Assessing the Impact of Childhood Interventions on Subsequent Drug Use

United States

About the Conference

Research indicates that psychiatric disorders are frequently comorbid with drug use disorders, and that some childhood psychopathological conditions are associated with increased risk for drug abuse. This suggests that treating psychiatric disorders in childhood may have implications for reducing later risk for drug abuse and might serve as a potentially effective drug abuse prevention approach for some children and adolescents. However, this question has been little studied so far. Concerns also exist about childhood mental health interventions that may increase risk for subsequent drug abuse, as has been suggested by some regarding stimulant medication. Research on the effectiveness of treating psychiatric conditions associated with increased risk for drug abuse also holds potential for adding to knowledge about etiologic pathways to drug abuse. The chief aim of this meeting therefore was to lay the foundation for studying whether childhood psychiatric interventions can serve both as treatment for the childhood disorder and as a drug abuse prevention strategy for those at high risk.

The conference was held on May 23-24, 2000, at the Hotel Washington in Washington DC. Program Staff from the National Institute on Drug Abuse, NIH, with participation of Staff from the National Institute of Mental Health, organized and sponsored this meeting, which was attended by approximately 125 researchers with background and interest potentially to work on this new area of research. The goal of encouraging and facilitating research on these questions was addressed in four sections. First, background information was presented to review current knowledge about the epidemiology, basic science, and developmental trajectories of early psychopathology and later drug abuse. Second, a range of exemplar studies currently underway were presented and discussed. Third, methodological challenges to this type of research were reviewed, and fourth, presentations and discussion about addressing practical and ethical barriers to implementing such research.

Remarks by Richard Millstein, J.D. Deputy Director, National Institute on Drug Abuse, NIH

Thank you, Meyer [Glantz], and good morning, everyone. Yes, the two people are one. And it is my pleasure to welcome you here to this meeting to focus on the impact of childhood interventions on subsequent drug abuse, an extremely complex area of drug abuse etiology that we need to know much more about. Let me start, please, by thanking everyone. We are really proud that we at NIDA have joined with the National Institute of Mental Health (NIMH) in sponsoring what promises to be a most interesting, productive, and, I hope, provocative exchange in our area of common interest.

A number of people deserve special recognition, including Dr. Glantz, the meeting Chair; and from NIDA, Drs. James Colliver, Elizabeth Robertson, Vincent Smeriglio, and Naimah Weinberg, who will be serving as Session Chairs; and Drs. Lynda Erinoff and Kathleen Etz for their efforts on the Junior Investigator Committee. I know that a number of individuals at NIMH were prominently involved here, too, including Drs. Editha Nottelmann, Doreen Koretz, and Benedetto Vitiello. Thank you to all of them.

We at NIDA feel very fortunate to have recruited many of the Nation=s most renowned experts in this area to help review the knowledge base, to identify research gaps and as yet untapped sources of potentially useful data, and to provide some resources for future research. We are hopeful that topics addressed and the discussion generated over the next few days will encourage and facilitate research in this novel and necessary area and, more specifically, identify and explore ways to resolve problematic methodological issues and motivate those already looking at separate aspects of this complex picture to extend the breadth of focus in their study designs.

As many of you know, in our attempts to identify and quantify potential risk factors for drug abuse, NIDA has had a longstanding interest in assessing the impact of various childhood psychopathologies. In fact, nearly 3 years ago, in July 1997, we held a workshop to look at the extent of our knowledge in this area. Back then, following 2 days of overview and databased, speculative, and synthesizing discussions, the panel of experts that had been brought together unanimously endorsed the conclusion that a wide range of diagnosable psychiatric disorders—premorbid to substance abuse—are associated with subsequent substance abuse. Intuitively, it would then follow that treatment for these disorders should have a positive impact on reducing later risk for drug abuse; that is, for some children and adolescents, interventions for existing psychopathologies may serve as existing drug abuse prevention approaches. The problem is, of course, that we do not know for certain that this is always the case and for whom. For example, one possible exception may be ADHD, the most common childhood Axis I mental disorder.

