Journal of Substance Abuse Treatment 21 (2001) 161 – 165
Brief article
Dual diagnosis and successful participation of adolescents in substance abuse treatment Brian K. Wise, M.D., M.P.H.a, Steven P. Cuffe, M.D.b,c,*, Timothy Fischer, D.O.d a
b
Department of Psychiatry University of Colorado, Denver, CO, USA Division of Child and Adolescent Psychiatry Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC, USA c William S. Hall Psychiatric Institute, Columbia, SC, USA d William J. McCord Adolescent Treatment Facility, Orangeburg, SC, USA Received 13 December 2000; received in revised form 31 May 2001; accepted 11 June 2001
Abstract A retrospective record review of one year of admissions to a residential adolescent substance abuse treatment program (N = 91) examined the prevalence of comorbid psychiatric disorders and factors associated with successful treatment participation. Psychiatric and substance use disorders (SUD) were diagnosed by DSM-IV criteria. Successful participation was based on multiple factors assessed by the treatment team. Consistent with prior studies, there was considerable comorbidity (63.7%) with both disruptive (Attention Deficit Hyperactivity Disorder [ADHD], 11%; Conduct Disorder [CD], 24%) and other disorders (depression, 24%; adjustment disorder, 7.7%; bipolar disorder, 3.3%). Male gender was negatively associated (OR = 0.23, P = 0.019) with successful participation in univariate analyses, as was ADHD (OR = 0.18, P = 0.007). CD (OR = 0.37, P = 0.053) approached significance. Multivariate analysis reveals ADHD was significant while having CD and being male approached significance. Psychotropic medication use and other diagnoses were not associated with successful participation. It is concluded that further research on the relationship between ADHD, CD, and substance abuse treatment is needed. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Dual diagnosis; Adolescent; Substance abuse; Treatment
1. Introduction The dual diagnosis of psychiatric and substance use disorders (SUD) in adolescents is increasingly recognized as a serious problem among both clinicians and researchers. The clinical consequences of comorbidity are often quite severe, with one study reporting strong associations of comorbidity with academic problems, increased mental health service utilization, history of suicide attempts and moderate associations with problems in role functioning and conflicts with parents (Lewinsohn, Rohde, & Seeley, 1995). Two large population-based studies of adolescents with psychiatric disorders report on comorbidity with SUD. In a population of 14- to 18-year-old adolescents diagnosed with SUD, Lewinsohn, Hops, Roberts, Seeley, and Andrews * Corresponding author. Division of Child and Adolescent Psychiatry, William S. Hall Psychiatric Institute, P.O. Box 202, Columbia, SC 29202, USA. Tel.: +1-803-898-1593; fax: +1-803-898-1617. E-mail address:
[email protected] (S.P. Cuffe).
(1993) reported lifetime prevalence for any disorder (60.0%), unipolar depression (49.3%), disruptive disorder (25.4%), and anxiety disorder (16.2%). The lifetime odds ratios for having another psychiatric disorder were significant for any disorder (OR = 4.3), disruptive disorders (OR = 5.6), eating disorders (OR = 5.0), unipolar depression (OR = 4.5), and anxiety disorder (OR = 2.2). In the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, Kandel, Johnson, Bird, Weissman, and Goodman (1999) found prevalences for current (within the past six months) comorbid psychiatric disorder in adolescents with a SUD were: any anxiety disorder (20.0%), any mood disorder (32.0%), any disruptive disorder (Attention Deficit Hyperactivity Disorder [ADHD], Conduct Disorder [CD], Oppositional Defiant Disorder) (68.0%), and any anxiety, mood, or disruptive disorder (76.0%). Most of the clinical studies reviewed have examined the presence of psychopathology in samples of substance abusing adolescents (DeMilio, 1989; Kaminer, 1991; Milin,
