NEUROPSYCHOLOGICAL ASSESSMENT OF ADOLESCENT POLYDRUG USERS AND NEUROLOGICALLY IMPAIRED ADOLESCENTS by MICHAEL J. RATHEAL, B.A., M.Ed.

A DISSERTATION IN EDUCATION Submitted to the Graduate Faculty of Texas Tech University in

Partial F u l f i l l m e n t of

the Requirements for the Degree of DOCTOR OF EDUCATION

Approved

Accepted

December, 1988

10^

to\'

ACKNOWLEDGMENTS

I wish to thank Dr. Paul Dixon for his support in preparation of this study. Not only in this effort, but in

my academic career he put in to practice the theories of learning and motivation which provided a structure for the enthusiasm I felt for this experience. I appreciate the

support and expertise of my committee: Dr. Gerard Bensberg, Dr. John Nevius, Dr. Arlin Peterson, and Dr. Gerald Parr. I also thank my fellow students for their support and stimulation throughout this process. I would like to acknowledge the support provided by Dr. Ray Brown who was employer, colleague, and friend throughout this project. He contributed emotional support,

encouragement, and direction in reaching this goal. My most intense gratitude goes to my family. First of

all, to my remarkable husband, Otto Ratheal, who not only tolerated the stress of this experience and took good care of me and our family, but spent countless hours preparing the final copy. My sons, Devin and Ian, provided ongoing

inspiration to complete this task so that I could build with Legos and make cookies without guilt. I thank my

sister, Stephani Windham, for her undying sympathetic encouragement and finally my mother, Nita Hisey, who made me believe I could do it in the first place. ii

CONTENTS ACKNOWLEDGMENTS TABLES CHAPTER I. INTRODUCTION Statement of the Problem Purpose of the Study Limitations and Considerations of the study II. REVIEW OF RELATED LITERATURE History of Drug Abuse in the United States Adolescent Drug Use Assessment of Cognitive Functioning . . . . Cognitive Functioning of Polydrug Users . . Summary and Review of Hypotheses III. METHODOLOGY Subjects Instruments Demographic and Background Data Medical History Demographic Data Psychological Functioning Measures of Cognitive Ability
111

ii vi

1 1 3

4 8

8 13 17 23 35 38 38 39 ... 39 39 40 40 .... . . 42 44

General Intellectual Ability

Academic Achievement Memory and New Learning Visual-Spatial and VisualPerceptual Ability Higher Conceptual Processing Attention and Concentration Design and Analysis Procedures IV. RESULTS Descriptive Data Subjects Demographics on Polydrug Subjects Medical History of the Polydrug Subjects Categories of Drugs Used Psychological Functioning of Polydrug Subjects Medical History of the Neurologically Impaired Subjects Clinical Impairment Ratings Hypothesis Testing Hypothesis 1 Discussion of Cinical Significance of Group Means Hypothesis 2 V. DISCUSSION AND CONCLUSIONS Summary
TV

44 45 46 . . . . 46 47 48 49 52 52 52 . . 53

55 55 60 61 61 63 63

63 74 77 77

Discussion of the Study Summary of Results Implications for Further Research Implications for the Professional Conclusions REFERENCES APPENDICES A. B. C. MEDICAL HISTORY QUESTIONNAIRE DEMOGRAPHIC QUESTIONNAIRE GLOSSARY . . . .

80 87 89 90 92 94

100 102 105

TABLES

1. 2. 3. 4. 5. 6. 7. 8. 9.

DEMOGRAPHIC CHARACTERISTICS OF ALL SUBJECTS DEMOGRAPHIC VARIABLES OF THE POLYDRUG GROUP MEDICAL HISTORY QUESTIONNAIRE CATEGORIES OF DRUGS USED FREQUENCIES OF CLINICAL IMPAIRMENT RATINGS FREQUENCIES OF UNIMPAIRED AND IMPAIRED CLINICAL RATINGS COMPARISON OF NEUROPSYCHOLOGICAL TEST RESULTS OF POLYDRUG USERS AND NEUROLOGIC GROUPS COMPARISON OF STATISTICAL FINDINGS AND CLINICAL IMPAIRMENT RATINGS ON INDIVIDUAL TESTS . T-TEST COMPARISON OF CLINICAL IMPAIRMENT RATINGS

54 56 58 59 62 62 64 70 76

VI

CHAPTER I INTRODUCTION Statement of the Problem Drug use is a problem which has become part of our "cultural clothing" (Parsons & Farr, 1981). Millions of

people are involved in the use of illegal substances and their use has become so widely accepted that drugs such as marijuana and cocaine have been casually accepted as part of social gatherings. The exploration of illegal drug use

and abuse is extremely complex and assessment in this area only began in the early 1970*s. Parsons and Farr (1981)

relate the difficulty in studying this question to the numerous factors which contribute to drug abuse and the historical paucity of adequate measurement tools in this area. The acute effects of drug use and drug abuse are well documented in medical literature. Whether or not long-term

cognitive dysfunction is associated with intense or chronic drug use has only recently been investigated (Grant & Mohns, 1975; Parsons & Farr, 1981). There is a well

established pattern of cognitive deficits associated with chronic alcohol abuse but questions remain regarding the contribution of nutritional deficits, possible premorbid brain dysfunction, and toxic additives to the findings.

Well controlled studies of populations using a single category of drugs; sedatives, marijuana, stimulants, hallucinogens, and narcotics, found no lasting cerebral dysfunction. It appears, however, that abuse of a single category of drug does not represent the current drug use pattern. Rather, a pattern of simultaneous and sequential drug use is typical of the adults and youth currently involved in drug use; therefore, the question of the effect of polydrug use on cognitive functioning needed investigation. Six

studies were located which attempted to respond to this question (Adams et al., 1975; Bruhn & Maage, 1975; Grant, Adams, Carl in, Rennick, Judd, & Schooff, 1978; Grant et al., 1978b; Grant & Judd, 1976; Grant et al., 1976). the exception of one study located in Denmark (Bruhn & Maage, 1975), the studies were immediate precursors to, or part of, a grant funded by the National Institute on Drug Abuse. These investigations documented long-lasting With

cerebral deficits in polydrug abusers whose mean ages ranged from 25 to 26 years. With the increasing drug use

by adolescents and the documented trend toward polydrug use in this population (Pandina & White, 1981), the question of the effects of chronic, multiple drug use on brain function needs assessment for this group.

Purpose of the Study The research which supports a connection between polydrug use and cognitive deficits has been done on a young, but not an adolescent, population. Further, the

studies were completed at a time when "designer drugs" were not being used. This study provides empirical data

regarding cognitive functioning of polydrug abusing adolescents relative to a sample of neurologically impaired teenagers who were matched for age. There are several reasons why this data may be valuable to professionals working with treatment of adolescent drug abuse: 1. Adolescent drug use is viewed as a failure to meet

the challenges of adolescent development; identification of cognitive impairment associated with drug abuse may contribute to prevention arguments, to motivation for seeking treatment, and to reduction of recidivism. 2. Identification of cognitive impairment in polydrug

abusing adolescents may assist treatment providers in modifying therapeutic approaches to accommodate an individual patient's abilities. 3. Identification of cognitive impairment in a young

population of drug abuse may suggest the existence of premorbid levels of cognitive deficit which could assist in identification of a vulnerable target population for special attention in prevention services.

This study provides additional data regarding demographic and psychological functioning of adolescents who are involved in polydrug abuse to a degree which has identified them as in need of inpatient treatment.

Limitations and Considerations of the Study This study was conducted in an inpatient hospital treatment setting and certain limitations and restrictions were necessary as a result of the need to avoid disruption of the program. The patient's inpatient status was not

within the control of the examiner. The most revealing information about the effects of drug abuse on cognitive functioning would accurately account for levels of drug use, both cumulative use and intensity of single episodes of use. Obtaining a truly

accurate picture of drug use patterns from a self-report measure has limitations. The subjects may have memory A need to give

difficulty for periods of intense drug use.

socially desirable responses may affect the patient's reporting of drug involvement. The procedures used in this study, neuropsychological measures of brain functioning, are typically used to assess identified brain pathology such as tumors, stroke, and head injury. Their use in identifying less specific and

possibly reversible deficits is less well established and therefore validity of the measures may be questioned. The issue of deficits itself is somewhat ambiguous. child may show a pattern of strengths and weaknesses on a psychometric measure of intelligence, and although some abilities may fall in the borderline range of ability they do not necessarily indicate deficient brain functioning. The measures used must cover both broadly and in depth each major category of ability in order to describe levels of functioning and, even then, it is the pattern of performance, rather than any individual test which truly indicates level of ability. The confounding effect of psychopathology on brain function must be dealt with in attempting to describe causal factors for any observed brain dysfunction. The A

relationship of illegal drug use to psychological maladjustment has been the predominant focus of the literature dealing with attribution of causes. Several studies

(Grant et al., 1978; Kilpatrick et al., 1976; Penk et al., 1979) have found evidence of psychological maladjustment in drug abusers. There is research support for dysfunctional

cognitive ability in chronic and acute schizophrenics (Rodnight, 1983). Lezak (1983) states that "the incon-

sistent or erratic expression of cognitive defects suggests a psychiatric disturbance" (p.233). Therefore it is

important to differentiate between deficient functioning which is related to personality characteristics and deficient functioning which is related to impaired brain integrity from drug abuse. The existence of possibly lower levels of premorbid functioning must be differentiated from drug related impairment. Parsons and Farr (1981) state that performance

on neuropsychological measures is highly correlated to the subject's general level of cognitive ability. They further

discuss the possibility that some users of illegal drugs may have lower levels of ability to begin with, resulting in failure experiences, which could represent a contributing factor to involvement with drugs rather than a result of drug abuse. This presents a problem because of the lack

of information about premorbid functioning on the patients in the study. If this information were available, analysis

of individual patterns of functioning would yield comparative data which would be more descriptive of possible drug effects. Both of the subject groups in this study include males and females. Laterality and functional differences have

been consistently demonstrated between the sexes with females performing better on verbal measures and males on visuospatial measures. Lezak (1983) discusses the differ-

ences between males and females in deficits related to a

unilateral lesion, while men show significant impairment on the side where the lesion is located, women show more diffuse deficits. The same kind of differences are found in

studies exploring the lateralization effects of handedness. The most stringently controlled study of brain impairment would attempt to minimize the variability of cerebral organization within each subject group by selecting perhaps only right-handed males but this extent of exclusion was not possible in the present study due to the small subject population available.

CHAPTER II REVIEW OF RELATED LITERATURE

With the onset of public awareness regarding substance abuse a search for causes and effects began. The problem

of the abuse of psychopharmacological drugs has been laid at the door of parents, peers, environmental stressors, and improper medical supervision of addictive substances. No

pattern has been empirically defined for movement from the use of "soft" drugs such as marijuana and alcohol to "hard" drugs including barbiturates, amphetamines, and opiates. Nevertheless, there is evidence that drug abuse is increasingly best described in multiple use terms (Kornblith, 1981) and that cognitive deficits are associated with polydrug abuse.