In recent years one of the major controversies concerning ADHD, as you know, has centered on the use of psychostimulants to treat the condition, and the potential abuse liability of these drugs. Psychostimulants, including amphetamines, methylphenidate, and pemoline, are by far the most widely researched, clinically effective, and commonly prescribed treatments for ADHD. And yet, despite evidence documenting these compounds= efficacy in treating ADHD, questions about the need for or effectiveness of these compounds, and concerns about the potential for abuse or addiction, remain in the minds of too many—both in the public at large and within segments of the medical community. Again, although there are some data to the contrary, many worry that use of psychostimulants in childhood can increase an individual=s risk for drug abuse later in life. Really, then, more research is needed to delineate the long-term benefits and any potential risks.

The impact of treating other psychopathologies experienced in childhood also is uncertain. The research, although clearly needed, has not yet been done. Few if any drug abuse prevention programs target childhood psychopathologies. Mental health research to develop and test treatments for psychopathologies in children typically do not look at long-term substance abuse outcomes.

We at NIDA are interested in exploring a new area of drug abuse etiology, particularly one that offers additional possibilities of prevention and early intervention. The approach we are proposing to take in building a research program in this area is also relatively unique in that, when possible, we would like to build on programs and methods that are already in progress. Ongoing trials of mental health interventions for childhood psychopathologies, for example, might be extended to incorporate a focus on drug abuse outcomes. We are interested in developing a program that maximizes the efforts and knowledge gained by both mental health and drug abuse researchers studying the relationship between childhood psychopathologies and later drug abuse.

So, on behalf of NIDA, I would like to express my gratitude to all the meeting participants for your willingness to share your knowledge and your perspectives on this important issue. Our motive in bringing together clinicians and researchers, including a number of relatively young scholars from both the drug abuse and mental health fields, is to bring a broad array of views and ideas to bear on this issue. By facilitating an interchange on areas of mutual interest, we hope we can successfully encourage many of you to incorporate additional issues into the future research you undertake and help us build this sorely needed knowledge base. Again, thank you. I look forward to the views in the presentations and discussions to follow.

Remarks by Steven E. Hyman, M.D. Director, National Institute of Mental Health, NIH

Good morning. Unfortunately for me I have to oscillate between two meetings in the same building, and since human cloning is not yet practicable, I will be a bit impolite and be going back and forth. But I think it is really important to focus on some critical issues facing us in our collaborative deliberations. I am very keen on this kind of collaboration with NIDA, which is absolutely critical if we expect to seriously address these problems.

Let me put my interests and concerns in context. On Thursday, I had the opportunity to testify before a Senate committee on parity for health insurance for mental disorders, and a number of people also raised the issue of insurance parity for substance abuse. One of the issues in discussing these matters before the Senate was exactly this: that there are, in the long run, enormous health benefits and cost offsets if we treat early mental disorders in an appropriate and effective fashion. An example that came up, because it is always in the public mind, is ADHD. But arrayed on the other side, of course, are people who have money to lose, in essence, by extending insurance coverage to children with a diversity of disorders, and they would say again and again, ALet me see your data.@ They have become increasingly sophisticated and, in fact, asked questions that are not beneath contempt, but are rather questions that we ought to be concerned about. That is to say, we really do need to understand the impact of early interventions in mental disorders on long-term outcomes. Despite some wonderful and helpful forays, we do not have the data that will convince them or convince us yet.

The reasons for that, however, are complex and difficult, and will require, I think, this group of people to take us to the next level. In particular, the issues have to do with understanding that we are faced with very long-term developmental issues. We are looking at risk factors operating very early in life. We are looking at the onset of mental disorders very early in life in many cases. Therefore, the children with the worst ADHD might be showing behavioral signs and symptoms as early as age 2 or 3; for mood disorders, as early as age 5 or 6; and for anxiety disorders probably also quite early in life. And we are thinking about outcomes perhaps almost a decade later. Despite the good research that has been done, we really cannot address, in a continuous way, the impact of interventions at different early stages on these very late outcomes.