0740-5472/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 1 ) 0 0 1 9 3 - 3
162
B.K. Wise et al. / Journal of Substance Abuse Treatment 21 (2001) 161–165
1996; Stowell & Estroff, 1992; Bukstein, Glancy, & Kaminer, 1992; Hovens, Cantwell, & Kiriakos, 1994; Grilo et al., 1995; Grilo, Becker, Fehon, Edell, & McGlashan, 1996; Wilens, Biederman, Abrantes, & Spencer, 1997; Biederman et al., 1997; Myers, Stewart, & Brown, 1998). The psychiatric disorders most consistently reported to have high prevalence rates have been CD (59%-32%), and mood disorders (including major depression and adjustment disorder) (61%-35%). Other disorders include ADHD and anxiety disorders; however, there is some debate as to whether ADHD’s association with SUD is primarily through their co-association with CD (Disney, Elkins, McGue, & Iacono, 1999; Biederman et al., 1997; Mannuzza et al., 1991; Barkley, Fischer, Edelbrock, & Smallish, 1990; Halikas, Meller, Morse, & Lyttle, 1990). Studies have also produced conflicting results regarding anxiety disorders. Clinical studies that have examined psychiatric samples for the comorbidity of SUD are fewer in number (Greenbaum, Prange, Friedman, & Silver, 1991; King et al., 1996; Fehon et al., 1997). In a sample of adolescents with ‘‘severe emotional disturbances,’’ Greenbaum et al. (1991) found higher rates of substance abuse among adolescents with either severe CD or severe depressive disorder. In comparing hospitalized patients with and without CD, Fehon et al. (1997) found that those with CD were more likely to have either ADHD or SUD whereas patients without CD were more likely to have either a psychotic disorder or an eating disorder. In a group of depressed adolescents, significant predictors of comorbid alcohol and substance abuse in females were longer depressive episodes, more conduct problems and psychosocial impairment, and more active involvement in relationships. Predictors for males included CD, older age, and problems with schoolwork (King et al., 1996). Some research has been performed regarding the impact of dual diagnosis on substance abuse treatment outcome. It has been suggested that symptom severity as well as the type of psychiatric diagnosis may have predictive value in the treatment response of patients with SUDs (Kaminer, 1994; Stowell, 1991). In a sample of 64 adolescents admitted to a psychiatric hospital, Kaminer, Tarter, Bukstein, and Kabene (1992) compared treatment completers (who comprised 78.1% of the sample) and non-completers among dually diagnosed substance abusing adolescents. They found that affective and adjustment disorders (24.5% and 26.5% of completers, respectively; both p < 0.10) demonstrated a trend toward higher prevalence among treatment completers whereas non-completers were more likely to be assigned a CD diagnosis (78.6% of non-completers; p < .05). Further, they found no difference between groups with respect to demographics, legal status, educational level, lifetime psychiatric diagnosis in the parents and caretakers, living arrangements, treatment history, and perception of treatment benefits. In addition, they found that a higher percentage of treatment completers than non-completers received psychotropic medications.
The current study reports the experience of a residential adolescent substance abuse treatment program. The relationship between psychiatric diagnosis, age, gender, race, psychotropic medication use, and successful participation in the treatment program was examined. Study hypotheses included: (1) adolescents with disruptive disorders (ADHD and CD) will be less likely to successfully participate in treatment; (2) adolescents with nondisruptive disorders will be more likely to successfully participate in treatment; (3) demographic variables should not be major discriminant factors for successful participation in treatment; and (4) current psychotropic medication use should increase the odds of successful participation in treatment.
