oa Editorial

The lead article in this issue is an essay by Joseph Noshpitz on the Shakespeare play “Love's Labor's Lost,” in which Noshpitz analyzes the play in terms of what it reveals about pubertal development. Although written sometime before 1997, when Noshpitz died, it was never published. In it Noshpitz also reminds us of how endlessly fascinating normal pubertal development is. I won't say more here, other than to say how enjoyable it was to read and edit Noshpitz's work (and remember that he was my first editor) as I have a commentary on this article immediately following it. Several articles in this issue deal with substance abuse related disorders and treatment in adolescents. According to the American Psychiatric Association, 7%-10% of adolescents are in need of treatment for substance use disorders (Kleber et al., 2007) and: Alcohol and other psychoactive substance use, abuse, and dependence in children and adolescents continue to present a serious public health problem in the United States. Alcohol and other substance use are among the leading causes of morbidity and mortality from motor vehicle accidents, suicidal behavior, violence, drowning, and unprotected sexual activity in this population. The Substance Abuse and Mental Health Services Administration (SAMHSA), has called substance abuse treatment for teenagers “A major unmet need” (2002). Among youths in the U.S. aged 12 to 17, there were 1.1 million (4.5 percent) who needed treatment for an illicit drug use problem in 2009. Of this group, only 115,000 received treatment at a specialty facility (10.5 percent of youths aged 12 to 17 who needed treatment), leaving 983,000 youths who needed treatment but did not receive it at a specialty facility. In 2009, there were 1.2 million youths (4.8 percent) aged 12 to 17 who needed treatment for an alcohol use problem. Of this group, only 96,000 received treatment at a specialty facility (0.4 percent of all youths and 8.2 percent of youths who needed treatment), leaving almost 1.1 million youths who needed but did not receive treatment (Substance Abuse and Mental Health Services Administration, 2010). Traditionally, many psychiatrists who treated adolescents were not knowledgeable about or comfortable treating substance abuse problems, and those psychiatrists who provided treatment for substance abuse were not comfortable treating adolescents. I had no formal training in addiction psychiatry during my residencies in general and child and adolescent psychiatry in the 1970s. I learned what I did through a moonlighting job at a substance abuse treatment program in a local community hospital. Although today, formal training in the treatment of substance use disorders is a required part of general psychiatry residency training in the US, only one month is required. There is no stipulation of how much time in child and adolescent psychiatry training programs must be devoted to substance use disorders.1 If one looks at the manpower numbers they are not encouraging. The American Academy of Addiction Psychiatry's website (www.aaap.org) indicates that there are 1,000 AAAP members (membership is open to any psychiatrist who has an interest in addiction medicine, so not all members have had fellowships). Following the completion of general psychiatry training, residents may take advanced training in the form of fellowships. To be formally trained in child and adolescent psychiatry and in addiction psychiatry requires two fellowships, adding a minimum of 3 years of training to general psychiatry training. While undoubtedly there are many psychiatrists without formal training in addiction who are qualified to treat adolescents with substance use problems, it is clear that even if the total number were 5,000 there would not be enough to treat the million plus adolescents who need treatment. Leaving aside the issue of manpower, most substance abuse treatment programs are not tailored for adolescents. Such approaches as Twelve Steps, therapeutic communities, and relapse prevention were all originally developed for adults. Children and adolescents are generally more likely to have abuse rather than dependence disorders and are less likely to appreciate the need for entering and remaining in treatment (Kleber et al., 2007). Adolescents who abuse substances are likely to abuse more than one substance, and are also likely to have other psychiatric disorders, such as conduct disorders, mood disorders, and attention-deficit hyperactivity disorder (Langenbach et al., 2010; Grilo, Becker, Fehon, Edell, & McGlashan, 1996). This level of complexity requires a sophisticated level of knowledge and skill in planning and delivering treatment. A particular challenge is the youngster with ADHD and addiction. Dominic Ferro addresses this problem and summarizes data presented at the 2010 ASAP Annual Meeting. While still a relatively underdeveloped field, substance abuse treatment for adolescents has evolved to the point that there now are specialized treatment programs and psychiatrists trained in addiction medicine and adolescent psychiatry. Richard Rosner, one of these psychiatrists, writes about relapse prevention, which does have a strong evidence base, and about his observations of self-help groups. He is critical of the emphasis on a “higher Power” in AA and NA and sees it as antithetical to the need to develop a greater sense of self-efficacy, which is part of the relapse prevention approach. Interesting, the APA Practice Guidelines cite a study of AA that indicates participants do gain an increased sense of efficacy, at least in terms of their perception of control over their addiction. It may be that each of these approaches (relapse prevention and AA/NA) is effective for a different subset of patients. Kelly and colleagues found that more severely addicted adolescents tended to participate more fully in AA and NA (attending meetings, completing steps, having sponsors) than those who were less impaired, and suggested that relapse prevention may be more appropriate for less severely addicted adolescents, while the AA/NA approach is more suitable for those with more severe problems (Kelly, Myers, & Brown, 2002). The notion that different approaches are appropriate for different individuals should certainly not come as a surprise, and it is an indication of how far the field of adolescent substance abuse treatment still has to go to catch up with treatment for other disorders. Charles Goldberg describes an inpatient treatment program for teenagers with drug and alcohol problems and links the Twelve Steps to various principles utilized in psychodynamic psychotherapy with youngsters in the program. Historically, outcome data to guide treatment decisions have been lacking. This is starting to change. Relapse prevention has a reasonably sound evidence base, which includes controlled studies (Irvin, Bowers, Dunn, & Wang, 1999). AA/NA, where all studies are essentially naturalistic, remains controversial, with reviews of the literature coming to different conclusions about its efficacy (Kaskutas, 2009; Ferri, Amato, & Davoli, 2009). Bunt reviews the literature on the efficacy of the therapeutic community for the adolescent substance abuser, and finds that there is reasonably good support for it. As with AA/NA, studies are naturalistic. One cannot simply assign patients to no treatment or sham treatment, so this situation is not likely to change. What has changed, and will continue to change, is the level of sophistication in measuring change and analyzing results.....