History of Drug Abuse in the United States The entry of middle class, white youth into the drug scene of the 1960's and 1970's presented a troubling phenomenon to our society (Josephson & Carroll, 1974). As

long as drug use was confined to a lower class, minority population it seemed somehow less odious and more understandable. Kissin (1982) states,

The history of drug dependence is the history of man's search for 'the occasional release 8

from the intolerable clutch of reality' through the taking into his bodyby ingestion, inhalation, or injectionof some magical chemical substance, (p. 2) It did not seem to be a societal failure when the lower classes of an industrialized nation needed more "escape" than other groups, but when the use of drugs became widespread among advantaged youth the message seemed to change. Josephson and Carroll (1974) suggest that this phenomenon was interpreted by parents and parental surrogates such as schools as a threat to "self-control and the work ethic and therefore the very moral fabric of society" (p.xvi). Kissin (1982) and Blum (1969) review the history of drug use. Numerous artifacts suggest the existence of beer The discovery of dis-

from about 6400 B.C. (Blum, 1969).

tilled spirits made alcohol much more readily available. Kissin (1982) indicates that the idea of the "drunkard" appeared and there were epidemics of alcoholism among England's lower classes until the government levied a tax which put liquor beyond the economic reach of the poor. Kissin (1982) indicates that the use of psychoactive drugs was limited by geographic availability with the earliest recorded use of marijuana in China in 2737 B.C. For centuries the drug was known outside the Eastern cultures but was not widely adopted. The use of cannabis in-

creased when the Napoleonic soldiers returned from Egypt with hashish. Its early use in Europe was confined to the

10 artistic and literary elite. The early use of cannabis in

the United States followed much the same pattern. Other botanical substances, cocaine and plant hallucinogens, were likewise confined to specific geographical areas initially. Kissin (1982) and Blum (1969) discuss the

use of psychoactive substances in many religious ceremonies and Kissin notes that the peyote ritual of the Mescalero Apaches is a legal practice in the United States today. Availability, however, is not the only variable predicting the use of a particular drug. Kissin (1982) states that

cocaine use has been dated to pre-Columbian societies but spread very little to the conquering Spaniards. The author

suggests that the method of ingestion, chewing the leaves, may have been culturally unacceptable. After the active

ingredient was isolated, it was used by a German military doctor in the 1880's to relieve fatigue among army troops. The later findings related to the addictive properties and induced psychosis essentially eliminated its use medically. Stating that "health hazards are not the only factors underlying public concern about drugs" (p.xxi) Josephson and Carroll (1974) discuss that while evidence is strong for the health hazards presented by certain drugs they continue to be protected by our society. Some drugs have

become such an accepted part of American culture that they are not considered drugs at all. Nicotine and caffeine are

11 the most commonly used drugs throughout the world (Kissin, 1982). Blum (1969) also points out that health concerns

are not necessarily the major reason for a strong social policy regarding specific drugs. Ray (1978) describes four pharmacological revolutions which paved the way for the current level of illegal drug use. Historically, drugs were part of folk remedies, reli-

gious ceremonies, and celebrations and were only available if they were indigenous to a region. Advances in chemistry

brought about enormous changes in medicine in the 20th century. The development of vaccines for the control of

communicable diseases represents the first of Ray's revolutions. Secondly, the discovery of antibiotic drugs,

including sulfa and penicillin, made major changes in medical care. While these two revolutions were directed at

physical health, Ray's third revolution was the use of tranquilizers in the treatment of mental illness. "The

tranquilizers introduced to the public the concept that drugs which act on the mind could be used to return one's mental health to normal" (Ray, 1978, p.4). The fourth revolution was the advent of the oral contraceptive. perspective is that. For the first time potent chemicals clearly labeled as drugs are being widely used by healthy people because of their social convenience. No longer are we eliminating infection to have a healthy body, neither are we reducing anxiety to have a better functioning mind. Now we are His

12 adding a drug to alter a healthy body and mind because of the convenience it offers in interpersonal contacts, (p.4) An additional chemical push, specific to the drug underworld, has been the development of the so called "designer drugs" which mimic the effects of the more established illegal substances. Kissin (1982) discusses the effect of the 18th Amendment on the level of drug use in the United States. Although Prohibition was effective in reducing the consumption of alcohol and the incidence of alcoholism to levels lower than before its adoption or after its repeal, an unexpected side effect was the development of a powerful institution, organized crime, which continues to exert a major force behind the availability and sale of illegal drugs. Discovery of indigenous substances with mind-altering properties proceeded from accidental ingestion or inhalation to intentional use in order to enhance or escape the human condition. to such drug use. There were often religious connotations The exact reasons for acceptance or

rejection of a particular psychoactive substance into a culture are varied, affected by politics, economics, cultural values, and sometimes by accurate information related to drug effects. In America, the Indians used a variety of

hallucinogenic plants and tobacco was indigenous as well.

13 With the immigration of Europeans, alcohol became the drug of choice and few other substances were widely used. This

remained the case until after World War II when the effects of hallucinogens became widely known and their availability to the "disenchanted youth . . . led, in the late 1950s and 1960s, to the unfolding of a drug culture so powerful that it influenced the drug-taking pattern of the world" (Kissin, 1982, p. 14). Since that time there has been consistent movement toward increased drug use by younger age groups involving a larger variety of illegal substances.

Adolescent Drug Use Standard American values proscribe the nonmedical use of drugs by youth with the exception of alcohol which the culture perceives as a hallmark of adulthood (Jessor & Jessor, 1975). Baumrind (1985) discusses the risk-taking

behavior which is typical of adolescent development and that for the majority of adolescents who experiments with drugs this behavior is self-limited to the stage of early adolescence in which the teenager is seeking accommodation of Attainment of formal operational capacities; transition of conventional to principled morality; increased importance of peer relative to family as a socialization context; increased self-centeredness joined with enhanced roletaking ability; and, finally, jeopardized selfesteem, (p. 14)

14 The increased social acceptance of the recreational use of marijuana and cocaine by adults in recent years has lessened the censure for involvement with these drugs. The

most common pattern of substance abuse among teenagers is the combined use of alcohol and marijuana (Pandina & White, 1981). Patterns of drug use by nonpatient or nontreatment The typical approach

populations are difficult to obtain.

to gathering this data is a self-report questionnaire circulated in public school settings. Data are also obtained

by assessing pretreatment levels of drug involvement in patients involved in drug treatment programs. In a search

for causes of polydrug involvement by high school students, Kamali and Steer (1976) report. The attitudes which were related to polydrug involvement reflected a hedonistic quest for pleasant sensations and expanded creativity while simultaneously denying that drug use was potentially harmful, (p.342) Dembo et al. (1985) discuss the sociocultural and personality variables contributing to drug use. In a concept

they call "relative deviance" the authors describe the view that for inner city urban youth, drug involvement is a prosocial behavior and is egosyntonic while for adolescents whose cultural values proscribe drug use, it is egodystonic and therefore more likely to be related to psychopathology. Hawkins, Lischner, & Catalano (1985) state that factors such as early conduct problems predict a variety of

15 antisocial behaviors including drug abuse. These authors

review research regarding aggressiveness ratings by firstgrade teachers and low academic achievement at the end of elementary school and find support for these issues as predictors of delinquency and drug abuse. The investigation becomes more complicated when current substance use patterns are considered. Although

most studies of polydrug involvement have studied drug preferences, there are a few which have investigated patterns of multiple use (Kliner & Pickens, 1982). Multiple-drug use has become the norm rather than the exception with the combination of alcohol and marijuana being the most common (Pandina & White, 1981; Pandina et al. 1981). In a sample of 1,970 high school and junior

high students Pandina and White (1981) found only 6% who reported never having used alcohol or drugs. Eighty-nine

percent of this population had tried alcohol and 74% were current users. Fifty percent had tried cannabis and 37% This study also included a client

were current users.

population which was drawn from referrals to an agency responsible for coordinating services for troubled adolescents. Of the 224 subjects in the client group, 81% were

current users of alcohol and 66% were current users of marijuana. Pandina et al. (1981) indicated that 41% of the

students in their survey used alcohol only, 17% used

16 alcohol and marijuana, 5% used alcohol, marijuana, and one other drug, and 11% used alcohol, marijuana, and at least two other drugs. In a study of prisoners in a correctional facility for men under 21 years of age, Marini et al. (1978) found 32.8% of this population to be regularly using two drugs in addition to alcohol and marijuana, 36.2% of the prisoners were regularly using more than two drugs in addition to alcohol and marijuana. In a study of polydrug use by high

school students Kamali and Steer (1976) found a multipleuse pattern among 273 of 840 students. The most common use

pattern by this group was alcohol and cannabis. The impact of drug use on children's lives can be investigated from many perspectives. In terms of prevention,

research seeks to understand the contributing factors; peer pressure, family dynamics, preexisting genetic vulnerability, and the effects of education programs aimed at sensitizing children to the dangers related to drug use. Investigations deal with the involvement of drug users in other illegal activities and subsequently with the legal system. Studies have also sought to correlate academic

achievement and personality factors with drug abuse. Little attention has been directed at the cognitive functioning of a drug abusing population of adolescents. No studies were located which used general intelligence or

17 any cognitive measure, other than school achievement, in assessing the characteristics of this population.

Assessment of Cognitive Functioning Intelligence tests and other measures of cognitive ability are based on an individual's responses to standardized procedures. The results are intended to describe the

person's current functioning and to reflect potential which may not be evident from the standardized score. When psychologists speak of potential intelligence of a child, their interpretations are based under two categories: (1) test scatter and (2) measures of intellectual deterioration. Test scatter involves both intertest patterns and intratest variability of performances. (Magnussen, 1979, p.560-561) A common example of the first category is a child who shows failures on early items of a task while successfully completing later, presumably more difficult items. In this

case, interpretation of the child's performance usually involves some response characteristic such as anxiety rather than ability. A difference between ability and potential is also postulated in situations where the current level of functioning is presumed to be lower than the level of premorbid ability. This is the second category suggested by MagnusA clear case of this exists when there has An example would be a

sen (1979).

been a known injury to the brain.

