teens – Vista Hill Center for Child and Youth Psychiatry

4 Traits That Put Kids at Risk for Addiction 4/6/23

Shirley Fett — Wed, 05 Apr 2023 23:34:17 +0000

The looming question of “What can we do to curb the addiction crisis facing our youth?” has remained unanswered because there is no single way to reduce the drug and alcohol epidemic in our society. Traditional anti-drug education in schools that focuses on scare tactics and the message “Just Say No”, has been found to be largely ineffective in children and adolescents who at the highest risk for drug abuse.

Recent anti-drug education programs work on identifying those youth who are at highest risk for drug abuse, realizing that most teens who experiment with drugs do not develop an addiction and that there are patterns in a person’s temperament that put him at a higher risk for addiction. Early trials show that personality testing or other ways to assess temperamental factors can identify adolescents who are at the highest risk, with the goal to target those risky traits before they lead to problems.

One such program named PreVenture, based at the University of Montreal, looks at these traits and has identified four thought to put kids at risk for addiction; the first three are related to mental health issues which pose a serious risk for drug and alcohol abuse:

Impulsiveness: This trait goes hand-in-hand with ADHD.
Anxiety sensitivity: Linked to panic disorder, anxiety sensitivity can be seen in individuals who are hyper-vigilant and scared of physical signs of anxiety.
Hopelessness: When a person feels hopeless, they are often depressed. Depression is a very common trait and precursor to addiction.
Sensation-seeking: Though not linked to mental health issues, people who enjoy thrills and intense experiences, will also generally like drugs and alcohol.

One way to look at this is that most at-risk children can be spotted early if they present with these symptoms. Early interventions to improve these risky traits can then be implemented.

It is also important to keep in mind that a teen who turns to drugs because of hopelessness has different expectations than a teen who turns to drugs for thrills. Distorted cognitive thinking plays a role for some adolescents who turn to drugs.

In the PreVenture model, teachers are educated about these traits and students are taught ways to manage their problematic traits in a general educational workshop approach without being called out for being “at risk”. One hypothesis is that the teacher training helps make teachers more empathic to high-risk students thereby increasing their connection to their school community, which has been shown to decrease drug use.

Studies that have looked at this model have shown a decrease in binge drinking, frequent drug use, and alcohol-related problems. Other studies have shown improvement in non-addiction symptoms as well, including depression, panic attacks and impulsive behavior, which are direct sequelae of the identified 4 high-risk traits.

The idea that identifying and addressing high-risk traits for addiction can be impactful for children and adolescents is a hopeful one and can be implemented across settings, including schools, communities and medical homes. More research can be done to determine what specific types of interventions can be helpful once those at-risk youth are identified.

PreVenture

Program to Reduce Teen Addiction

Screening for Suicide Risk Among Teens

creativefusion — Thu, 07 Jul 2016 18:18:30 +0000

Suicide is now the second leading cause of death in adolescents, in the United States, surpassing homicide and second only behind unintentional injuries (motor vehicle accidents, accidental overdose). This switch occurred because of both a reduction in deaths from homicide and a modest increase in deaths from suicide. Deaths from suicide had been decreasing from 1990 to 2000; this seems partly related to better treatment options for depression in teens, including access to mental health services and antidepressant medications. The rate has been fluctuating in the last 15 years, partly because of increase in certain risk factors, and there is concern about the negative influence of the FDA Black Box warning on antidepressant medications on the prescribing practices of these medications in the primary care setting. Teen girls are more likely to make suicide attempts and teen boys are more likely to have completed suicides.

