide objective information to the treating clinician
for screening, diagnosis and to monitor adherence to treatment and outcome.
In clinic settings, drug testing is practical and cost-effective using point-ofcare immunoassay test kits on urine samples to detect the presence of substancesof abuse. To confirm a positive result, gas chromatography and mass spectroscopy
may be required in some circumstances (e.g., if legal penalties apply). The main
limitation is that the period during which most substances can be detected range
from 1-3 days and care must be taken to prevent tinkering with the sample (sample
should be provided under direct supervision by same-sex staff; pH or specific weightof the sample helps to check whether there is dilution; measuring the temperatureis also helpful to prevent tampering). Point-of-care immunoassay tests on saliva
can also be performed; however, they are more expensive and detection period isshorter (6-12 hours). Hair testing detects drug use in the last 3 months (except forthe previous 7 days). Samples are difficult to adulterate but perming, bleachingand straightening treatments may alter drug levels in hair samples; the test is
expensive and cannot be done on-site. Sweat testing prospectively investigates
substance use over 1-3 weeks. The patch collects traces of the substances and their
metabolites left from evaporated sweat; it is also expensive although a little lessthan hair testing. Drug testing of blood samples is useful in avoiding tampering
but is invasive and costly.
It is important to consider several factors before conducting a drug screen:•••

Adolescents are expected to enter into a confidential relationship withthe therapist if they are shown to be competent to give consent. Hence,
it is a good practice to explain the needs and implications (both of
positive or negative results) of the drug screen and obtain informed
consent from the adolescent
It is not advisable to request for a drug screen solely because of parental
suspicion
The therapist is encouraged to discuss with the adolescent the limits ofClick on the picture to viewa high school student talking
about his battle with drugs(10:05)

Sniffing solvents

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IACAPAP Textbook of Child and Adolescent Mental Healthconfidentiality, who will be informed of the results of the drug screen
and what the process will be.
It is important to bear in mind that substances such as amphetamines,
cocaine, and opiates are not likely to be detectable in the urine after 1-4 days (seeTable G.3.1). The availability of these laboratory tests does not obviate the needfor careful screening via interview and self-report, but they are an important toolin the assessment and monitoring of substance use. Moreover, use of drug screensincreases the reliability of the adolescent’s self-reported substance use, which canhave therapeutic value in itself. One approach to requesting a drug screen is to tell
the adolescent that it is likely to be positive if they have used cannabis in the pastmonth. If the adolescent endorses substance use, the clinician may not wish toobtain a drug screen. Another common clinical and research practice is to consider
a refused drug screen as equivalent to a positive screen. (Goldstein, 2009)

TREATMENT
After a comprehensive assessment, the young person and their parents
should be involved in planning the treatment. Treatment goals will largely dependon the motivation and circumstances of each individual. It is useful to view thesubstance abuse as a symptom of a complex dysfunction in the young person,
the family, school and social environment requiring an overall management plan,
which should also address issues such as attachment, educational needs, physicaland psychological health, lifestyle, peer relationships and psychological stress in acoordinated manner.

Click on the picture to accessinformation about club drugs
provided by NIDA (US)The level of care required will be determined by the intensity and complexityof the presenting problems and the needs of the patient. The management planshould be realistic, acceptable to the patient and the family, and feasible within
the available resources. Adolescents whose frequency of drug use is low and drugrelated problems mild, are best managed by their family physician. For those
who abuse drugs frequently and have moderate to severe drug-related psychiatriccomorbidities, they are best managed by a child and adolescent mental healthteam. Referral to a specialized addiction team is appropriate if the complex needsof the youngster cannot be met by the lower level of care.
Some interventions directly address the substance use and include: psychoeducation, enhancement of motivation, harm reduction interventions and relapse
prevention. Others target different aspects such as social skills, family relationships,
mood, impulse control, mental and physical health.
Brief interventions
These are opportunistically offered in settings such as family clinic, social
care settings and emergency departments to people with limited contact withdrug services who use drugs but do not have a full blown drug use disorder.
Information and advice about reducing the risks of drug misuse (e.g., exposure
to blood-borne viruses) are to be provided to all of them during routine contacts
or opportunistically. Sessions aimed at enhancing the motivation to change druguse behavior can thus be arranged. During the session, therapists need to explore
ambivalence about drug use and possible treatment. Increased rates of abstinencefrom heroin, cocaine, and amphetamine have been demonstrated with this minimal
intervention (Bernstein et al, 2005; Baker et al, 2005).