18 person with an injury to the left hemisphere of the brain. In such a case, performance on measures of verbal ability are typically uniformly low. The best measure of premorbid The

language ability may be a test of oral reading.

person's performance on such a task, which involves an overlearned skill, is often the most accurate measure of premorbid ability. An exception to this would be a focal

injury resulting in expressive aphasia. A third category considered in the assessment of undemonstrated potential involves areas in which a child may have lacked opportunity to develop. An example of this is

described by Kaufmann (1979) in his caution against using instruments normed on native English speakers in assessing the verbal ability of children who learned English as a second language. A second example of an area of cognitive

deficit based on lack of opportunity is found in children from backgrounds where little emphasis is placed on academic achievement. That will frequently result in the

child having a limited fund of general information even when measures of memory are unimpaired. After Cattell (Anastasi, 1982) introduced the idea of describing individual differences in mental ability through testing, assessment of intelligence began to increase in importance as an educational and psychological tool. Spearman reflected the generally held belief that

19 intelligence was a unitary concept and "that for the purposes of assessing the amount of general intelligence possessed by a person any test is as good as any other, as long as its correlation with a is equally high" (Jackson & Messsick, 1978, p.414). A contrasting, multidimensional

view of intelligence was proposed by L. L. Thurstone (Guttman, 1978). This perspective on intelligence

resulted from increased sophistication in statistical methods which allowed for analysis of commonalities and differences among mental processes. that As refinements in testing and data-handling techniques have afforded greater precision and control over observations of intellectual behavior, it has become evident that much of the behavior that tests measure is directly referrable to specific intellectual functions, (p. 21) She describes four primary categories of cognitive ability; receptive, memory and learning, thinking, and expressive. In order to describe the specificity of neurological impairment, Lezak provides the following example. A brilliant research scientist was struck on the right side of his head by falling rock while mountain climbing. He was unconscious for several hours and then confused for several days, but was able to return to a full research and writing schedule shortly thereafter. On psychological tests taken six weeks after the injury, he achieved scores within the top 1-5% range on al1 tests of both verbal and visuoconstructive skills, with the single exception of a picture-arranging test requiring serial organization of cartoons into stories. On Lezak (1983) states

20 this test his score, at approximately the bottom tenth percentile, was almost in the border 1ine defective ability range. He was then given a serial reasoning test involving letter and number patterns which he answered correctly, but only after taking about 25 minutes to do what most bright adults can finish in 5. He reported that his previous high level of work performance was unchanged except for difficulty with sequential organization when writing research papers, (p. 21-22) The testing and interpretation of findings in this situation is a neuropsychological assessment. It involves an

evaluation of cognitive ability in a variety of areas to provide a picture of current functioning. This includes

comparative strengths and weaknesses and prediction of undemonstrated potential and premorbid ability. The history of neuropsychology is reported by Horton and Puente (1986). The authors report that attempts to localize brain deficits are recorded as early as 2500 and 3000 B.C. Paul Broca was responsible for pinpointing the

first neurological cite of a specific function with his studies in aphasia and this work was furthered by Kurt Goldstein's study of soldiers with traumatic head injuries. Parallel to the work of European scientists were the individual case studies by Russian A. R. Luria. Neuropsy-

chological assessment began as a companion to neurological and psychiatric evaluations of patients' abilities. Much

of the early research dealt with establishing the credibility of the assessment procedures so that the tests could

21 accurately predict the cite of a lesion or trauma. With

the advent of medical technology which can provide pictures of the brain, computed tomography (C.T.) scans, electroencephlagrams (EEG), and magnetic resonance imaging (MRI), this function of neuropsychological assessment became less important. Despite the fact that the medical procedures could tell the physician what the brain looked like more effectively than neuropsychological tests, they could not provide information about the functional ability of the brain. The

task of defining strengths and weaknesses and identifying subtle forms of brain deficit remained the function of the neuropsychologist. In addition to providing descriptive

information it is the clinician's responsibility to (1) establish the existence of any cognitive deficits related to this insult, (2) establish the relative magnitude of this insult, (3) estimate the patient's ability to return to his previous life-style, and (4) suggest remediation programs. (Crockett, Clark, & Klonoff, 1981, p. 2) Although neuropsychology began as an adjunct to medical treatment, the research boundaries have widened so that the techniques are currently used in assessment of learning disabilities, personality, and behavioral disturbances. Application of neuropsychological assessment to

clinical, rather than medical, populations began approximately 20 years ago and there is extensive literature

22 on the effects of chronic alcohol abuse on cognitive functioning (Parsons & Farr, 1981). Crockett, Clark, and

Klonoff (1981) cite studies using neuropsychological evaluation in examination of delinquent behavior which suggest that mild left hemisphere dysfunction, combined with poor environmental controls, predict delinquency. Dorman (1982) correlated personality and neurotic variables of school-age boys, seven to 14 years old, with neuropsychological performance and found that in the younger age group, seven- and eight-year-olds, disorders of conduct were related to impaired cognitive functioning. The author

posed the question of whether cognitive deficits were manifested in extraverted, uninhibited behavior as well as on measures of intellectual function or if certain patterns of psychopathology negatively affect cognitive functioning. This kind of research represents a new application of the procedures in a field which only began at the start of the 20th century. While the potential for furthering the

knowledge of brain-behavior relationships is immense, applications of neuropsychological procedures in these areas reach beyond the traditional use of the techniques. This

study involves such an expansion of these psychometric techniques in evaluating the effects of polydrug use on cognitive functioning.

23 Cognitive Functioning of Polydrug Users The clinical impression of the "burned-out" drug user and information regarding the powerful mind-altering properties of drugs have raised the question of possibly diminished cognitive capacity, either long-term or with a very slow rate of recovery. The effects of chronic alcohol

use are well documented and are reflected in deficits in brain functioning. The most dramatic picture of alcohol-

related dysfunction is presented in the Wernicke-Korsakoff Syndrome. This is an amnestic syndrome resulting from

chronic alcoholism and the nutritional deficits which accompany it. The more ubiquitous disability associated

with chronic alcohol abuse is poor adaptive functioning. Two areas of cognitive deficit, abstract reasoning and complex perceptual motor ability, are consistently reported in the research on the neuropsychological functioning of alcoholics (Kleinknecht & Goldstein, 1972). In review of the literature examining the effects of heavy drug use on neuropsychological test performance Parsons and Farr (1981) and Grant and Mohns (1975) found no evidence of cognitive deficits resulting from prolonged heavy drug use except during intoxication. Their reviews

included studies on marijuana, sedatives, stimulants, hallucinogens, and narcotics. These studies were inves-

tigations of the abuse of a single category of drug.

24 Grant et al. (1978) state that . . . It is no longer meaningful to describe North American drug abusers simply as "marijuana users" or "stimulant abusers" since there is every likelihood that such groups will also have substantial experience with alcohol, sedatives, tobacco, and perhaps opiates. (P.1063) Rather, a pattern of simultaneous or sequential abuse of drugs was found to be typical of persons heavily involved in drug-taking. Simultaneous use indicates involvement.of

more than one drug category in order to obtain a certain desired result. Sequential use indicates involvement of

more than one drug category in sequence in order to counteract or enhance the effects of the first drug. Neuropsychological assessment of this population revealed organic impairment in subjects with heavy, multiple-drug use histories. Parsons and Farr (1981) discuss the difficulty of assessing the cognitive effects of drug usage in polydrug abusers. Evaluation of this group presents significant

confounding variables to an understanding of the observed deficits. Poor nutritional intake, psychopathology, head

injuries related to intoxication and the relative contribution of various drug categories are all possible contributors to the cognitive impairment. The fact appears

to be, however, that the real world presents a population in which arbitrary distinctions are difficult to justify and may not exist.

25 In one of the first studies to address the possible chronic, deleterious effects of polydrug abuse on intellectual and cognitive functioning, Bruhn and Maage (1975) studied 87 men in the state prison system of Denmark. The

subjects were separated into four categories of drug involvement based on responses to a clinical interview covering drug history; 1) no drug experience; 2) marijuana and hallucinogens; 3) marijuana, hallucinogens, and amphetamines; and 4) marijuana, hallucinogens, amphetamines, and narcotics. The subjects were administered the WAIS and

measures of abstract reasoning ability, learning and memory tests, auditory perception, analysis of complex designs, and a continuous reaction time test. The authors found no

difference between controls and drug users, or among categories of drug users on any measure of cognitive ability. In their review of these findings. Grant et al. (1976) suggest that lack of discriminate results may have been due to the statistical analysis of differences on each assessment procedure rather than analysis of response patterns which is the clinical method of determining deficit from premorbid functioning. In a second pioneering study, Adams et al. (1975) completed neuropsychological evaluation of 51 polydrug users in a Detroit treatment center. This was an inpatient

study and the initial assessment with an expanded Hal stead-

26 Reitan battery was completed within three days of admission. A repeatable portion of the battery was admin-

istered three times; approximately one week after initial assessment, at the end of the first month of hospitalization, and at discharge. The average age of the population A comparison

was 26.7 years with 11.8 years of education.

of the individual procedures to normative data showed the polydrug population to be functioning in the impaired range on all measures except one (Trail Making Test, Part A ) . The subjects of the Adams et al. study were compared to data provided by the San Diego Polydrug Study Unit on normals, general medical patients, and neurological patients, matched for age and education. The results showed no significant differences between the polydrug subjects and the neurological patients with the exception of one procedure. The performance of the polydrug group was poorer than the normals on eight measures (Category, Speech, Tapping with both hands. Trails A, Trails B at the P<.05; grip strength with both hands at the P<.001 level; and Rhythm at the P<.01 level). These findings describe the cognitive func-

tioning of the polydrug users as similar to patients with identified neurological impairment. The authors did find

improvements on the repeatable measures battery but were unable to rule out the possibility that these were due to practice effects and learning.

27 Adams et al. (1975) completed a cluster analysis on the data from their polydrug subjects and found two patterns of performance. For one group. Performance IQ This group included no

exceeded Verbal IQ by 12 points.

high school graduates and the subjects produced poor scores on measures of academic achievement. This group was

younger, had more failures on tasks involving receptive language and reported using fewer categories of drugs but using these heavily. The authors suggest

For the group [cluster 1], there is a clear superiority in performance IQ. In investigating the subjects who could be classified into the group we found that 1) No subject in the cluster had finished high school 2) All achievement scores (WRAT) were uniformly low 3) Performance IQ was an average 12 points better than verbal IQ 4) The groups reported using fewer kinds of drug more intensively 5) The group tended to be younger than the rest of the sample and 6) More receptive language errors were present in the testing records, (p. 159) The subjects in the second cluster had better academic records. They reported using a wider variety of drugs but

less heavily "tending to use barbiturates and narcotics, rather than marijuana, amphetamines, or the heavier hallucinogens" (Adams et al., 1975, p. 159). The second group also showed more psychopathology based on the MMPI profiles. A preliminary study by Grant et al. (1976) investigated the long-term cognitive effects of heavy polydrug use. The authors compared the performance of 22 young men

28 who were admitted to a residential treatment program for youthful narcotics addicts. The subjects were assessed at

a mean of 60 days after admission in order to minimize toxic and withdrawal effects on the testing. The HalsteadThe

Reitan neuropsychological battery was administered.

results were compared to matched groups of medical patients and neurological patients. Each profile of test results

was submitted to an experienced neuropsychologist for rating in one of two categories, normal or abnormal. The

findings indicated that half of the polydrug subjects were functioning in the impaired range of mental ability. dividual measures on which they performed more poorly included Performance IQ, Full-scale IQ, Picture Completion, and Object Assembly on the WAIS; Category Test; nondominant time on TPT; and time for both hands on the TPT. The drug In-

users performed better on the Rhythm Test than the medical controls. The investigators were unable to establish a

specific pattern of drug use relative to neuropsychological results. Another question explored by the authors was the relationship of a history of head injury to cognitive functioning. A high incidence of head injury for heavy

drug users is revealed in medical histories which include numerous falls and motor vehicle accidents related to intoxication (Parsons & Farr, 1981). This study did not

29 support such a relationship in their small subject population. Further, the authors did not find that

psychiatric illness was related to cerebral dysfunction. The investigators discuss their results very cautiously, stating that "Those individuals who demonstrate neuropsychological abnormality, according to our evaluation of these tests, would be said to have mild, generalized cerebral dysfunction" (p. 977). They also state that the possibility of a lower level of premorbid functioning could not be entirely ruled out. Following these efforts, a collaborative study supported by the National Institute of Drug Abuse was established. Eight polydrug treatment centers participated

in an investigation of the neuropsychological performance of their patients. In the studies by Grant and his asso-

ciates (Grant & Judd, 1976; Grant, Adams, Carlin, Rennick, Judd & Schooff, 1978; Grant et al., 1978b) 37% of their population scored in the impaired range on neuropsychological measures. The subjects were 151 persons seeking The comparison

treatment at one of the designated centers.

group was 59 volunteers who were screened for demographic similarities to the drug abuse group. The assessment

included administration of the Halstead-Reitan battery initially and at a three-month follow-up.