If this were simply a matter of money, I am sure that we and NIDA, together, would have the will to do it. But of course, as you know, trying to understand these very long-term outcomes faces difficulties in organizing the investigation and also ethical difficulties. That is, the most ideal kinds of studies, which might involve randomization with long-term followup, rapidly move into the ethical gray zone as we think about how long a child can be part of an experiment, even if we do not know the right answers. The MTA trial, which was so important in addressing the treatment of ADHD, lasted for 14 months, 1 school year plus a summer, in essence. It is hard to see how we could ethically keep children randomized longer than that period of time. Also, one needs to think about retention, about power, and about the fact that the child is changing before our eyes as he or she moves from developmental stage to developmental stage. Despite these difficulties and obstacles, we are in a challenging world. We do need to know, ultimately, what interventions will make a difference. We need to know this information not only to encourage employers and insurers who in many ways were the skeptical audience listening to the Senate hearing, but also obviously to practice—not because it sounds right and good to intervene early, but because the interventions that we want to import into health care settings, schools, and other settings are the right ones. We need to determine how they should be administered and understand their impact.

I believe that we have an enormous amount of hard work ahead of us, and we will hear about very important data that have created a platform. Other important data will be arriving in the next 5 or 10 years on genetic risk factors that may indeed be shared between what we can now hypothesize to be primary substance use disorders and mental disorders. But we obviously cannot wait for these data. It is clear that as a community, as a shared community between drug abuse researchers and mental health researchers, we have our important work cut out for us. I wish you the best of luck in your discussions and deliberations today. Thank you.

Commissioned Papers

Commissioned papers were written by:

• Barbara J. Burns, Ph.D., Scott N. Compton, Ph.D., Helen L. Egger, M.D., and Elizabeth M.Z. Farmer, Ph.D.
  Services Effectiveness Research Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
  An Annotated Review of the Evidence Base for Psychosocial and Psychopharmacological Interventions for Children with Attention-Deficit/Hyperactivity Disorder, Major Depressive Disorder, Disruptive Behavior Disorders, Anxiety Disorders, and Posttraumatic Stress Disorder (Supported in part by NIDA Contract 263-MJ-919512).  Download paper (PDF, 482KB)
• E. Jane Costello, Tonya D. Armstrong, and Alaattin Erkanli
  Center for Developmental Epidemiology, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3454, DUMC, Durham NC 27710
  Report on the Developmental Epidemiology of Comorbid Psychiatric and Substance Use Disorders, Presented to the National Institute on Drug Abuse April 2000. Download paper (PDF, 527KB)
• Paul E. Greenbaum
  Department of Child and Family Studies, Louis de la Parte Florida Mental Health Institute, University of South Florida
  Service Use Among Adolescents With Comorbid Mental Health and Substance Use Disorders.  Download paper (PDF, 127KB)
• Chi-Ming Kam and Linda M. Collins
  The Methodology Center, Pennsylvania State University
  Annotated Bibliography on Research Methods.  Download paper (PDF, 440KB)

Selected Bibliography

Armstrong, T.D., & Costello, E.J. (2002). Community Studies on Adolescent Substance Use, Abuse, or Dependence and Psychiatric Comorbidity: A Literature Review. Journal of Consulting and Clinical Psychology, 70, 1224-1239.

Beitchman, J.H., Douglas, L., Wilson, B., Johnson, C., Young, A., Atkinson, L., Escobar, M., & Taback, N. (1999). Adolescent Substance Use Disorders: Findings From a 14-Year Follow-Up of Speech and Language Impaired and Control Children. Journal of Clinical Child Psychology, 28, 312-321.

Cicchetti, D., & Rogosch, F.S. (1999). Psychopathology as Risk for Adolescent Substance Use Disorders: A Developmental Psychopathology Perspective. Journal of Clinical Child Psychology, 28, 355-365.

Clark, D.B., Parker, A.M., & Lynch, K.G. (1999). Psychopathology and Substance-Related Problems During Early Adolescence: A Survival Analysis. Journal of Clinical Child Psychology, 28, 333-341.

Clark, D.B., & Winters, K.C. (2002). Measuring Risks and Outcomes in Substance Use Disorders Prevention Research. Journal of Consulting and Clinical Psychology, 70, 1207-1223.

Compton, S.N., Egger, H.L., Burns, B.J., & Robertson E. (2002). Review of the Evidence Base for Treatment of Childhood Psychopathology: Internalizing Disorders. Journal of Consulting and Clinical Psychology, 70, 1240-1266.