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IACAPAP Textbook of Child and Adolescent Mental HealthSelf-help groups
Narcotic Anonymous and Cocaine Anonymous are the best examples. They
are based on the 12-step principles, which emphasize abstinence as the goal oftreatment (see also Chapter G.1). While definite evidence of effectiveness is stilllacking, weekly or more frequent 12-step participation seems to be associatedwith lower drug and alcohol consumption (Fiorentine, 1999). Possible mediating
effects of social support and religious service attendance in maintaining long-term
recovery among adolescents have also been postulated (Chi et al, 2009).
Motivational interviewing
Motivational interviewing is a technique that helps patients explore andresolve their ambivalence about drug taking. This is achieved through reflective
listening, development of discrepancy, sidestepping resistance by responding with
empathy and understanding, and supporting self-efficacy in order to commit andreach a decision to change (Miller & Rollnick, 1991).
The therapist is encouraged to adopt a non-judgmental stance and steer
the patient to express concern and identify problems related to the substanceabuse. Through empathetic listening and reflection of the patient’s response in a
modified form, the patient is encouraged to express the discrepancy between his
personal ideal goals and the actual behaviors (e.g., desire to be a top hair-stylist
but to continue drinking alcohol despite hand tremor). This helps to increase themotivation to change.
To reduce the resistance to change, the therapist should avoid confrontation
and argument with patients (e.g., whether methamphetamine use enhances one’s
working performance or not). Instead the therapist should be able to understandthe patient’s frame of reference, filter and amplify the patient’s encouraging
thoughts, elicit statements from the patient that encourage change, match the stageof change of the patient, and express acceptance and affirmation of the patient’s
freedom of choice and self-direction (Rollnick & Miller, 1995).
Drug users who received motivational interviewing were more likely to
reduce their drug use, comply more with treatment requirements, stay longer intreatment, have fewer post-treatment psychiatric problems, become abstinent more
often and have fewer relapses (Baker et al, 2001; Daley et al, 1998; Macgowan &Engle, 2010; Saunders et al, 1995).
Relapse prevention
Relapse prevention combines behavioral skills training, cognitive training
and lifestyle change (Marlatt & Gordon, 1985). The goal is to teach drug users
to identify, anticipate and cope with the high risk situations that may lead torelapse. Patients are encouraged to set achievable behavioral goals to enhance theirself-efficacy. Myths about the perceived effects of drugs on the patient should beclarified. Reframing the meaning of events leading to lapses helps to minimize
the sense of failure, encourage the establishment of a lapse management plan andreduce the chances of relapse. In addition, patients are encouraged to increase
their engagement in rewarding or stress-reducing activities in their daily routine toenhance the self-efficacy.

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IACAPAP Textbook of Child and Adolescent Mental Health