30 In these studies, evaluation of cognitive deficits was based on the clinical judgment of a neuropsychologist's rating of the individual profiles in one of six categories Better than average performance; average performance; borderline, atypical, but not clearly deficient performance; mildly impaired performance; moderately impaired performance; and severely impaired performance. (Grant et al., 1978b) The relationship of drug use to neuropsychological performance was evaluated by multivariate analysis of variance (MANOVA), with group membership and clinical rating of impairment as independent variables. The results indicated

that heavy use of CNS depressants and opiates was related to increased neuropsychologial impairment. Factor analysis

of the assessment instruments resulted in four factors 1) general verbal intelligence, 2) a nonverbal factor involving visual motor, tactual, and perceptual skills, 3) simple language perception and psychomotor speed, and 4) motor strength. The polydrug group scored poorer than normals on Reanalysis of the data, controlling

factors 1, 2 and 4.

for the contribution of education, removed verbal intelligence, factor 1, from the Main Effects. The authors felt

that the error variance involved in factor 4, grip strength, and its small contribution to the overall solution hindered interpretation of this factor. The final

result was the finding that both the psychiatric group and the polydrug group performed significantly (fi<.01) poorer

31 on the nonverbal measures (WAIS-R: Digit Symbol, Picture

Completion, Block Design, Picture Arrangement, Object Assembly and on the TPT: memory and location).

The interpretation of these data is problematic, however, due to the difficulty in distinguishing cognitive deficits based on drug use and deficits based on serious psychopathology. In the Grant et al. study (1978b), 26% of

a matched psychiatric population scored in the impaired range as well. Parsons and Farr (1981) note two factors

which complicate an understanding of the data on the effects of polydrug use, To separate neuropsychological impairment due to prolonged polydrug use from that associated with more serious psychopathology remains a pressing problem in this research. Second, and perhaps related to the life-style and the psychopathology issues, these investigators [Grant et al.] also noted that polydrug abusers, as a group, report greater instance of traumatic head injury (23%) and severe headache (28%) than either psychiatric control or nonpatient control group, (p.348) Grant and his associates answer this issue by describing the research on the Halstead-Reitan battery with schizophrenics (Lacks et al. 1970; Klonoff et al. 1970). They

indicate that persons diagnosed as schizophrenic account for most of the variability in the psychiatric control group and that only three of their polydrug subjects were diagnosed as schizophrenic.

32 In concluding their findings Grant et al. (1978b) state. It is striking that among the polydrug abusers, only depressant and opiate drugs could be related to observed impairment. . . . We interpret our data and previous reports to suggest that heavy, persistent amphetamine use is not related to neuropsychological impairment in most youthful users, although a few persons might indeed be at risk for idiosyncratic reasons (e.g., preexisting hypertension, vasculitis, or allergic diathesis) yet to be determined, (p. 1071) They also indicate, based on the three-month follow-up testing, that the deficits apparent at initial testing showed little reversibility. They discuss the implications

for the treatment of patients experiencing cognitive deficits and suggest that these patients should be directed toward Highly structured, practically oriented interventions in which communications are simple and straight forward than to therapies producing high emotional arousal (and further neuropsychological disorganization), such as encounter groups." (Grant, Adams, Carlin, Rennick, Judd, & Schooff, 1978, p. 183) In response to contradictory findings regarding the cognitive effects of inhalant abuse, Korman et al. (1981) studied 68 inhalant-abusing and 41 other-drug-abusing adolescents. All of the subjects were classified as poly-

drug users and were given a neuropsychological battery. Analysis of covariance revealed a main effects difference between the two groups. The inhalant abusers performed

significantly more poorly (p<.05) on 20 of the individual

33 assessment procedures. The finding of impairment on both

global and specific measures of ability led the authors to conclude that the deficits represented diffuse brain impairment. Although the authors did not apply clinical

impairment ratings to the polydrug subjects, scores on the 20 measures showing significant differences were provided. Application of clinical ratings to these scores describes the inhalant abusers as functioning in the moderate range of impairment while the polydrug subjects' functioning appeared to be in the mild range of impairment suggesting that the entire population of this study showed diffuse brain dysfunction with greater impairment by the adolescents emphasizing inhalant abuse. Although neuropsychological assessment of cognitive functioning appears to be a fruitful approach to describing certain clinical groups there are methodological problems which must be acknowledged. When comparing cognitive var-

iables, issues such as age, education, and socioeconomic status (SES) are known to have effects on scores. Parsons

and Farr (1981) describe the "thorny, but unavoidable issue" (p. 347) of general intelligence. There are two First,

aspects to the issue of general cognitive ability. if groups are to be judged as equal for comparative

purposes the equality of ability should be a premorbid measure. Second, the authors state that if the subjects

34 are pulled from a population with higher levels of general ability, such as college students, their abilities may be resistant to demonstrating deficits as measured by neuropsychological instruments. General intellectual ability is

highly positively correlated with the outcome of cognitive functioning subsequent to brain injury. Symonds (as cited

in Lezak, 1983) states "It is not only the kind of injury that matters, but the kind of head." Reliable measures of premorbid ability are difficult to obtain because few subjects would have received assessments previous to the development of the clinical concern. Lezak (1983) reports two methods of estimating premorbid ability. It should be noted that she is discussing these

variables as they relate to assessment of individual patients, not groups. One method involves choosing a

cognitive measure which has been shown to be resistant to the effects of brain damage and using this as a benchmark against which to evaluate all other performance. The

Vocabulary and Picture Completion subtests of the Weschler scales and reading test scores from academic achievement measures are often used because of the supposed resistance of old, overlearned skills to the effects of cognitive dysfunction. These measures are not usually thought to be

accurate predictors of premorbid ability in patients with left hemisphere damage.

35 Summary and Review of Hypotheses The review of the literature establishes the impairment of cognitive functioning as the result of polydrug use involving certain categories of drug use. In the

best controlled, most extensive of these studies. Grant et al., 1978b, the findings suggest that areas of dysfunction involve nonverbal ability in visual-spatial, tactualspatial and visual-perceptual areas. These are the areas

commonly thought to be most sensitive to brain impairment. These deficits were found in polydrug abusers involved with depressants and opiates. Other drug categories were not The subject populations in Demographic

related to observed impairment.

the preceding research were young adults.

research regarding drug use indicates a continued downward trend in age in the use of drugs and establishes the norm of polydrug usage in those adolescents using drugs. As the result of this review of the literature the pertinent question regarding the cognitive functioning of adolescent polydrug users is whether they exhibit cognitive deficits relative to performance on neuropsychological assessment procedures. In order to respond to this

question the following hypotheses will be investigated: Hypothesis 1. Adolescents in a drug addiction

treatment program will demonstrate cognitive functioning on neuropsychological measures of brain function which

36 will not significantly differ from adolescents who are neurologically impaired. The suggestion that the cognitive ability of polydrug abusing adolescents will resemble that of neurologically impaired teenagers is supported by the findings of Adams et al. (1975) and the results of the national collaborative study directed by Igor Grant (Grant, Adams, Carlin, Rennick, Judd, & Schooff, 1978; Grant et al., 1978; Grant

& Judd, 1976, Grant et al., 1976) in which polydrug users in their early 20's were found to experience "mild generalized cerebral dysfunction" (Grant et al., 1976, p. 977). Hypothesis 2. Adolescents in a drug addiction

treatment program will demonstrate cognitive deficits on neuropsychological measures of brain function based on a clinical pattern analysis of an experienced neuropsychologist. Grant et al. (1978b) used clinical assessments of experienced neuropsychologists as the best measure of levels of deficit. They recommend this procedure because

the mean scores of groups are not reflective of the functioning of the individual and because analysis of the pattern of performance, relative strengths and weaknesses, is the clinical basis of assessing neuropsychological deficit. This hypothesis suggests that if the pattern of

37 cognitive performance by the polydrug abusing adolescents looks like that of someone who has impaired functioning then their ability can be described as impaired.

CHAPTER III METHODOLOGY

The review of the literature related to adolescent drug use and the possibility of related cognitive deficits suggests several areas for investigation. As the result of

previous research findings the current investigation was proposed to test the hypotheses presented in the previous chapter. This chapter describes the research design,

methodology, and analysis of the data.

Subjects The polydrug subjects of the study were inpatients at a private psychiatric hospital in a southwest community. Participation was voluntary and involved signed permission by the patient, the parents, and the attending physician. Initial screening was done to determine if there was evidence of acute neurological impairment such as previous head trauma, acute or chronic physical disease, gross psychopathology such as psychosis or schizophrenia, and sensory or motor deficits which would impede the subject's performance of the test battery. from the study for these reasons. No subjects were excluded Detoxification of the

subjects was assessed through evaluation of medical staff based on urine drug screening and the subjects' behavior. 38

39 The patients at the hospital represent the middle and upper-middle socioeconomic strata. The determination of substance addiction for the inpatient population was based on the admitting diagnosis of the attending physician in compliance with the definition of "substance addiction" of the hospital. These

criteria were consistent with the Diagnostic and Statistical Manual of the American Psychiatric Association (1980). The second group of subjects were adolescents who had been evaluated subsequent to significant neurological trauma. Their neuropsychological testing was conducted as

part of the routine medical follow-up in order to assess cognitive functioning and to develop recommendations for treatment.

Instruments Demographic and Background Data Medical History The Medical History Questionnaire (Grant, Adams, Carlin, Rennick, Judd & Schooff, 1978) evaluates the presence of trauma or illness which could account for abnormal neurological findings. This questionnaire was used with

the polydrug subjects to assess medical events which might

40 establish prior cause for the existence of neurological dysfunction. (See Appendix A.)

Demographic Data Following the recommendations of Gersick et al. (1980) the demographic data covered age, sex, socioeconomic status, religion (denominational affiliation and degree of religiosity), level of academic achievement, race and ethnicity. Through the interview with this instrument the

polydrug subjects also reported information on peer, family, and community variables. naire appears in Appendix B. The demographic question-

Psychological Functioning The Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway & McKinley, 1967) is the most commonly administered objective personality instrument. This inventory

is completed by all adolescent inpatients at the psychiatric hospital. questions. The inventory consists of 566 true-false

The responses are then scored on 10 clinical

scales describing major classifications of psychopathology. Four validity scales are included which evaluate the subject's attitude toward the test. This instrument is

criterion referenced so that responses are compared to responses of criterion groups such as hypochondriacal and psychopathic deviance. As Anastasi (1982) points out, one

41 weakness of the MMPI is that each scale was developed by comparing the criterion group to the normative sample rather than criterion groups to one another. High cor-

relations among the diagnostic scales call into question their ability to differentiate among diagnostic categories (Anastasi, 1982). Retest reliability is reported to range

between .50 to the low .90's (Hathaway & McKinley, 1967). A particular difficulty arises with application of the MMPI to the special population of this study. Adolescent norms

are available (Green, 1980) but adequate interpretation of the findings is still uncertain. Green (1980) suggests

the use of adult interpretive data based on adolescent norms. This is the format which was used in this inves-

tigation. The Beck Depression Inventory (BDI) (Beck & Steer, 1987) is a widely used instrument in quantifying depressive symptoms in adults and adolescents. It is a self-report

questionnaire of 21 items to which the person responds on a four-point Likert scale. Interpretation of the scores is

based on total points and evaluation of critical items relating to suicidal ideation and hopelessness. The manual

suggests the following guidelines for evaluating individual scores: Scores from 0 to 9 are considered within the normal range or asymptomatic; scores of 10 to 18 indicate mild-moderate depression; scores of 19 to 29 indicate moderate-severe depression;

42 and scores of 30 to 63 indicate extremely severe depression, (p. 7) Test-retest administrations of the BDI in clinical populations should reflect improvement after exposure to therapeutic treatment and therefore reliability coefficients vary depending on the population. Test-retest

correlations for psychiatric patients ranged from .48 to .86 while studies of nonpsychiatric patients ranged from .60 to .90. With regard to content validity the scale

reflects the diagnostic criteria associated with depression in the DSM-III with the exception of symptoms which were felt to produce a high number of false positives. The

authors indicate that discriminant validity has been shown by the BDI ability to discriminate among diagnostic categories. Construct validity has been evaluated against the Beck Hopelessness

concept of hopelessness through the

Scale and has been found positively related to the BDI. The BDI has been assessed for concurrent validity with the MMPI-D Scale, Zung Self-rating Depression Scale, psychiatric ratings and correlations range from .55 to .73 (Beck & Steer, 1987).

