One of your outpatients whom you have been treating for anxiety disorder calls you for help. Her daughter has reported that her bottle of stimulant medication is missing. She suspects her 19-year-old brother, who has started abusing marijuana and has just been arrested by the police after he and his friends were found with unprescribed oxycodone pills. What do you do? How would you assess this young man, taking into consideration his psychosocial environment? Since law enforcement is involved, what would your recommendations be and what are the possible treatment options? This scenario is not unusual, and the Clinical Handbook of Adolescent Addiction, edited by forensic psychiatrist Richard Rosner of New York University Medical Center, comes in very handy. Rosner's attributes of being patient and thorough permeate the book, in content and organization.
The book has seven sections divided into easily understood chapters. The first section examines the scourge of addiction and what adolescent psychiatrists should know. The authors compare epidemiological data regarding addiction in the United States to statistics in the United Kingdom. This section is followed by a discussion of assessment of the substance-using adolescent, including the emergency room examination; management of toxidromes (syndromes caused by high levels of toxins in the body); the use of screening tools and psychological instruments; the impact of psychiatric comorbidities; and the significance of toxicologic testing, with comparative discussions of urine, blood, hair, saliva, and sweat.
Risk and prevention are examined, including Kandel's Gateway and the Reverse Gateway Hypotheses and the relevance of preventive measures being directed toward the use of gateway drugs. Discussions of the clinical aspects of specific drugs are useful. Case vignettes illustrate how cannabis use can affect adolescents.
The challenge of working with adolescents who have substance use disorders requires a skill set that includes structure, managing resistance, and consistency. Rational emotive therapy can be a useful tool to recognize and dispute irrationality in resistant evaluees. Ara Anspikian, in a section on “Promising Practices,” describes the Network for the Improvement of Addiction Treatment (NIATx), including practical considerations, such as attendance and no-show policies, moving clients through various levels of care, and using motivational incentives to foster rehabilitation.
The text contains discussions of clinical aspects of special topics, including sexual addiction, compulsive masturbation, dependence on pornography, telephone sex addiction, and cybersex dependence. These behaviors are facilitated by access to electronic technology, including the Internet, which permits sexting and cybersex, among others.
Although the book is a great resource for general clinicians, the forensic aspect of each section was relatively sparse. The section devoted to the forensic facets of addiction mostly addresses confidentiality, consent, third-party liability for supplying adolescents with illegal substances, and the role of drug courts as alternatives to incarceration in adolescent drug offenders. Although there is a discussion of cultural assessment, the author does not explore how our current legal system comparatively deals with adolescent substance use within the various subcultures. I would have welcomed a discussion of how psychiatric comorbidities like attention-deficit/hyperactivity disorder, anxiety disorders, and mood disorders may or may not mitigate disposition and sentencing.
The chapter on toxicology, although useful, could have elaborated more on when to test, how often to test, the significance of particulate contamination, and the concept of chain of custody. Also, it would have been useful for readers of this journal if the authors had compared and contrasted voluntary and court-mandated admissions in terms of compliance and success rates. Other omissions include a discussion of sexting and cybersex and confidentiality and what role these play in criminal proceedings of adolescents with substance use disorder.
Given that the book was not specifically geared toward forensic psychiatric practitioners, I highly recommend the book for clinicians. The delicate balance of being comprehensive without being intimidating definitely adds to its attractiveness. One hopes that future editions will contain more forensic elaborations.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2014 American Academy of Psychiatry and the Law