2. Materials and methods This study reports on a retrospective record review of all admissions (n = 97) to a residential adolescent substance abuse treatment program in South Carolina for a full year. The treatment program has an average length of stay of approximately 30 days. The program combines a 12-step component based on Alcoholics Anonymous with educational groups on the addictive process and effects of drugs; individual and group counseling; family therapy; skills building groups such as anger management; and appropriate use of psychotropic medications. The institution’s Review Board approved the project after expedited review. Data were collected in a nonidentified manner to protect the confidentiality of the adolescents by medical students who were blind to outcome condition. All admissions evaluated by a child psychiatrist were included in the study with the exception of those who were either without a substance abuse diagnosis, over age 18, or under age 13 (n = 2). On a few occasions (n = 4) an adolescent was admitted to the facility but discharged prior to evaluation by the child psychiatrist. These subjects were also excluded from the study leaving a final sample size of 91 (93.8% of all admissions). The same child psychiatrist evaluated each participant. Diagnoses of psychiatric disorders were made by the child psychiatrist based on strict Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) criteria. Since only one clinician diagnosed psychiatric disorders, no inter-rater comparisons were possible. SUD diagnoses were made independently by the same child psychiatrist making the psychiatric diagnoses and a family physician with subspecialty certification in addiction medicine. Disagreements in diagnoses were discussed, and a consensus diagnosis made. All diagnoses were made based on direct clinical evaluation of the adolescents at the time of admission, and a review of all pertinent available records. Diagnostic information was later abstracted from the record by the medical students. Further data collected included age, race, gender, use of current psychotropic medications, and successful or unsuc-
B.K. Wise et al. / Journal of Substance Abuse Treatment 21 (2001) 161–165 Table 1 Comparison of successful vs. nonsuccessful treatment group by independent variables Successful participation in treatment Yes (n = 68) N (%)
No: (n = 23) N (%)
Gender Male Females
41 (67.2%) 27 (90.0%)
20 (32.8%) 3 (10.0%)
Race Black White
27 (73.0%) 41 (76.0%)
10 (27.0%) 13 (24.0%)
Age (yrs) Younger: 13 – 15 Older: 16 – 18
32 (82.0%) 36 (69.2%)
7 (18.0%) 16 (30.8%)
Substance abuse/depend 1 substance 2 substances 3+ substances Substance abuse only Any psychiatric disorder Disruptive disorder CD ADHD ODD Nondisruptive disorder Major depression Dysthymia Adjustment disorder Bipolar disorder Psychotropic medications
16 38 14 25 42 17 13 4 1 25 14 4 6 3 19
5 12 6 8 16 10 9 6 0 6 3 1 1 1 5
(76.1%) (76.0%) (70.0%) (75.8%) (72.4%) (63.0%) (59.1%) (40.0%) (100.0%) (80.6%) (82.3%) (80.0%) (85.7%) (75.0%) (79.2%)
(23.9%) (24.0%) (30.0%) (24.2%) (27.6%) (37.0%) (40.9%) (60.0%) (0.0%) (19.4%) (17.7%) (20.0%) (14.3%) (25.0%) (20.8%)
cessful participation in the program. Determination of successful participation in the program was made by the treatment team at the time of discharge. The treatment team consisted of the program director, the medical director (TF), the psychiatric consultant (SPC), the primary counselor, and the head nurse. Factors considered in this decision included attendance and positive interactions in treatment groups, level of denial of problems, quality of products from treatment projects, and interactions with peers and nursing staff during unstructured time. Each aspect of the youth’s treatment was specified on the child’s individualized treatment plan, with specific, measurable goals and objectives. The primary counselor and treatment team met weekly to assess the progress made on each goal, and determined successful attainment of goals and objectives based on the criteria in the treatment plan. The adolescent was determined to have successfully participated in the program when all the goals and objectives were met. Statistical analysis was achieved using Statistical Program for Social Science. Frequency distributions were calculated for demographic, diagnostic, and treatment variables. Logistic regression analyses were then used to explore the association of demographic, diagnostic (both substance use and psychiatric disorders) and psychotropic medication treatment variables with successful participation in the
163
substance abuse treatment program. All variables were initially examined in univariable models. The final multivariable model included all variables retaining significance at the 0.1 level after a backward elimination procedure.