Measures of Cognitive Ability Successful performance of a cognitive task is the result of the ability to execute the components which make up that task. Poor performance may be the result of the loss

43 of one contributing skill and not others. Not all

investigators agree about the primary and secondary abilities on cognitive tasks. This is clearly seen in the

three most popular classification systems for the WISC-R. Kaufmann (1979) discusses his factor analytic studies, Bannatyne's recategorization system, and Guilford's structure-of-intellect model and describes the varying view which each approach takes regarding the underlying abilities of the subtests of this instrument. There are also broad theoretical differences regarding the way in which the brain functions. The most widely

accepted approach to understanding brain-behavior relationships in the Western world is the lateralization of function theory. In this theory language-analytical skills

are thought to be the function of the left hemisphere of the brain while spatial-intuitive skills are the function of the right hemisphere. This view will be followed in

interpretation of the test data in this study because the related literature used this approach and therefore it provides the most comparative data. Further, the

descriptions of patterns of cognitive ability, relative strengths and weaknesses, will follow this approach and are consistent with the interpretations of Reitan and Wolfson (1985) and Lezak (1983).

44 General Intellectual Ability The age-appropriate form of the Wechsler scales was used as a measure of the general intelligence of the subjects. The results on the WISC-R and WAIS-R provide the

basis from which all major neuropsychological test batteries proceed (Lezak, 1983). The Full Scale IQ and the

Verbal and Performance IQ's are used extensively in educational settings to estimate academic functioning. In

neuropsychological assessment of cognitive ability the subtests of the Wechsler scales are typically evaluated individually according to the components of ability thought to affect performance. Split-half reliability for the

three global intelligence measures are .97, .93, and .97 for Verbal, Performance, and Full Scale IQs, respectively, for the WAIS-R and .94, .90, and .96 for the WISC-R (Wechsler, 1974; Wechsler, 1981). Both versions of the

Wechsler scale have been found to have high correlations with academic achievement and with the Stanford-Binet.

Academic Achievement The Wide Range Achievement Test - Revised (WRAT-R) (Jastak, Bijou, & Jastak, 1984) was administered to assess the subject's level of academic achievement in the traditional areas of spelling, reading, and math calculation. Test-retest reliability was determined from the normative

45 group. For the ages included in the study the results were

.90 for reading, .89 for spelling, and .79 for arithmetic. The content validity of the subtests is clear in that they are meant to measure basic academic skills. Item diffi-

culty was determined by the Rasch method of mathematical analysis of ability and difficulty and indicated that the item reflects a full range of difficulty. Construct valid-

ity is supported by the high item separation reliability coefficients which indicates that the measures are sensitive to developmental changes across the ages included. Concurrent validity reflects that the WRAT-R is comparable to other achievement measures with correlations in the high .60's, .70's, and .80's (Jastak, Bijou, & Jastak, 1984).

Memory and New Learning The Auditory-Verbal Learning Test (AVLT) (cited in Lezak, 1983) is used to assess the subject's ability to learn new verbal material. A series of 15 words is pre-

sented orally by the examiner after which the subject is requested to say as many as are remembered. The list is

presented four additional times to assess the efficiency and rate of learning. Reliability information was unConcurrent validity was

available on this instrument.

supported by the finding that recall of the number of words on the AVLT is similar to that of digits forward of the

46 Wechsler Digit Span subtest. Miceli et al. (1981) found

that a modification of the AVLT discriminated well between patients with right and left hemisphere lesions.

Visual-Spatial and Visual-Perceptual Ability The Complex Figure Test (CFT) (cited in Lezak, 1983) is a complex visual-perceptual drawing task which includes a recall trial. The subject is presented a design and Erasures

asked to reproduce it on a blank sheet of paper. are permitted.

The subject is not informed of the recall After an intervening and cognitively

trial of the task.

unrelated task, the subject is asked to draw the figure from memory. The task assesses visual-spatial perception,

organization of complex visual information, and visual memory. No reliability information was available on this Discriminant validity is suggested by the

instrument.

consistent ability of the figure drawing to differentiate between localized lesions (Lezak, 1983).

Higher Conceptual Processing The Wisconsin Card Sorting Test (WCST) (Heaton, 1981) was selected to assess abstract reasoning ability. This is

a deductive reasoning task which requires the subject to identify simple categories and develop and maintain correct response sets based on feedback from the examiner. The

47 subject is given two decks of 64 cards each and asked to match each of the cards to one of four key cards (marked with one red triangle, two green stars, three yellow crosses, and four blue circles). The subject's cards vary The principle of

randomly on color, number, and shape.

correctness is established by the examiner and must be deduced by the subject by the "correct" or "incorrect" verbal feedback provided by the examiner to each attempted match. After the subject has made 10 consecutive correct

responses, the examiner shifts to another sorting principle. Problems on this instrument can come from

difficulty identifying the categories, perseveration to an incorrect category, or shifting to an incorrect category before the criterion is met. No reliability information Construct and discrim-

was available on this instrument.

inant validity are supported by high correlations with the WAIS Full Scale IQ and the Halstead-Reitan Battery Average Impairment Rating when normals and brain damaged patients were compared.

Attention and Concentration The Trail Making Test combines two parts which assess visual scanning and complex attentional functions. On Part

A the subject is required to connect "as quickly as he can," in consecutive order, a set of circled numbers. On

48 Part B the subject must perform the same task but alternate between numbers and letters (e.g., 1-A-2-B). Digit Span

would be an example of the simplest task of attention and recall, while Part B of the Trail Making Test is a complex task of visual tracking, conceptual tracking, and ability to shift response sets appropriately (Lezak, 1983). Lezak

(1983) found test-retest coefficients of .78 for Trails A and .67 for Trails B. The author found significant

(e<.001) practice effect on Trails A while Trails B did not improve significantly.

Design and Analysis The results of the performance of the polydrug group were compared to a matched sample of neurological patients. The t-test was used to statistically evaluate these comparisons. The data were reviewed by a certified psychologist with clinical training and three years experience in neuropsychological assessment. The clinician rated the

subject's performance on a six-point scale ranging from above average ability to profound cognitive impairment. The rater was blind to the subject's group membership and reviewed the pattern of performance to determine the impairment rating. In the analysis of these data the first

three categories (above average, average and mildly

49 impaired) were classified as "unimpaired" with the remaining three categories (moderately, severely, and profoundly impaired) classified as "impaired." This

grouping is consistent with the procedures used in the national study by Grant, Adams, Carlin, Rennick, Judd, Schooff, et al. (1978). The t-test was used to provide a

comparison of the performance rating of the polydrug and the neurological groups. The independent variables were group membership with the dependent variables being the cognitive measures and the overall impairment ratings.

Procedures The investigator administered the age appropriate Wechsler scale and the neuropsychological procedures. Each

subject was told that participation was voluntary and would not affect the course of treatment and that consent could be withdrawn at any time. The researcher chose to admin-

ister the cognitive instruments in the same order to all subjects. An alternative would have been to systematically Varying the instruments would have This was

vary the presentation.

controlled for fatigue and motivation factors.

not done, however, so that the results would provide the most valid comparison to the findings of the neurologically

50 impaired subjects who had been previously tested in that format. The medical history questionnaire and the demographic information were obtained during an interview with the subject at the time of the testing. The MMPI and BOF were

administered by hospital personnel as part of its assessment procedures. The standard format at the hospital

involved the use of a computer administration and analysis of the responses on the MMPI. Due to the schedule of therapeutic activities in which the polydrug subjects were involved, their testing was typically completed during two sessions on consecutive days. The total time required for administration of the This did not include

battery was approximately five hours.

completion of the MMPI which was scheduled by the hospital. The testing of the neurologically impaired subjects was typically done within the same day with three hours of the testing completed in the morning, a break for lunch and the remaining two hours completed in the afternoon. The data on the neurological subjects represented patients who had been tested over the previous five years. The evaluations had been completed by the staff of a rehabilitation facility in the same community as the hospital. When multiple assessments on a patient were

available, the most recent one was chosen in order to

51 reflect a stable picture of the patient's ability and to minimize the acute disorienting effects of the injury on the test results. The clinical rater had no prior knowledge of the subjects. The data on each individual's performance was

presented on a summary sheet on which there was no identifying information.

CHAPTER IV RESULTS

This study was a comparison of two groups of adolescents on measures of cognitive ability. One group was

receiving inpatient treatment in a psychiatric hospital related to substance abuse. The other group was comprised

of adolescents with medically substantiated neurological impairment related to closed head injuries or neurosurgery. The neurological subjects were tested over a three-year period of time in a rehabilitation center. The performance

of all subjects was compared to available normative data. The purpose of the study was to determine if adolescent polydrug abusers would show cognitive deficits on neuropsychological measures which are commonly used to determine functional ability after neurological trauma.

Descriptive Data Subjects The subjects studied were 31 adolescents, 16 polydrug abusers and 15 teenagers with a history of neurological trauma. Their ages ranged from 12 to 19 years with a mean The subjects in the drug group were

age of 16.7 years.

somewhat younger than in the neurological group but the differences were nonsignificant, t(29)=-0.76, fi<.45. There 52

53 were 22 Anglos and nine Hispanics. The subjects comprised

two intact groups, polydrug abusers and neurologically impaired. Table 1 presents this information for each group.

Demographics on Polydrug Subjects Demographic information on the polydrug subjects was collected by the examiner in an interview at the time of the testing. Corresponding data on the neurologic group

were unavailable because they were tested prior to the initiation of the study. Typical subjects from the poly-

drug group were Protestant and described themselves as mildly religious. predominated. The middle class socioeconomic strata

Nine of the 16 subjects reported a per-

ception of having sustained cognitive impairment as the result of drug use. Areas of perceived impairment included The age of the

memory loss and slowed reaction time.

subjects at the first exposure to drugs ranged from seven to 16 years (M = 10.31, SD = 4.49). The duration of drug

use ranged from one to nine years (M = 4.31, SD = 2.28). Thirteen of the subjects (81.4%) reported a parent or grandparent with a history of alcohol or drug addiction. One subject who reported no addiction problem in this group of relatives was adopted and had no information about the biological parents. Ten of the 14 subjects with siblings

54 TABLE 1 DEMOGRAPHIC CHARACTERISTICS OF ALL SUBJECTS

Item Number Age M SD Grade M SD Sex Male Female Race White Nonwhite

Polydrug Users n 16

Neurologically Users n 15

16.19 1 .5

17.19 3.18

9.63 1 .54

10.07 2.23

8 8

12 3

10 5

12 4

55 (71.4%) reported a sibling with an addiction problem. Ten

of the subjects had been arrested in connection with their drug use. These data plus marital history and educational

history of the parents are reported in Table 2.