Review on 24 interventions focusing on substance use showed that relapse
prevention has comparable effectiveness to other active treatments (Carroll, 1996),
may reduce the intensity of relapse episodes if relapse occurs and has significantly
better outcomes even for more impaired substance abusers (Carroll et al, 1991;
Carroll et al, 1995). A recent extensive review found that self-help interventions
based on a relapse prevention approach showed a significant overall effect inincreasing long-term abstinence in smokers (Agboola et al, 2010). Another metaanalysis of 53 controlled trials of CBT primarily based on the a relapse prevention
approach showed that 58% of individuals who received CBT had better outcomesthan those in comparison conditions (Magill & Ray, 2009).
Contingency management
Contingency management is a type of reinforcement program to motivate
drug users to abstain by rewarding them with cash or vouchers for shoppingor privileges such as take-home methadone (see also Chapters G.1 and G.2).
Abstinence is usually assessed through urine drug testing. The amount of the
reward (e.g., the monetary value of the vouchers) usually increases with theincreasing duration of continuous abstinence (e.g., number of consecutive drugfree urine tests). It has been found that contingency management is useful for
non-responsive patients (Gossop, 2003).
Family-based interventions
Family-based interventions have shown some success in decreasing substanceuse, reducing the risk for further substance involvement, better retention intreatment and bolstering protective factors in multiple domains of the adolescent’s
life.

Click on the picture toview a clip that can berecommended for parent
education on teen drug use(3:39)

Multi-dimensional family therapy aims to change adolescents’ drug abusing
lifestyle into a developmentally normative way of life, to improve functioning,
to increase parents’ commitment and improve their parenting skills andcommunication with the adolescent (Liddle, 2002). Multi-dimensional family
therapy seeks to reduce risk factors and promote protective factors in the individual,family, peer and school domains, reduce the substance use and delinquency (Liddle
et al, 2004; Rowe et al, 2003; Rowe 2010). A study found that multi-dimensionalfamily therapy produced superior treatment outcomes in youth with more severe
drug use and greater psychiatric co-morbidity when compared with individuallyfocused cognitive-behavioral therapy (Henderson et al, 2010).
Pharmacological treatment
Pharmacotherapy for young people who regularly misuse substances can beused to reduce immediate harm from substance misuse, stabilize the young people
and enable them to move to abstinence (Department of Health UK, 2007).
Pharmacological treatment is useful in:•

Treatment of drug withdrawal−

During the process of detoxification−

To eliminate or reduce the severity of withdrawal symptoms
when the physically dependent user stops taking drugs

Other substance use G.3

15

IACAPAP Textbook of Child and Adolescent Mental Health••

Substitute treatment (also called maintenance or replacement therapy)− The prescription of a substance with similar pharmacologicalaction to the drug of dependence, but with a lower degree of risk
− To reduce the exposure to risk behaviors and stabilize healthand social functioning before addressing the physical adaptation
dimension of dependence
Relapse prevention− To prevent relapse after detoxification.

Benzodiazepines dependence
Detoxification of patients who suffer from benzodiazepine dependence,
rare in the young, should be carefully planned and closely monitored for presenceof withdrawal symptoms like insomnia, restlessness, muscle spasm and seizures.
Monitoring mental state and suicidal risk is also necessary. Inpatient detoxification
is best considered for those whose compliance was poor in the past or who are at
risk of developing severe withdrawal symptoms such as convulsions. A long acting
benzodiazepine (e.g., diazepam) in a gradually reducing dose regimen is widelyused in the detoxification process. Prescription of benzodiazepines as maintenancetreatment is not recommended.
Stimulant dependence
Symptoms like craving, insomnia or hypersomnia, lethargy, agitation anddepression, are reported when a regular user stops taking stimulants. However, no
medication is effective for the treatment of amphetamine withdrawal (Shoptaw
et al, 2009). The presence of depressed mood, irritability, violent and suicidal
ideation during the withdrawal period requires close monitoring. Psychotic
episodes related to stimulant use are usually short-lived and subside spontaneously
after cessation of use. Substitute treatment (e.g., bupropion, dexamphetamine,
methylphenidate, modafinil, mazindol, methamphetamine and selegiline) is notrecommended (Castells et al, 2010; Department of Health UK, 2007).
Opiate dependence
Opiate withdrawal can be very uncomfortable but is rarely life-threatening.
Patients usually complain of musculoskeletal pain, insomnia, nausea or vomiting,gooseflesh, chills, sweating, running nose, yawning and watery eyes. Withdrawal
symptoms can be relieved by:
•
•
•
•
•

Click on the picture toaccess a website aboutamphetamines createdby Turning Point Alcoholand Drug Centre in
Melbourne (Australia). It
offers self-help informationand treatment options formethamphetamine users anduseful information for families
and health professionals.