3. Results Of the 91 total subjects with a substance abuse problem, 58 (63.7%) of the individuals received a psychiatric diagnosis. The mean age was 15.36 years old with 61 males (67.0%) and 55 (60.4%) Caucasians. The most common drugs of abuse were marijuana (91.2%), alcohol (60.8%), and cocaine (29.7%). Polysubstance abuse was common, with 76.9% of the sample using two or more drugs. Major depression and/or dysthymia was diagnosed in 24% of the adolescents, ADHD in 11%, CD in 24%, bipolar disorder in 3.3%, and adjustment disorder in 7.7%. In all, 68 adolescents (74.7%) were designated by the treatment team as successful participants. Frequencies for successful versus nonsuccessful participation in treatment across the variables of interest are presented in Table 1. Females had a higher frequency of successful participation in treatment (90%) than males (67.2%). Additionally, adolescents with ADHD (40%) and CD (59.1%) had lower frequencies of successful participation. In the univariable models on successful participation (see Table 2), only two variables, gender and having an ADHD diagnosis, yielded significant results. Males were significantly less likely to successfully participate in the treatment program (OR = 0.228; p = 0.019), as were adolescents with an ADHD diagnosis (OR = 0.177; p = 0.007). None of the other variables significantly increased or decreased one’s
Table 2 Univariable and multivariable logistic regression models on successful participation in treatment OR
95% CI
p-value
Univariable models Race (African-Americans) Age (Older age group) Sex (Males) Alcohol Marijuana Cocaine Psychotropic meds ADHD CD Polysubstance abuse Depression/Dysthymia Any Psychological# disorder Substance abuse only
0.805 0.492 0.228 0.753 0.984 1.266 0.762 0.177 0.368 0.903 1.462 1.031 1.157
(0.31-2.10) (0.18-1.35) (0.06-0.84) (0.27-2.08) (0.18-5.25) (0.44-3.67) (0.46-3.703) (0.045-0.699) (0.131-1.033) (0.29-2.82) (0.43-4.93) (0.40-2.66) (044-3.04)
0.657 0.164 0.019 0.583 0.985 0.663 0.609 0.007 0.053 0.860 0.539 0.949 0.768
Multivariable models CD # Sex (Males) # ADHD
0.16 0.23 0.14
(0.019-1.410) (0.046-1.116) (0.022-0.902)
0.0995 0.0680 0.0386
#
variables included in the final model.
164
B.K. Wise et al. / Journal of Substance Abuse Treatment 21 (2001) 161–165
likelihood for successful participation in treatment in univariate analysis. However, having a CD diagnosis demonstrated a trend to decrease one’s probability of successful participation in treatment (OR = 0.368; p = 0.053). In the multivariable logistic regression analysis (Table 2) the p-value for inclusion in the model was extended to 0.1 in order to find the most robust model by including those variables which were approaching significant levels. In multivariate analysis, being diagnosed with ADHD (OR = 0.14; p = 0.0386) was significant and being male (OR = 0.23; p = 0.0680) and having a CD diagnosis (OR = 0.16; p = 0.0995) approached significance for decreasing one’s likelihood of successful treatment.
4. Discussion Given the limited research on adolescent substance abuse treatment it is difficult to assess whether these findings are typical, but some comparisons to earlier studies can be offered. Our findings are consistent with those of Kaminer et al. (1992) on two important factors: (1) the rate of poor treatment outcome as judged by treatment participation in the current study and completion in the Kaminer study was similar (25.3% and 21.9% respectively), and (2) both found adolescents with disruptive disorders were less likely to have been successful. An interesting result was that adolescents with ADHD in this study were significantly more associated with nonsuccessful treatment participation than adolescents with CD (which demonstrated only a trend in this direction). A few studies may help shed some insight on these results. Wilens, Biederman, and Mick (1998) reported that in comparing adults with and without ADHD, adults with ADHD had a longer duration of psychoactive SUD as well as longer time to reach remission. In contrast, Disney et al. (1999) reported that when controlling for CD, ADHD did not significantly increase the risk of substance use problems. Chilcoat and Breslau (1999) reported that children with ADHD and high externalizing problems were at risk for early drug use in comparison with children with ADHD and low externalizing problems. Further post hoc analysis of the current study’s ADHD population revealed an interesting trend. Among the adolescents with both ADHD and CD (n = 5), 20% were successful treatment participants, whereas among ADHD adolescents without CD (n = 5), 60% were successful treatment participants. The same is true for CD, with 70.6% of adolescents with CD alone successfully participating. This suggests the possibility that comorbid CD may play a role in the association of ADHD with poor treatment participation, but small numbers did not allow the statistical power to detect the interaction. It is also possible that comorbid CD was missed in some of the remaining children with ADHD who were unsuccessful.