Medical History of the Polydrug Subjects Information from medical histories was used in assessing the polydrug subjects' neurological background to determine if exclusion from the study was necessary. Four

of the subjects did have histories of minor head injuries related to falls and motor vehicle accidents, none of these injuries had resulted in loss of consciousness. Seven

subjects reported having experienced loss of consciousness related to drug use and eight indicated having been under general anesthesia for surgeries such as tonsilectomies. Eleven subjects indicated that they experienced frequent headaches and eight reported having been diagnosed with learning disabilities. These data are reported in Table 3.

Categories of Drugs Used The frequencies of involvement with differing categories of drugs are presented in Table 4. This group of

adolescents was heavily involved in stimulant and marijuana use (87.5%). Alcohol use was third highest with 68.8%. The two

Only two subjects listed no stimulant use.

56 TABLE 2 DEMOGRAPHIC VARIABLES OF THE POLYDRUG GROUP

VARIABLE LIFE SATISFACTION 1 - 3 4 - 6 7-10

VARIABLE

PERCEPTION OF IMPAIRMENT 31.3

8

No Yes RELIGIOUS PREFERENCE

40.0 60.0

50.0 18.8

SOCIOECONOMIC STATUS Protestant Lower class Middle class Upper class 12 2 12.5 Catholic 75.0 Other 12.5 EXTENT OF RELIGIOUS FEELING PARENTS' MARITAL STATUS Strongly Married Divorced Widowed 6 37.5 Moderately 43.8 Fairly 18.7 Mildly Very Little Not at all 4 5 3 0 0 3 10

66.7 13.3 20.0

0.0 20.0 26.7 33.3 20.0 0.0

QUALITY OF PARENTS' MARRIAGE Close and Warm 10 Cold and distant Angry and Hostile 62.5 31.3 6.3

57 TABLE 2 Continued

VARIABLE

VARIABLE

MOTHER'S EDUCATION Less than high school High school Some College College Graduate Post graduate work AGE FIRST USED DRUGS 0 0.0

FATHER'S EDUCATION Less than high school High school Some college College graduate 0 0.0 Post graduate work 1 6.3 0 0.0 FAMILY HISTORY OF ALCOHOL OR DRUG ADDICTION Father 10 1 62.5 6.3 56.3 6.3 50.0 6.3 18.8 50.0 18.8 12.5

3 8 3 2

11 4

68.8 24.0

7 8 9 10 12 13 14 15 16

1 1 2 1 6 1 2 1 1

6.3 Mother 6.3 Paternal Grandfather 9 12.5 Paternal Grandmother 1 6.3 Maternal Grandfather 8 37.5 Maternal Grandmother 6.3 12.5 6.3 6.3
SIBLING HISTORY OF ALCOHOL OR DRUG ADDICTION Yes
1

Total subjects with first degree relative with history of addiction 13

81.4

10

62.5 37.5

No

58 TABLE 3 MEDICAL HISTORY QUESTIONNAIRE QUESTIONS n

%

Difficult maternal pregnancy Premature birth Subject required postnatal observation Subject hospitalized before age 6

1 0 0 2

6.3 0.0 0.0

12.5
6.3

1 Febrile convulsions (without other disease) 1

Learning difficulties in school Traumatic head injury Posttraumatic amnesia Nontraumatic unconsciousness Diagnostic brain tests History of neurological disease Epilepsy Overdose requiring hospitalization Severe headaches Frequent muscular weakness Numbness of extremities Frequent faintness or dizziness General anesthesia

8 4 1 7 3 0 0 4
11

50.0 25.0
6.3

43.8 18.8
0.0 0.0

25.0 68.8 37.5

6 5 6 8

31 . 3
37.5 80.0

59 TABLE 4 CATEGORIES OF DRUGS USED

DRUG Marijuana Stimulants Cocaine Oral stimulants Intravenous stimulants Alcohol Hallucinogens Depressants Narcotics Inhalants

n 14 14 11 7 2 11 4 3 3 2

87.5 87.5 68.8 43.8 12.5 68.8 25.0 18.8 18.8 12.5

60 subjects involved in intravenous use of stimulants reported injections every four to six hours through the day. One

subject, however, reported alcohol as the primary drug of choice.

Psychological Functioning of Polydrug Subjects The results of the MMPI provided little information in assessing the presence or absence of psychopathology in this population. Only nine of the 16 subjects produced

valid results on the instrument and the hospital was unable to locate the results on one of these patients. Two

patients could not read well enough to complete the MMPI and were evaluated by the psychology staff of the hospital with other measures. invalid results. The remaining six subjects produced

The validity scales suggested that the

invalid results were due to response bias reflecting random responses, "fake bad" or "fake good" response sets. Several of the subjects stated during the neuropsychological testing that they had been unwilling to respond appropriately due to the length of the instrument. Eleven subjects received the Beck Depression Inventory (M = 12.82, SD = 10.14). The results indicate that the

group fell in the lower end of the mild-moderate range of depression.

61 Medical History of the Neurologically Impaired Subjects The neurologically impaired group was made up of 14 victims of closed head injuries, one patient who had neurosurgery for removal of a tumor. Cognitive data were On

provided by the rehabilitation center on 21 patients.

five of the patients raw data were unavailable and on one patient the extent of paralysis prevented the administration of nonverbal test items. If more than one

neuropsychological battery had been administered, the most current results were used. The length of time since the

injury or trauma ranged from one month to 10 years (M = 15.40, SD 29.54).

Clinical Impairment Ratings The clinical ratings were categorized into six levels of performance, above average, average, mild deficit, moderate deficit, severe deficit, and profound deficit based on assessment of the pattern of ability. Absolute

frequencies and relative percentages for the subjects are presented in Table 5. These categories were collapsed into

two levels, reflecting functioning within normal limits (above average, average, and mild deficit) and impaired functioning (moderate, severe, and profound deficit). Absolute frequencies and relative percentages of the unimpaired and impaired ratings are presented in Table 6.

62 TABLE 5 FREQUENCIES OF CLINICAL IMPAIRMENT RATINGS

IMPAIRMENT RATING

POLYDRUG n %

NEUROLOGICAL
n
%

TOTAL

n
2 6 14 6 3 0

%
6.5 19.4 45.2 19.3 9.6 0.0

Above average Average Mild impairment Moderate impairment Severe impairment Profound impairment

1 5 7 2 1 0

6.2 31 .3 43.8 12.5 6.2 0.0

1 1 7 4 2 0

6.7 6.7 46.7 26.7 13.2 0.0

TABLE 6 FREQUENCIES OF UNIMPAIRED AND IMPAIRED CLINICAL RATINGS

IMPAIRMENT RATING

POLYDRUG n %

NEUROLOGICAL n %

TOTAL n %

Unimpai red Impai red

13 3

81.2 18.8

9 6

60.0 40.0

22 9

71.0 29.0

63 Hypothesis Testing Hypothesis 1 Hypothesis 1 stated that subjects in a drug addiction treatment program would score no differently on neuropsychological measures of cognitive ability than subjects with medically identified neurological impairment. The hy-

pothesis was tested using a two-tailed t-test procedure (df=29). The results reflected that the neurological 1y

impaired subjects scored significantly poorer on numerous measures. The Digit Symbol/Coding subtest of the Wechsler

scales; Trail Making Test, Parts A and B; and the AuditoryVerbal Learning Test, trials 5 and 6 were significant at e<.001. Performance I.Q., Arithmetic, and Digit Span of

the Wechsler scales and perseverative responses on the Wisconsin Card Sort were significant at fi.<.01. The Full Scale I.Q., the Picture Completion and Block Design subtests of the Wechsler scales and the recognition trial of the Auditory Verbal Learning Test were significant at fi<.05. Complete results are reported in Table 7. are graphically represented in Figure 1. Discussion of Clinical Significance of Group Means Clinical review of individual tests and the assignment of impairment ratings established by normative data is The data

64 TABLE 7 COMPARISON OF NEUROPSYCHOLOGICAL TEST RESULTS OF POLYDRUG USERS AND NEUROLOGIC GROUPS

TEST WECHSLER INTELLIGENCE SCALE FULL SCALE IQ VERBAL IQ PERFORMANCE IQ INFORMATION COMPREHENSION ARITHMETIC SIMILARITIES DIGIT SPAN VOCABULARY DIGIT SYMBOL PICTURE COMPLETION BLOCK DESIGN PICTURE ARRANGEMENT OBJECT ASSEMBLY

DRUG (n=16) MEAN

NEUROLOGIC (n=i5) MEAN

97.06 95.06 100.56 7.94 9.75 9.00 9.75 9.75 9.12 9.81 10.44 10.44 11.13 10.13

87.20 87.93 88.07 7.20 8.40 6.93 9.00 7.01 8.13 6.87 8.13 8.47 9.67 8.20

2.04 1.53 2.49 0.82 1.39 2.10 0.69 2.49 0.98 2.99 2.46 1.72 1.38 1.72

.051 .137 .019 .421 .176 .044 .494 .019 .335 .006 .020 .097 .185 .097

65 TABLE 7 - Continued

TEST

DRUG (n=16) MEAN

NEUROLOGIC (n=15) MEAN

WIDE RANGE ACHIEVEMENT TEST-REVISED READING SPELLING ARITHMETIC

91.94
88.81

93.93 93.07 78.93

-0.34 -0.51 0.94

.735 .613 .353

86.69

AUDITORY-VERBAL LEARNING TEST TRIAL 1 TRIAL 5 TRIAL B TRIAL 6 TRIAL 5-6* RECOGNITION TRIAL 5.87 12.88 4.94 11.88 1.19 13.94 5.13 10.40 3.80 9.07 1.40 12.93 1.44 3.03 1.76 2.49 -0.43 2.09 .160 .005 .088 .019 .668 .046

COMPLEX FIGURE TEST COPIED TRIAL RECALL TRIAL PERCENTAGE RECALLED 30.43 17.97 58.31 27.17 16.83 59.73 1.56 0.40 -0.19 .130 .691 .849

* Low score represents better performance

66 TABLE 7 Continued

TEST

DRUG (n=16) MEAN

NEUROLOGIC (11=15) MEAN

B.