Because of the prevalence of suicidal thoughts in adolescents, it is important for all medical and mental health providers to be comfortable asking questions related to suicide risk. With these new findings, the American Academy of Pediatrics revised their 2007 guidelines on “Suicide and Suicide Attempts in Adolescents” this month to urge pediatricians to screen patients for suicidal thoughts. The report identifies risk factors linked to teen suicide attempts, including:

Family history of completed suicide and suicide attempts
Personal history of suicide attempt and/or non-suicidal self injury
History of physical, sexual or emotional abuse or neglect
Mood disorders and psychotic disorders
Drug and alcohol use
Sexual orientation
Firearms in the home
Strained parent-child relationship or living outside of the home
Poor school attendance and/or performance
Bullying, including cyber-bullying – highest risk in teens who are both bullies and victims of bullying
Internet exposure – particularly concerning if using more than 5 hours/day

Screening for suicidal thoughts is important, and studies show that asking about suicide risk does not increase the risk of suicide attempts or “put the idea in the patient’s head” as some providers are concerned. It is helpful to talk with a teen patient privately to increase their comfort in disclosing sensitive information, but it is also important to review mandated reporting with the teen. An example of an appropriate screening question is: “Have you ever thought about killing yourself or wished you were dead or never born?” It is best to embed a question like this in the middle of other questions about depressive symptoms, after asking more general questions about how things are going for the teen at home, at school, with friends, etc. The follow up question could be “Have you ever done anything on purpose to hurt or kill yourself?” If the answer to either question is yes, it is important to obtain more details. It is particularly important to assess lethality and intent in determining the appropriate management. In most cases, if there is a concern about acute risk, a provider should err on the side of caution and seek out emergency mental health services.

This report is relevant in that it highlights the importance for all providers to feel comfortable asking about suicide risk in patients. It is our hope that this article brings each of you closer to that goal.

References:

http://pediatrics.aappublications.org/content/early/2016/06/24/peds.2016-1420

http://www.usatoday.com/story/news/health/2016/06/27/pediatricians-urged-screen-suicide-risks-among-teens/86348186/

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/With-suicide-Now-Teens’-Second-Leading-Cause-of-Death-Pediatricians-Urged-to-Ask-About-its-Risks.aspx

Treatment for Anxiety in Children and Adolescents

creativefusion — Thu, 02 Jun 2016 15:33:46 +0000

The presenting symptoms of anxiety in children and adolescents were discussed in last week’s edition and today’s focuses on treatment in pediatric populations. Primary care pediatric providers can play a major role in diagnosis, treatment planning, prescribing and, as needed, referring for consultation or specialty intervention.

Treatment options include therapy or a combination of therapy and medication:

For patients with mild-moderate symptoms, a therapy approach is preferred, with the option incorporate medication if the therapy is not effective.
For patients with moderate-severe symptoms with significant impairment in daily functioning, it may be warranted to consider starting with a combination of medication and therapy.

The key is that therapy is the important component to treatment of anxiety disorders in pediatrics, with medication used as an adjunctive treatment when needed. Therapy to address anxiety can easily be tailored to work with very young patients and is very effective. Types of therapy used include: cognitive behavioral therapy, exposure response prevention therapy, and relaxation techniques, among others.

Medications used to treat anxiety fall into two general categories: medications that treat the underlying anxiety and prevent future symptomatology and medications that treat acute symptoms, such as a panic attack. Medications in the first category include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazipine, and buspirone. The SSRIs are the first line agents. This class includes: fluoxetine, citalopram, escitalopram, sertraline, fluvoxamine, and paroxetine. Although prompt relief may result, just as with treating depression, the medication may take 4-6 weeks to have full impact, so patience is important. Also of note, often a higher dose may be needed to fully treat anxiety symptoms as compared to depressive symptoms.

The motto to “start low and go slow” remains relevant to limit activation and thereby increase anxiety during the titration process. So, for example if one is considering prescribing citalopram for anxiety for a 10 year-old patient, consider starting at 5 mg q-day for one week then 10 mg q-day for 1 week then 20 mg q-day and assessing the response. Some patients experience akathisia (internal feeling of restlessness), which can feel like a worsening of their anxiety, if the dose is titrated too quickly. Other side effects include sleep disturbance, GI upset and headache but most of these symptoms are dose related and will resolve over time.

The treatment of anxiety disorders in pediatric patients is mostly off label. Only fluoxetine (ages 7+), sertraline (ages 6+) and fluvoxamine (ages 8+) have FDA approval for treatment of obsessive-compulsive disorder (OCD).

When prescribing any antidepressant medication to treat anxiety, it is appropriate to review the FDA black box warning about the increased risk of spontaneous reporting of suicidal thoughts, even if the medication is not being prescribed to treat depression per se.