In this study the lack of an association between psychotropic medication use and successful treatment participation, which was found by Kaminer et al. (1992), may be due to a number of factors including potential differences in the sample populations as well as possible differences in type and duration of medication treatment. However, the number of adolescents with psychiatric disorders who received medications in the current study (27.5%) is similar to the Kaminer study (26.6%), and adolescents in both studies were mainly treated with antidepressants (72% in the current study), which are noted for not reaching full efficacy until 2-4 weeks, and mood stabilizers. More research is needed to understand the impact of psychotropic medication treatment on the substance abuse treatment process. When interpreting these results, some consideration should be given to the potential limitations of the current study. First, the sample size is small, which decreases statistical power for examining individual diagnoses. Second, this study lacks posttreatment outcome measures, such as relapse rates after discharge. The use of successful treatment participation as an indicator of actual posttreatment outcome has not been established and limits the generalizability of the results. Third, the study uses clinical diagnoses as opposed to diagnoses obtained from a structured diagnostic interview. The benefits of a structured interview are potentially improved reliability of diagnoses, and assurance that all diagnostic areas have been examined. Finally, the method of determining successful treatment participation in the study, while clearly delineated and clinically useful, is not a standardized instrument. This last potential limitation may also serve as a strength. In this study, an individual was considered a successful participant when meeting his or her specific, individualized treatment goals as determined by the treatment team rather than rigidly defined measures that may or may not address particular needs of an individual. Other studies have used attrition rates as outcome measures that may or may not adequately assess treatment efficacy. Given that over 60% of this sample had a comorbid psychiatric disorder, these results add to the growing literature on the pervasiveness of psychiatric comorbidity among adolescents admitted to a substance abuse treatment center. The findings of this study suggest that adolescents with disruptive disorders, especially ADHD, are less likely to successfully participate in substance abuse treatment programs. This points to the need to screen all substance abuse admissions for comorbid psychiatric disorders as this may identify adolescents at high risk for unsuccessful treatment, as well as the need to modify components of the treatment plan to meet individualized treatment needs. This study may also indicate a need to develop more intensive treatment plans for children with comorbid ADHD and SUD. In the current study, ADHD was more significantly associated with treatment resistance than was CD, however, only half of the adolescents with ADHD were being treated with psychotropic medications. Biederman,
B.K. Wise et al. / Journal of Substance Abuse Treatment 21 (2001) 161–165
Wilens, Mick, Spencer, and Faraone (1999) report in a recent study that psychotropic treatment of children with ADHD reduces risk of SUD. Perhaps more aggressive treatment of ADHD in the adolescents in the current study would have improved their substance abuse treatment outcome. Further research is needed to examine the association between treatment of ADHD and successful treatment of adolescents in substance abuse treatment programs. The findings from this study also demonstrate the need for future research in other areas. The relationship between ADHD and CD in adolescents with SUD clearly warrants future research. Other important research areas include the use of psychotropic medications in comorbid populations, long term outcome studies, and a comparison of outcomes between intensive outpatient and residential treatment settings.
References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (4th ed.). Washington, DC: American Psychiatric Association. Barkley, R. A., Fischer, M., Edelbrock, C. S., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8 year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546 – 557. Biederman, J., Wilens, T., Mick, E., Faraone, S. V., Weber, W., Curtis, S., Thornell, A., Pfister, K., Jetton, J. G., & Soriano, J. (1997). Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 21 – 29. Biederman, J., Wilens, T., Mick, E., Spencer, T., & Faraone, S. (1999). Pharmacotherapy of attention-deficit/hyperactive disorder reduces risk for substance use disorder. Pediatrics, 104, e20. Bukstein, O., Glancy, L., & Kaminer, Y. (1992). Patterns of affective comorbidity in a clinical population of dually diagnosed adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1041 – 1045. Chilcoat, H. D., & Breslau, N. (1999). Pathways from ADHD to early drug use. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1347 – 1354. DeMilio, L. (1989). Psychiatric syndromes in adolescent substance abusers. American Journal of Psychiatry, 146, 1212 – 1214. Disney, E. R., Elkins, I. J., McGue, M., & Iacono, W. G. (1999). Effects of ADHD, conduct disorder, and gender on substance use and abuse in adolescence. American Journal of Psychiatry, 156, 1515 – 1521. Fehon, D. C., Becker, D. F., Grilo, C. M., Walker, M. L., Levy, K. N., Edell, W. S., & McGlashan, T. H. (1997). Diagnostic comorbidity in hospitalized adolescents with conduct disorder. Comprehensive Psychiatry, 31 (3), 141 – 145. Greenbaum, P. E., Prange, M. E., Friedman, R. M., & Silver, S. E. (1991). Substance abuse prevalence and comorbidity with other psychiatric disorders among adolescents with severe emotional disturbances. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 575 – 583.