Gradually reducing the dose of methadone
Buprenorphine
Clonidine and lofexidine
Symptomatic treatment
Acupuncture.

When the patient is not ready for complete abstinence from opiates,
methadone maintenance treatment can be suggested as substitution therapy(though this is not accepted or legal in some countries). Methadone maintenancehelps to relieve withdrawal symptoms, eliminate craving and block the euphoric
effects of illicit opioids. Methadone maintenance also helps to reduce thetransmission of infections associated with intravenous injection such as hepatitisand HIV because it helps to reduce injecting, sharing needles and risky sexual
behavior (e.g., multiple partners or exchange of sex for drugs or money) among

Other substance use G.3

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IACAPAP Textbook of Child and Adolescent Mental Healthheroin dependent individuals (Gossop et al, 2002; Gowing et al, 2011; Sorensen& Copeland, 2000). It is the treatment of choice for pregnant adolescents who
abuse heroin.
Despite abundant evidence about its usefulness in reducing the harm of
opioid dependence, there is controversy about methadone maintenance in many
countries. This is because methadone maintenance is regarded as a legally available
opioid. In addition, it is also not uncommon to find that some patients receiving
methadone maintenance also use heroin.
Buprenorphine is a partial opioid agonist-antagonist at least as effective as
methadone as a substitution agent in reducing illicit opioid use and retaining
patients in treatment (Johnson et al, 2000). When compared with methadone,
buprenorphine is safe – lower risk of overdose – and is well tolerated. Fewer
withdrawal symptoms are also reported during detoxification. A combination ofbuprenorphine and naloxone (Suboxone®) has replaced the previous buprenorphine
preparation (Subutex®) to prevent the drug from being used intravenously.
Suboxone® comes as sublingual tablet and film. Both of them are to be taken once
daily. Suboxone® film, in contrast to sublingual tablet, has a better taste and takes
shorter time to dissolve.

Click on the picture to accessthe Australian National
Inhalants information Service
that provides information
about inhalant abuse.

Naltrexone is an oral long-acting opioid antagonist which blocks or reduces
the effects of opioids including euphoria. Naltrexone is well tolerated at the usual
dose, only becoming aversive by precipitating withdrawal symptoms in persons
using opioids. It may play a role in preventing relapse to opioid use after withdrawal(Marsch et al, 2005), although it is used more often in the management of
alcoholism. Opiate-containing medications (e.g., cough syrup, pain killers) should
be avoided when a patient is on naltrexone. Because of the risk of hepatotoxicity,
baseline tests and regular monitoring of liver function is recommended.
Inhalant abuse
There is no specific medication available for detoxification frominhalants. During acute intoxication, the patient should be assessed and treated
symptomatically. Hydration and cardiorespiratory status should be monitored
closely. A calm and supportive environment is necessary. Antiarrhythmic
drugs or beta-blockers are sometime necessary to stabilize the myocardium;
sympathomimetics or bronchodilators should be avoided. Comorbid psychiatricconditions should be treated accordingly (Williams et al, 2007; Baydala 2010).

PREVENTION
Substance use in adolescents is the result of the interplay between risk andprotective factors in the individual, family, peer group, school and local social
community. The objectives of prevention are to reduce or delay the initiation of
drug use, to delay progression from experimentation to problematic use and tominimize complications.
Universal prevention
Universal prevention activities can be general-population-based and schoolbased. The content is mainly focused on information transfer, information about
the latest drug scene, the possible complication and ways to handle this are conveyed
to the general public through the media and talks to increase the public’s awareness

Other substance use G.3

Click on the picture to watcha clip from the fictional
movie “Samson and Delilah”
depicting petrol sniffing inaboriginal Australians andits effects. Samson and
Delilah's world is small—anisolated community in theCentral Australian desert.
When tragedy strikes theyturn their backs on homeand embark on a journeyof survival. Lost, unwanted
and alone they discover thatlife isn't always fair, but love
never judges (14:56)