Costello, J.E., Erkanli, A., Federman, E., & Angold, A. (1999). Development of Psychiatric Comorbidity With Substance Abuse in Adolescents: Effects of Timing and Sex. Journal of Clinical Child Psychology, 28, 298-311.

Farmer, E., Compton, S. N., Burns, B.J., & Robertson E. (2002). Review of the Evidence Base for Treatment of Childhood Psychopathology: Externalizing Disorders. Journal of Consulting and Clinical Psychology, 70, 1267-1302.

Glantz, M. D. (1992). A Developmental Psychopathology Model of Drug Abuse Vulnerability. In M. D. Glantz & R. Pickens (Eds.). Vulnerability to Drug Abuse. (pp. 389-418). Washington, D.C.: American Psychological Association.

Glantz, M.D. (2002). Introduction to the Special Issue on the Impact of Child Psychopathology Interventions on Subsequent Substance Abuse: Pieces of the Puzzle. Journal of Consulting and Clinical Psychology, 70, 1203-1206.

Glantz, M.D., & Leshner, A.I. (2000). Drug Abuse and Developmental Psychopathology. Development and Psychopathology, 12, 795-814.

Glantz, M.D., Weinberg, N.Z., Miner, L.L., & Colliver, J.D. (1999). The Etiology of Drug Abuse: Mapping the Paths. In M. D. Glantz & C. R. Hartell, (Eds.). Drug Abuse: Origins and Interventions. (pp. 3-46). Washington, D.C.: American Psychological Association.

Greenbaum, P.E., Foster-Johnson, L., & Petrila, A. (1996). Co-Occurring Addictive and Mental Disorders Among Adolescents: Prevalence Research and Future Directions. American Journal of Orthopsychiatry, 66, 52-60.

Greene, R.W., Biederman, J., Faraone, S.V., & Wilens, T. (1999). Further Validation of Social Impairment as a Predictor of Substance Use Disorders: Findings From a Sample of Siblings of Boys With ADHD. Journal of Clinical Child Psychology, 28, 349-354.

Kendall, P.C., & Kessler, R.C. (2002). The Impact of Childhood Psychopathology Interventions on Subsequent Substance Abuse: Policy Implications, Comments and Recommendations. Journal of Consulting and Clinical Psychology, 70, 1303-1306.

Loeber, R., Stouthamer-Loeber, M., & Raskin White, H. (1999). Developmental Aspects of Delinquency and Internalizing Problems and Their Association With Persistent Juvenile Substance Use Between Ages 7 and 18. Journal of Clinical Child Psychology, 28, 322-332.

Michael, K.D., & Crowley, S.L. (2002). How Effective Are Treatments for Child and Adolescent Depression? A Meta-Analytic Review. Clinical Psychology Review, 22, 247-269.

Rende, R., & Weissman, M. M. (1999). Sibling Aggregation for Psychopathology in Offspring of Opiate Addicts: Effects of Parental Comorbidity. Journal of Clinical Child Psychology, 28, 342-348.

Webster-Stratton, C., & Taylor, T. (2001). Nipping Early Risk Factors in the Bud: Preventing Substance Abuse, Delinquency, and Violence in Adolescence Through Interventions Targeted at Young Children (0-8 Years). Prevention Science, 2, 165-192.

Weinberg, N.Z., & Glantz, M.D. (1999). Child Psychopathology Risk Factors for Drug Abuse: Overview. Journal of Clinical Child Psychology, 28, 290-297.

Weinberg, N.Z., Rahdert, E.Q., Colliver, J.D., & Glantz, M.D. (1998). Adolescent Substance Abuse: A Review of the Past 10 Years. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 252-261.

Program Contacts

Investigators are strongly encouraged to contact NIDA program staff to discuss possible grant applications on these subjects. Most applications will fall within the purview of the Division of Epidemiology, Prevention, and Services Research. Descriptions of relevant program areas and staff contacts can be found at https://www.drugabuse.gov/about-nida/organization/divisions/division-epidemiology-services-prevention-research-despr. For more information related to this meeting or for assistance with referrals to appropriate program staff, contact Dr. Naimah Weinberg, Epidemiology Research Branch,  301-402-1908.