165
Grilo, C., Becker, D., Fehon, D., Edell, W., & McGlashan, T. (1996). Conduct disorder, substance use disorders, and coexisting conduct and substance use disorders in adolescent inpatients. American Journal of Psychiatry, 153, 914 – 920. Grilo, C. M., Becker, D. F., Walker, M. L., Levy, K. N., Edell, W. S., & McGlashan, T. H. (1995). Psychiatric comorbidity in adolescent inpatients with substance use disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1085 – 1091. Halikas, J. A., Meller, J., Morse, C., & Lyttle, M. D. (1990). Predicting substance abuse in juvenile offenders: Attention deficit disorder versus aggressivity. Child Psychiatry and Human Development, 21, 49 – 55. Hovens, J., Cantwell, D., & Kiriakos, R. (1994). Psychiatric comorbidity in hospitalised adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 476 – 483. Kaminer, Y. (1991). The magnitude of concurrent psychiatric disorders in hospitalised substance abusing adolescents. Child Psychiatry and Human Development, 22, 89 – 95. Kaminer, Y. (1994). Adolescent Substance Abuse: A Comprehensive Guide to Theory and Practice. New York, NY: Plenum. Kaminer, Y., Tarter, R. E., Bukstein, O. G., & Kabene, M. (1992). Comparison between treatment completers and noncompleters among dually diagnosed substance-abusing adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1046 – 1049. Kandel, D. B., Johnson, J. G., Bird, H. R., Weissman, M. M., Goodman, S. H., Lahey, B. B., Regier, D. A., & Schwab-Stone, M. E. (1999). Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 38 (6), 693 – 699. King, C., Ghaziuddin, N., McGovern, L., Brand, E., Hill, E., & Naylor, M. (1996). Predictors of comorbid alcohol and substance abuse in depressed adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 743 – 751. Lewinsohn, P. M., Hops, H., Roberts, R. E., Seeley, J. R., & Andrews, J. A. (1993). Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Child Psychology, 102, 133 – 144. Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1995). Adolescent psychopathology: III. The clinical consequences of comorbidity. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 510 – 519. Mannuzza, S., Gittelman-Klein, R., Bonagura, N., Malloy, P., Giampino, T., & Addali, K. (1991). Hyperactive boys almost grown up. V. Replication of psychiatric status. Archives of General Psychiatry, 48, 77 – 83. Milin, R. P. (1996). Comorbidity of substance abuse and psychotic disorders: focus on adolescents and young adults. Child & Adolescent Psychiatric Clinics of North America, 5, 111 – 122. Myers, M., Stewart, D., & Brown, S. (1998). Progression from conduct disorder to antisocial personality disorder following treatment for adolescent substance abuse. American Journal of Psychiatry, 155, 479 – 485. Stowell, R. J. A. (1991). Adolescent substance abuse: Dual diagnosis issues. Psychiatric Annals, 21, 98 – 104. Stowell, R. J. A., & Estroff, T. W. (1992). Psychiatric disorders in substanceabusing adolescent inpatients: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 1036 – 1040. Wilens, T., Biederman, J., Abrantes, A., & Spencer, T. (1997). Clinical characteristics of psychiatrically referred adolescent outpatients with substance use disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 941 – 947. Wilens, T., Biederman, J., & Mick, E. (1998). Does ADHD affect the course of substance abuse? Findings from a sample of adults with and without ADHD. American Journal of Addictions, 7, 156 – 163.