17

IACAPAP Textbook of Child and Adolescent Mental Healthof drug issues. Training on personal and social skills, advice on curriculum design
to improve knowledge of drug-related issues and parenting skills can be provided
through school-based activities. It has been shown that school-based programs
aimed at improving social skills are effective in reducing drug use (Faggiano etal, 2005), but not so successful in reducing tobacco smoking and alcohol abuse(Thomas & Perera, 2006).
The European Drug Addiction Prevention trial is one of the large scale
school-based programs which involved 170 schools (7079 pupils 12–14 years ofage) in seven European countries. The program consisted of a 12-hour curriculum
based on a comprehensive social influence approach with special emphasis oncorrecting the students’ beliefs about drugs and drug use. It has been shown that
there were persistent positive effects over 18 months for alcohol and cannabis use(Faggiano et al, 2010).
Targeted prevention
Targeted prevention focuses attention on those who are at higher risk of druguse. Vulnerable youth and their families are identified either by school teachers orby case workers for further skill-based training, e.g., impulse control and coping
skills training for the youth and parenting skills training for the parents. For
example, Project Towards No Drug Abuse (Project TND) is funded by the National
Institute on Drug Abuse for adolescents aged 14 to 19 years attending both regularand alternative schools. Project TND aims to prevent tobacco, alcohol, and otherdrug use and to help students make healthy, informed choices. It is taught throughtwelve 40 to 50-minute lessons and focuses on the following areas:
1.

2.

3.

Motivational factors:• Address students' attitudes, beliefs, expectations, and desires regarding
drug use• Address student’s cognitive misperceptions and myths around drug use.
Skills (social, self-control and coping skills):• Aim to provide students with healthier coping, communication andself-control skills so that they do not resort to substance use.
Decision-making:• How to make decisions• Make a commitment to not use drugs and to continue the conversations
from Project TND with their peers.

Click on the picture to viewa clip about whether parents
should talk about their drug
use with children (4:15)

Sussman and colleagues (2004) have shown that TND reduces substanceuse among adolescents both at short and long-term (1 year) follow-up. In addition,
they also showed that TND was effective among regular high school youth andhigh-risk youth who attend alternative high schools. However, stigma and selection
criteria for the “high risk” group may affect outcome.

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IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Agboola S, McNeill A, Coleman T et al (2010). A systematic
review of the effectiveness of smoking relapse
prevention interventions for abstinent smokers.
Addiction, 105:1362-1380.

Chen K, Kandel DB (1995). The natural history of drug use
from adolescence to the mid-thirties in a general
population sample. American Journal of Public Health,85:41-47.

Alia-Klein N, Parvaz MA, Woicik PA (2011). Gene x disease
interaction on orbitofrontal gray matter in cocaine
addiction. Archives of General Psychiatry, 68:283-294.

Chi FW, Kaskutas LA, Sterling S et al (2009). Twelve-step
affiliation and 3-year substance use outcomesamong adolescents: social support and religious
service attendance as potential mediators. Addiction,
104: 927–939.