WISCONSIN CARD SORTING TEST CORRECT ERRORS* 73.06 31.44 79.00 42.33 16.00 24.87 4.60 -1.59 -1.66 -0.55 -1.74 1.49 .123 .108 .595 .092 .146

NONPERSEVERATIVE ERRORS* 14.25 PERSEVERATIVE ERRORS* CATEGORIES COMPLETED 16.06 5.25

TRAIL MAKING TEST TRAILS A* TRAILS B* 22.38 59.38 44.60 107.87 -4.62 -3.23 .0001 .003

* Lower score represents better performance

67

1000 T
- DRUG GROUP o-NEUROLOGIC GROUP

100 e = e =
SCORES

10

-o=^^:z^^^t.~n^. :S^^8

1 -M

1
I

1
C

1
A

FSIQVIOPIO

S DS TESTS

V DSY PC BD PA OA

FIGURE 1 COMPARISON OF GROUP MEANS FROM TABLE 7

68

1000 T - DRUG GROUP o-NEUROLOGIC GROUP 100 - 0 = 0 SCORES

1 0

] -MII

III

I
*

IIIIIIIIIIh
* * * * *

R S A 1 5 B 6 5/6 R C R PR C E NEPECC A B VRAT AVLT CFT TESTS VCS TRAILS

* Low score represents b e t t e r performance.

FIGURE 1 -

Continued

69 important in understanding the real significance of the research findings in addition to the statistical significance. Without the use of available normative data and

cutoff scores for impairment indices, the meaning of the research findings is less than clear. The most meaningful

review of neuropsychological data is clinical examination of each individual's test results. Hypothesis 2. This was done in

At this point, however, the discussion will

involve the application of clinical impairment ratings to the group means. This represents a loss of some descrip-

tive information but aids in analysis of the functional ability suggested for each of the clinically identified groups. It is important to recall from the Procedures

section that clinical ratings of performance which are assessed as above average, average, and mildly impaired are considered within normal limits and that dysfunctional ability is demonstrated in moderate, severe, and profound levels of impairment. Table 8 reports the data for both groups in four categories. First, there were tasks on which the neuro-

logical ly impaired group was statistically different from the polydrug group and where this also represented a difference between impaired and unimpaired functioning. Second, there were tasks on which statistical differences

70 TABLE 8 COMPARISON OF STATISTICAL FINDINGS AND CLINICAL IMPAIRMENT RATINGS ON INDIVIDUAL TESTS

Significant differencesneurological group impaired

Significant differencesneurological group unimpaired

Nonsignificant differencesneurological group impaired

Nonsignificant differencesboth groups impaired

WAIS-A * WAIS-DS * WAIS-Dsym * AVLT-5 * AVLT-6 * TRAILS A * TRAILS B *

WAIS-PC AVLT-R

CFT-COPY * * WCS-PE * *

WAIS-I * CFTX * WRAT-A * *

* **

Mild

impairment impairment

Moderate

71 were found but where the scores of both groups fell within normal limits. Third, there were tests on which there were

not statistical differences but on which clinical ratings indicated impairment for the neurologic group. The final

category included two items on which there were not statistical differences but where the scores of both groups fell in the impaired range. Subtest scores on the Wechsler scales are evaluated against a mean of 10 and a standard deviation of 3 (Wechsler, 1981, 1974). Five subtests showed statistically In the

significant differences between the two groups.

verbal cluster of subtests. Arithmetic and Digit Span both showed poorer performance (fi<.05) by the neurologic group. In both instances the performance of the polydrug group was in the average range while the neurologic group showed a mild level of impairment on these tasks. With the nonverbal, perceptual organization subtests. Digit Symbol/Coding (p<.01) and Picture Completion (p<.05) showed statistically significant differences favoring the polydrug group. average range. In each case their functioning was in the The score of the neurologic group on

Picture Completion fell in the low average range while their Digit Symbol/Coding scores fell in the low average range of ability, suggesting a mild level of impairment.

72 The differences in group performance on Trails A and Trails B describe the polydrug group as functioning in the average range of ability while the neurologic group showed mild impairment on this complex task of visual attention and motor speed. The neurologic group's performance on

these two tests and the subtests of the Wechsler scales. Arithmetic, Digit Symbol/Coding, and Digit Span (on which the neurologic group showed statistically significant differences plus impairment ratings), are consistent with findings on patients with diffuse brain damage. These

problem areas are commonly found with head injured populations and are due to difficulty on tasks requiring sustained attention, mental tracking, and speeded motor ability (Lezak, 1983). The final tasks on which the neurologic group showed both statistically poorer performance and impairment were trials 5 and 6 of the AVLT. Lezak (1983) suggests that the

pattern of functioning demonstrated by the neurologic group reflects problems with new learning and retention of information. While their immediate recall was in the normal

range, along with the polydrug group, their learning across repeated trials was significantly poorer. Statistical

difference was found on the recognition trial as well but the neurologic group's score was not in the impaired range.

73 The neurologic group showed moderately impaired scores on three additional measures where statistically significant differences were not found, computational arithmetic on the WRAT-R, the copy trial of the CFT, and perseverative errors on the WCS. The arithmetic score is frequently The CFT

impaired in closed head injured populations.

represents a novel task which requires complex perceptual organization and planning and is also sensitive to diffuse brain impairment. Perseveration is an impairment in cognitive flexibility and the capacity to shift response sets as task requirements change. The normative data on the WCS

(Heaton, 1981) reports a mean of 12.6, SD = 10.2 for perseverati ve errors. Although these data were drawn on an

older population (M = 35.9, SD = 15.3) with high average Full Scale I. Q. (M = 114.0, SD = 11.7), recent research (Chelune & Baer, 1986) to establish developmental norms found that by the age of 10 years children's performance is comparable to adults. Using the adult norms as the inter-

pretive base for the functioning of the two groups in the current study, the score for the neurologic group on perseverati ve errors indicated moderate impairment. Two tests showed no differences between the groups but the scores for both were similar in suggesting lower levels of functioning. Scaled scores for both groups fell in the

74 low average range for the Information subtest of the Wechsler scales which assesses general fund of information. Good performance on this task is contributed to by verbal comprehension and memory (Kaufmann, 1979). Influences

which affect performance on this subtest include stimulation in the child's early environment, school learning, and intact remote memory, therefore the lower level of functioning in this area may be accounted for in a variety of ways. For one person it may be the result of problems

with retrieval of long-term memory while in another it may be the result of low academic motivation. The small n in

the present study prevented factor analysis of the data to investigate the factors which may have similarly or differentially affected the performance of each group. The other measure on which both groups performed poorly was the percentage of information recalled on the CFT. This score was based on Snow (cited in Lezak, 1983)

and was developed to evaluate the memory component of the task while controlling for the quality of the original performance on the copy trial. Both groups had difficulty

in this area suggesting a mild level of impairment.

Hypothesis 2 The second hypothesis stated that impairment ratings based on pattern analysis of each subject's performance

75 would show no significant differences between subjects in a drug addiction treatment program and neurological 1y impaired subjects. hypothesis. A t-test procedure was used to test the

There was no significant difference between

the means of the two groups (see Table 9).

76 TABLE 9 T-TEST COMPARISON OF CLINICAL IMPAIRMENT RATINGS

POLYDRUG (n=16) MEAN IMPAIRMENT RATINGS 1.81

NEUROLOGICAL (n=15) MEAN 2.33 -1.43 .163

CHAPTER V DISCUSSION AND CONCLUSIONS

Summary The purpose of this study was to examine the cognitive functioning of adolescents involved in significant abuse of multiple psychoactive drugs. The literature review re-

flected the existence of national concern regarding illegal drug use with a major focus on the use patterns of adolescents. A trend has been noted toward increased social

tolerance of the use of certain substances which have been popularly labeled as harmless and recreational such as marijuana and cocaine. Increased attention to the drug

problem in the United States began with an awareness of the growing drug use by white, middle class teens. While the

popular picture of drug use 20 years ago was heroin addiction in the urban ghetto and marijuana use on college campuses, the mean age of first use by subjects in this study was 10 years with the earliest exposure at the age of seven. A search for causes and effects has covered a broad spectrum of social, personality, and medical variables. The observation of the profound effects of intoxication with various drugs, including the psychotic episodes associated with amphetamine abuse, led to concern about 77

78 possible longer lasting cognitive impairment as the result of duration or intensity of drug use. Studies which

investigated cognitive impairment as the result of involvement with one drug did not support this hypothesis (Parsons & Farr, 1981 ). Investigation of drug taking behavior revealed a trend toward not only involvement of younger and younger children but also toward use of multiple substances either in sequence or simultaneously. The research on the cognitive

functioning of polydrug abusers with a young adult population did find evidence of mild, diffuse brain dysfunction (Adams et al. 1975; Grant, Adams, Carlin, Rennick, Judd, & Schooff, 1978). Earlier research by Bruhn and Maage (1975)

on Danish prison inmates found no differences among four subject groups: nondrug controls; users of marijuana and hallucinogens; users of marijuana, hallucinogens, and stimulants; and users of marijuana, hallucinogens, stimulants, and opiates. Grant et al. (1976) suggest that

Bruhn and Maage's lack of identification of cognitive dysfunction may have been the result of their analysis of the data on a test by test basis rather than using a clinical analysis of the pattern of individual performance and overall impairment ratings. The most comprehensive of

the studies on young adults involved with polydrug use (Grant, Adams, Carlin, Rennick, Judd, & Schooff, 1978)

79 found that duration and intensity of involvement with central nervous system depressants and opiates represented the greatest risk to the integrity of cognitive functioning. These results may also explain the discrepancy

with the Danish study since depressants and opiates were not heavily represented in that subject population. Based on these findings, the relevant question in this study was whether, in addition to academic and social problems, adolescents involved in polydrug use experienced impairment of cognitive ability. The study was a

comparison of two subject groups, adolescents with multiple-drug use histories and adolescents with a history of neurological trauma. Limitations on research design The polydrug

included the lack of random assignment.

adolescents were an intact group of inpatients at a private psychiatric facility. They were being treated in an The neurologically

adolescent addictive disease unit.

impaired group was matched for age to the drug group. These subjects had been tested using a modification of the Halstead-Reitan battery in the three years previous to the study. They were patients evaluated in a rehabilitation

program in the same community as the psychiatric hospital. Their evaluation was part of a routine medical follow-up of their injury. Fourteen of the subjects had experienced

closed head injuries most commonly related to motor vehicle

80 accidents. brain tumor. One of the subjects had had surgery to remove a The polydrug subjects were tested with the They additionally com-

same neuropsychological battery.

pleted a medical history, sociodemographic data, and personality assessment. The MMPI and BDI were administered Each hypothesis was tested

and scored by the hospital. with a t-test procedure.

Statistically significant results

favoring the polydrug subjects were found for 10 individual tests. In the 23 remaining tests no differences were found

between the neurologically impaired and the polydrug groups. On overall impairment ratings no difference was

found between the two groups.

Discussion of the Study This study described the cognitive functioning of adolescent polydrug abusers. It was stated that the

results of neuropsychological assessment of an adolescent polydrug group would show no significant differences from a group of adolescents who were neurologically impaired therefore suggesting the existence of mild, diffuse impairment related to polydrug use. The comparisons of

performance were made on each assessment procedure and on clinical analysis of overall ability. Although the results

of the clinical analysis indicated no difference between the groups, the explanation for the similarity between them

81 was that both groups were functioning within the lower range of normal limits. are: 1. Traumatically head injured adolescents involved in Possible reasons for the results

an outpatient treatment program represent a high level of adjustment in this population and the recovery of cognitive ability in some patients approaches normal limits with recovery times averaging more than one year. 2. Cognitive impairment related to the extent and

intensity of drug involvement by this youthful a population may not be reflected in neuropsychological performance. 3. Cognitive impairment from stimulant use, preferred

by these subjects, may not be reflected in performance on the individual procedures used in this battery. 4. The mild level of cognitive impairment suggested

by the overall clinical rating of the polydrug subjects may be descriptive of a group of adolescents who are vulnerable to involvement in multiple-drug use. An important question in understanding the results of an assessment of cognitive functioning is premorbid ability. In this study no measure of ability prior to the

onset of drug involvement or neurological trauma was available. Measures of verbal ability which reflect old,

overlearned skills are typically felt to be the most resistant to the debilitating effects of diffuse brain

82 damage. This resistance is demonstrated in the studies on Using the

adult alcoholics (Parsons & Farr, 1981).