When prescribing a medication, it is standard practice to first use an SSRI. If a patient has 2 or more adequate (in terms of dose and length of treatment) trials of SSRIs that are ineffective, one could consider an alternative, either an SNRI (venlafaxine or duloxetine) or mirtazapine, but consultation or referral to psychiatry would be advised in such situations. If there is some benefit from the SSRI, one could consider augmentation with mirtazapine or buspirone. The primary side effects to be concerned with mirtazapine include sedation and increased appetite. Buspirone has an onset of action of about 2 weeks. The primary side effects to be concerned with include: dizziness, fatigue and GI upset. Occasionally the atypical antipsychotics are considered as adjunctive treatment to treatment-resistant OCD.

Benzodiazepines, are rarely used in this population. Pediatric patients can have a paradoxical reaction to them and exhibit behavioral disinhibition. Other side effects include: physiological and psychological addiction, confusion, sedation and impaired fine motor coordination. If a medication to treat acute anxiety is needed, for example for a teenager who has very occasional panic attacks, one could consider hydroxyzine 25-50 mg on a prn basis, which is not associated with dependence. Side effects include: sleepiness, dizziness, and dry mouth.

When feasible, the use of rating scales can help in these efforts by documenting severity and monitoring clinical progress. A good tool to review, the SCARED, is accessible at. http://www.pediatricbipolar.pitt.edu/content.asp?id=2333#3304 and a broader array of tools is listed at the following website http://www2.massgeneral.org/schoolpsychiatry/screening_anxiety.asp

Anxiety in Children and Adolescents

creativefusion — Thu, 26 May 2016 18:09:26 +0000

Up to one in three children and adolescents experience clinically significant anxiety, and it is often under-recognized and under-treated. It is particularly important for primary care providers to be aware of the symptoms of anxiety in pediatric patients, because patients typically present first in this setting. Often the presenting complaint is a physical symptom, rather than “anxiety”.

First, it is important to determine what makes anxiety clinically significant. Anxiety is an expected, normal, transient response to stress and can be helpful with the warning of danger or coping with the stress. Clinically significant anxiety is an excessive response to external stress or related to an unidentifiable trigger. It is persistent rather than transient. It causes functional impairment, by exceeding the patient’s ability to cope with the stress and/or leading to avoidance behaviors.

General symptoms of anxiety in children include many worries about things before they happen, constant worries or concerns about family, school, friends or activities, fears or embarrassment or making mistakes, low self-esteem and lack of self-confidence. There are often somatic complaints as well, like stomachaches, headaches, and sleep disturbance, as well as a desire to avoid school and friends.

Specific symptoms of separation anxiety include constant thoughts and intense fears about the safety of parents and caregivers, refusing to go to school, frequent stomachaches and other physical complaints, extreme worries about sleeping away from home, being overly clingy, panic or tantrums at times of separation from parents, trouble sleeping or nightmares, and refusing to sleep without parents.

Specific symptoms of a phobia include extreme fear about a specific thing or situation (ex. dogs, insects, needles) and the fears cause significant distress and interfere with usual activities (ex. child refuses to go to the park because of a fear of seeing a dog).

Specific symptoms of social anxiety include fears of meeting or talking to people, avoidance of social situations despite a desire to attend, and few friends outside the family.

Anxiety disorders have a high rate of co-morbidity with other psychiatric disorders, primarily mood disorders, ADHD and other disruptive behavior disorders, and substance use disorders. It is therefore important to assess for these co-morbidities. To complicate things further, there can be some overlap with the specific symptoms of anxiety and other psychiatric disorders. For example, patients with Generalized Anxiety Disorder may “obsess” about daily worries, patients with Autism Spectrum Disorders have rituals, and patients with Major Depressive Disorder may ruminate or “obsess” over negative self-thoughts, but it does not mean that these patients also have Obsessive-Compulsive Disorder.

Early awareness and treatment of anxiety can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, substance misuse, and feelings of low self-esteem. It is important for primary care providers to be comfortable with assessing for anxiety in pediatric patients and linking families to appropriate resources when needed. Further information about treatment of anxiety symptoms in young patients will be addressed in a future e-weekly publication.