American Psychiatric Association (1994). Diagnostic andStatistical Manual of Mental Disorders, 4th Edition.
Washington, DC: American Psychiatric Association.
Armstrong TD, Costello EJ (2002). Community studies onadolescent substance use, abuse, or dependence andpsychiatric comorbidity. Journal of Consulting &Clinical Psychology, 70:1224-1239.
Babor TF (2011). Substance, not semantics, is the issue:comments on the proposed addiction criteria for
DSM-V. Addiction, 106:870-872.
Baer JS, Sampson PD, Barr HM et al (2003). Archives of General
Psychiatry, 60:377-385.
Baker A, Boggs TG, Lewin TJ (2001). Randomised controlled
trial of brief cognitivebehavioural interventions among regular users of amphetamine.
Addiction, 96:1279-1287.
Baker A, Lee NK, Claire M et al (2005). Brief cognitive
behavioural interventions for regular amphetamineusers: a step in the right direction. Addiction, 100:367378.
Baydala L (2010). Inhalant abuse. Paediatrics & Child Health,;15(7):443-448.
Bernstein J, Bernstein E, Tassiopoulos K et al (2005). Brief
motivational intervention at a clinic visit reducescocaine and heroin use. Drug and Alcohol Dependence,
77:49-59.
Bukstein OG, Bernet W, Arnold V et al (2005). Practiceparameter for the assessment and treatment ofchildren and adolescents with substance use disorders.
Journal of the American Academy of Child & Adolescent
Psychiatry, 44:609-621.
Carroll KM (1996). Relapse prevention as a psychosocial
treatment approach: a review of controlled clinical
trials. Journal of Consulting and Clinical Psychology,
4:46-54.
Carroll KM, Nich C, Rounsaville BJ (1995). Differential
symptom reduction in depressed cocaine abusers
treated with psychotherapy and pharmacology. Journalof Nervous and Mental Disease, 183:251-259.
Carroll KM, Rounsaville BJ, Gawin FH (1991). A comparative
trial of psychotherapies for ambulatory cocaine
abusers: Relapse prevention and interpersonal
psychotherapy. American Journal of Drug and Alcohol
Abuse, 17:229-247.
Castells X, Casas M, Pérez-Mañá C et al (2010). Efficacy ofpsychostimulant drugs for cocaine dependence.
Cochrane Database of Systematic Reviews, CD007380.
DOI: 10.1002/14651858.CD007380.pub3.

Other substance use G.3

Daley DC, Salloum IM, Zuckoff A at el (1998). Increasing
treatment adherence among outpatients withdepression and cocaine dependence: results of a pilot
study. American Journal of Psychiatry, 155:1611-1613.
Day NL, Goldschmidt L, Thomas CA (2006). Prenatal
marijuana exposure contributes to the prediction of
marijuana use at age 14. Addiction, 101:1313-1322.
Delaney-Black V, CHiodo LM, Hannigan JH et al (2011).
Neurotoxicology & Teratology, 33:110-119.
Department of Health, UK (2007). Drug Misuse and
Dependence: UK Guidelines on Clinical Management.
London: Department of Health (England), theScottish Government, Welsh Assembly Government
and Northern Ireland Executive.
Faggiano F, Vigna-Taglianti F, Burkhart G et al (2010). The
effectiveness of a school-based substance abuse
prevention program: 18-Month follow-up of the EUDap cluster randomized controlled trial. Drug andAlcohol Dependence, 108:56-64.
Faggiano, F., Vigna-Taglianti, F.D (2005). School-based
prevention for illicit drugs’ use. The Cochrane Databaseof Systematic Reviews (2) doi:10.1002/14651858, Art.
No.: CD003020.pub2.
Fergusson D, Woodward L (2000). Educational, psychosocialand early sexual outcomes of girls with conduct
problems in early adolescence. Journal of Child
Psychology and Psychiatry, 41:779-792.
Fiorentine R (1999). After drug treatment: Are 12-step programs
effective in maintaining abstinence? American Journalof Drug & Alcohol Abuse, 25:93-116.
Fuller E (ed) (2011). Smoking, Drinking and Drug Use among
Young People in England in 2010. Health and Social
Care Information Centre, Lifestyles Statistics.
Goldstein BI (2009). Managing adolescents with comorbid
depression and substance abuse. In Rey JM, Birmaher
B (eds). Treating Child and Adolescent Depression.
Philadelphia: Lippincott Williams & Wilkins.
Gossop M (2003). Drug Addiction and Its Treatment. New York.
NY: Oxford University Press.
Gossop M, Marsden J, Stewart D et al (2002). Reduced
injection risk and sexual risk behaviours after drug
misuse treatment: results from the National Treatment
Outcome Research Study. AIDS Care, 14:77-93.

19

IACAPAP Textbook of Child and Adolescent Mental HealthGowing L, Farrell MF, Bornemann R et al (2011). Oral
substitution treatment of injecting opioid users forprevention of HIV infection. Cochrane Database of
Systematic Reviews, CD004145.
Griensven FV, Supawitkul S, Kilmarx PH et al (2001). Rapid
assessment of sexual behavior, drug use, humanimmunodeficiency virus, and sexually transmitted
diseases in Northern Thai youth using audiocomputer-assisted self-interviewing and noninvasive
specimen collection. Pediatrics,; 108;1:e13
Haggerty KP, Skinner ML, MacKenzie EP et al (2007). A
randomized trial of Parents Who Care: effects on key
outcomes at 24-month follow-up. Prevention Science,
8:249-260.
Heilig M (2011). A welcome change that stops short of being
fully satisfying. Addiction, 106:874-875.
Henderson CE, Dakof GA, Greenbaum PE et al (2010).
Effectiveness of multidimensional family therapy withhigher severity substance-abusing adolescents: reportfrom two randomized controlled trials. Journal ofConsulting & Clinical Psychology, 78:885-897.
Johnson RE, Chutuape MA, Strain EC et al (2000). A
comparison of levomethadyl acetate, buprenorphineand methadone for opioid dependence. New England
Journal of Medicine, 343:1290-1297.
Johnston LD, O’Malley PM, Bachman JG et al (2011).
Monitoring the Future National Survey Results on
Drug Use, 1975–2010: Volume I, Secondary SchoolStudents. Ann Arbor: Institute for Social Research, The
University of Michigan.
Knight JR, Sherritt L, Shrier LA et al (2002). Validity of
CRAFFT substance abuse screening tests among
adolescent clinic patients. Archives in Paediatric &Adolescent Medicine, 156:607-614.
Knight JR Shrier, LA, Bravender TD et al (1999). A new brief
screen for adolescent substance abuse. Archives ofPediatrics & Adolescent Medicine,;153:591-596.
Liddle HA (2002). Multdimensional Family Therapy Treatment(MDFT) for Adolescent Cannabis Users. Rockville,
MD: Substance Abuse and Mental Health Services
Administration.
Liddle HA, Rowe CL, Dakof GA et al (2004). Early intervention
for adolescent substance abuse: Family based versus
group treatment. Journal of Psychoactive Drugs, 36:4963.
Macgowan MJ, Engle B (2010). Evidence for optimism:
behavior therapies and motivational interviewing
in adolescent substance abuse treatment. Child &Adolescent Psychiatric Clinics of North America, 19:527545.
Magill M, Ray LA (2009). Cognitive-behavioral treatment withadult alcohol and illicit drug users: a meta-analysisof randomized controlled trials. Journal of Studies on
Alcohol and Drugs, 70:516-527.
Marsch LA, Bickel WK, Badger GJ et al (2005). Comparisonof pharmacological treatments for opioid-dependent
adolescents. A randomized controlled trial. Archives ofGeneral Psychiatry, 62:1157-1164.

Other substance use G.3

Marlatt GA, Gordon JR (1985). Relapse Prevention: Maintenance
Strategies in the Treatment of Addictive Behaviors. New
York: Guilford Press.
Martino S, Grilo CM, Fehon DC (2000). Development of the
Drug Abuse Screening Test for Adolescents (DAST-A).
Addictive Behaviours, 25:57-70.
Meyer RE (2011). A commentary on ‘addiction and dependence
in DSM-V’. Addiction, 106:873-874.
Miller WR, Rollnick S (1991). Motivational Interviewing:
Preparing People for Change Addictive Behavior. New
York: Guildford Press.
Narcotics Division of Security Bureau, Hong Kong (2011). The
2008/09 Survey of Drug Use among Students. The
Government of Hong Kong SAR.
O’Brien C (2011). Addiction and dependence in DSM-V.
Addiction, 106:866-867.
Poznyak V, Reed GM, Clark N (2011). Applying aninternational public health perspective to proposedchanges for DSM-V. Addiction, 106:868-870.
Prochaska JO, DiClemente CC (1992). Stages of change in themodification of problem behaviors. In M Hersen, P M
Miller, R Eisler (eds), Progress in Behavior Modification
Vol 28. New York: Wadsworth Publishing, pp184218.
Rhee SH, Hewitt JK, Young SE et al(2003). Archives of General
Psychiatry, 60:1256-1264.
Rollnick S, Miller WR (1995). What is motivational
interviewing? Behavioral and Cognitive Psychotherapy,
23:325-335.
Rowe CL (2010). Multidimensional family therapy: addressing
co-occurring substance abuse and other problems
among adolescents with comprehensive family-based
treatment. Child & Adolescent Psychiatric Clinics ofNorth America, 19:563-576.
Rowe CL, Parker-Sloat B, Schwartz S et al (2003). Family
therapy for early adolescent substance abuse. In
Stevens S, Morral A (eds), Adolescent Drug Treatment:
Theory and Implementation in Eleven National Projects.
Binghamton, NY: Haworth Press, pp105-132.
Saunders B, Wilkinson C, Philips M (1995). The impact ofa brief motivational intervention with opiate users
attending a methadone programme. Addiction,
90:415-424.
Shoptaw SJ, KaoU,Heinzerling K et al (2009). Treatment
for amphetamine withdrawal. CochraneDatabaseof Systematic Reviews, CD003021. DOI:
10.1002/14651858. CD003021. pub2.
Sorensen JL, Copeland AL (2000). Drug abuse treatment as an
HIV prevention strategy: a review. Drug & Alcohol
Dependence, 59:17-31.
Subramaniam M, Cheok C, Verma S et al (2010). Validity of abrief screening instrument - CRAFFT in a multiethnic
Asian population. Addictive Behaviors, 35:1102-1104.
Sussman S, Earleywine M, Wills T et al (2004). The motivation,
skills, and decision-making model of "drug abuse"
prevention. Substance Use & Misuse, 39:1971-2016.

20

IACAPAP Textbook of Child and Adolescent Mental HealthThomas R, Perera R (2006). School-based programmes forpreventing smoking. The Cochrane Database of
Systematic Reviews, doi:10.1002/14651858, Art.
No.:CD001293.

Willner P (2000). Further validation and development of ascreening instrument for the assessment of substancemisuse in adolescents. Addiction, 95:1691-1698.

White V, Smith G (2009). Tobacco, Alcohol, Over-the-Counterand Illicit Substance Use among Australian Secondary
School Students 2008. Canberra: AustralianGovernment Department of Health and Aging.
Williams JF, Storck M et al (2007). Inhalant Abuse. Pediatrics,
119:1009-1017.

Winters KC, Martin CS, Chung T (2011). Substance use
disorders in DSM-V when applied to adolescents.
Addiction, 106:882-883.
World Health Organisation (1992). The ICD-10 Classification of
Mental and Behavioural Disorders. Clinical Descriptions
and Diagnostic Guidelines. Geneva: World HealthOrganization.

Appendix G.3.1
CRAFFTC

Have you ever ridden in a CAR driven by someone (including
yourself) who was “high” or had been using alcohol or drug?

R

Do you ever use alcohol or drug to RELAX, feel better about
yourself or to fit in?

A

Do you ever use alcohol or drug while you are by yourself,
ALONE?

F

Do you ever FORGET things you did while using alcohol or drugs?

F

Do your family or FRIENDS ever tell you that you should cut downon your drinking or drug use?

T

Have you ever gotten into TROUBLE while you were using alcoholor drugs?

Source: Knight JR, Sherritt L, Shrier LA et al (2002). Validity of the CRAFFT substance abuse screening test among
adolescent clinic patients. Archives of Pediatrics and Adolescent Medicine, 156:607-614.

Other substance use G.3

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