Vocabulary subtest of the Wechsler scales and the oral reading subtest of the WRAT-R as benchmarks of premorbid ability it appears that the functioning of both groups could be described as falling in the lower end of the average range of ability. Grant et al. (1976) state their

opinion that it was improbable that the deficits which were observed in their study of young adult polydrug abusers could have reflected premorbid cognitive ability but they had no way to control for this in their study. Related

studies on adult alcoholics have explored the possibility of preexisting lower levels of functioning as an explanation for the observed deficits in this population. De Obaldia et al. (1983) studied a group of 55 men admitted to a Veterans Administration alcohol treatment program and found that the poorest cognitive functioning was demonstrated by the quartile of the group reporting the most childhood symptoms related to hyperactivity and minimal brain dysfunction. Tarter and Alterman (1984) state.

Since the majority of deficits demonstrated in alcoholics are on tasks that involve sustained attention . . . there could be an additive effect of antecedent impairments and alcohol consumption to produce neuropsychological deficits in alcoholics, (p. 3) Lewis and Hordan (1986) review findings which link phencyclidine (POP) abusers with previous histories of learning

83 disabilities (LD) and learning disabilities with juvenile delinquency (JD) which is frequently associated with drug abuse. They state.

The LD-JD hypothesis derives from observation that LD is estimated to be present in 50 percent to 80 percent of the JD population, compared to estimates of LD's presence in 8 percent to 12 percent of the normal-IQ school-age population at large, (p. 192) Despite the lack of clinical findings of cognitive impairment in the current study, it is not possible to state whether the polydrug subjects' abilities were what they would have been in the absence of drug use. The polydrug group was statistically superior to the neurologically impaired group on 10 of the 33 assessment scores, 30 tests of specific ability and three composite intelligence scores. On only two of the tasks did the

polydrug group's performance indicate mild levels of impairment when compared to clinical ratings. On the 12

items on which the neurologic group's performance suggested impairment, seven of them were mild (within normal limits) and five were moderate. Despite the fact that the compar-

ison of group means comes out strongly favoring the polydrug group, the clinical assessment of each individual's performance analyzed in Hypothesis 2 showed no difference between the groups. This finding could result

from either good performance by the neurologic group or poor performance by the drug group. Seven subjects from

84 each group received overall impairment ratings suggesting low average cognitive functioning (mild impairment). Although this category falls within normal limits it is at the lower end of this range. Three of the polydrug

subjects and six of the neurologic group showed ability suggesting more than mild deficits. It is important to

recall that the clinical pattern analysis allows for ratings of impairment based on relative strengths and weakness so that an average Vocabulary score on the WAIS-R might represent impaired functioning if is was produced by an individual with a postgraduate degree in English. means that a clinical impairment rating might not contribute to a lowered group mean. Although the functioning This

of both groups suggests lower levels of average ability this rating falls within normal limits and therefore it appears more likely that the statistical similarity between the groups is the result of the relatively good functioning of the neurologically impaired group than significant impairment of the polydrug subjects. One explanation for the apparently intact cognitive functioning of the polydrug group may relate to the drug category favored by the adolescents in the study. The

drugs of choice for the adolescent group in the present study were stimulants and marijuana with a variety of other drugs in combination. Only two subjects listed no

85 stimulant use. This is consistent with other findings The

involving this age group (Kirby & Berry, 1975).

findings of this study are consistent with those of Grant, Adams, Carlin, Rennick, Judd, and Schooff (1978) in suggesting That heavy, persistent amphetamine use is not related to neuropsychological impairment in most youthful users, although a few persons might indeed be at risk for idiosyncratic reasons (e.g., preexisting hypertension, vasculitis, or allergic diathesis) yet to be determined, (p. 1071 ) This conclusion must be cautionary because of the small sample size and the absence of a normal group for comparison. The lack of interpretable findings regarding personality functioning of the adolescents in the drug treatment program was a disappointment. Little data were available

on psychological functioning due to invalid results on six of the MMPI's and no administration of this instrument due to the poor reading level of two of the subjects. In a

study of the personality correlates of polydrugs abusers, Kilpatrick et al. (1976) describe a group of 17 males, mean age 24.59 years, as emotionally labile and overresponsive to stimuli. They were found to be higher on measures of The authors state,

state anxiety but not trait anxiety.

Neurotocism and extraversion scores considered together and compared with Eysenck's norms (1968) categorize the polydrug users as high on both neuroticism and extraversion, which Eysenck

86 reports to be characteristic of under-socialized psychopaths, (p. 315) Kilpatrick's group of young adults was also found to be higher on sensation-seeking than controls. Despite

inadequate data from the MMPI, some evidence exists for undersocialized features in the functioning of the adolescents in the current study. Using the diagnosis of

conduct disorder under the DSM III criteria, elevation of Psychopathic Deviance (Scale 4) on valid MMPI profiles, and arrests as measures of social deviance, only two polydrug subjects did not meet this criteria. The same issue,

however, can be raised with the adolescent head injured group. Recent studies have suggested that this population

was involved in more risk-taking behavior prior to their accidents than their peers (Lezak, 1983; Rutter, 1981). They are described as "impulsive, overactive youngsters, who by nature are more inclined to participate in dangerous activities" (Begali, 1987). Responses to the BDI suggest a

moderate level of depression in the polydrug subjects. Some of the depressive features which these adolescents reported may have been affected by their recent hospitalizations in addition to more chronic concerns. Whether polydrug abuse by adolescents results in cognitive impairment is undetermined by this study. It

does appear that polydrug abuse which emphasizes stimulant use was not related to moderate to severe brain dysfunction

87 in the present group. Further research is needed to

resolve this question and to investigate the problem of whether such impairment would result from drug use or if the drug use could be subsequent to and associated with minimal brain deficits and therefore provide a predictor of vulnerability for drug involvement. question is twofold. The importance of this

First, if mild cognitive dysfunction

somehow, undoubtedly in combination with other variables, contributes to involvement in drug use then prevention strategies should focus on this population. Speaking of

this population. Grant et al (1978b) state that "It may be necessary to educate persons with such subtle disorders regarding their greater vulnerability to polydrug-induced impairment (p. 183)." The second part of this issue in-

volves the special therapeutic needs of a population with minimal brain dysfunction.

Summary of Results The cognitive effects of polydrug abuse by adolescents have not been studied previously and the lack of impairment findings on individual measurement procedures in this research cannot be taken to indicate that neurological ability is not affected by multiple drug use. Three issues

may be especially relevant in understanding the cognitive functioning demonstrated by the polydrug subjects of this

88 study. First, this study consisted of middle class Stimulating home environments are highly corGood

subjects.

related with the development of good verbal ability.

verbal skills are notoriously resistant to the effects of mild diffuse neurological dysfunction. Second, the poly-

drug subjects of this study fit the criteria for drug addiction according to the DSM III but within this framework the duration and intensity of their drug use was quite variable. One subject was in a third treatment program,

had extensive scars as the result of intravenous stimulant and opiate use, began using drugs at age nine, and was on probation for felony criminal charges related to drug use. The opposite end of the spectrum in this group was represented by a 15-year-old with a three-year history of abuse involving marijuana and alcohol. If the number of the

subjects in the study had been large enough, the extent and intensity of drug use could have been compared with overall clinical impairment ratings. The third issue, which has

been raised earlier, is the preference in this study for use of stimulants and the lack of research support for evidence of deficits in cognitive ability in any age group in which stimulant use predominated.

89 Implications for Further Research Future research in this area would need to consider several issues which arose during this study. A larger n

would be important in increasing the power of the statistical tests and to provide data for exploration of variables related to drug use categories. Availability of

a premorbid measure of functioning such as standardized academic achievement scores would be valuable in interpreting the results as would any reliable indicator of previously established learning disability or minimal brain dysfunction. Inclusion of a group of normal subjects would

assist in more clearly interpreting the results of the cognitive functioning of the polydrug group. This is an important area of study. One which in-

volves the identification of cognitive ability in polydrug abusing adolescents. It involves the investigation of

cognitive factors as etiologic and contributory or as effects of involvement with drug abuse. Research should

also be directed toward development of appropriate preventive and treatment interventions for adolescents with cognitive impairment. Grant, Adams, Carlin, Rennick, Judd,

and Schooff (1978) acknowledge this need and recommend avoiding therapies emphasizing intense emotional arousal and insight in patients with brain dysfunction.

90 Implications for the Professional The results of this study indicate that 10 of the subjects in an adolescent polydrug treatment program were identified to be functioning at or below the mildly impaired, low average, range of cognitive ability. This

finding was based on the clinical analysis of individual patterns of performance of each subject. Whether this

represents an effect, a cause, or a correlation to their drug abuse it suggests that neuropsychological assessment of this population can contribute to an understanding of the patient's functional ability which has great meaning in terms of effective treatment. If problems are individually

evident in attentional abilities or problem solving, therapeutic interventions must respond to a need for repetition of important material or assistance with processing treatment information. Lewis and Hordan (1986) suggest that the

high recidivism rate in their population of POP abusers could be primarily accounted for by treatment personnel's lack of information about and accommodation of patients' cognitive ability. In the absence of any type of im-

pairment, these are teenagers with significant adaptive problems and for those who additionally have cognitive deficits, identification of these and accommodation of the treatment plan is necessary. The Lewis and Hordan (1986)

findings of impaired verbal concept formation associated

91 with POP abuse suggests that verbal therapies in which most counselors are trained places the success or failure of the patient on an area of relative cognitive weakness. An additional finding is suggested by the outcome of this study. The response bias to the MMPI questionnaire by Archer (1987)

the polydrug subjects was disappointing. states that

For the oppositional and angry adolescent, the MMPI may present a welcomed opportunity to display noncooperation by responding in the slowest and most inappropriate fashion to each item. (p. 34) This finding is supported by the research of Newmark and Thibodeau (1979) on administration of the MMPI to adolescents in inpatient treatment settings. Modifying the

presentation of this instrument might be useful in obtaining valid and therefore interpretable results. Perhaps an explanation of the validity scales and their ability to detect a bias in responding would be sufficient to produce an appropriate test-taking attitude. Other

options would be to tie appropriate completion of the test to some aspect of the treatment program, to substitute another instrument or form of personality, or to delay the administration until the patient had developed a minimal commitment to the treatment program. Although this would

result in the loss of data regarding initial attitudes, information regarding the more enduring aspects of

92 personality functioning would not be lost and would be available on more patients. Interestingly all of the subjects approached for inclusion in the polydrug group volunteered. Although

there was occasional manipulation when a subject agreed to a time for the testing and at the last minute would reschedule in favor of a basketball game, the general attitude was cooperative. This may have been due to the

novelty of the type of testing included in this battery and the comraderie which developed among the patients who had completed the testing, another example of the adolescent vulnerability to peer pressure. Nevertheless, the coopera-

tion of the polydrug subjects suggests their amenability to this type of investigation.

Conclusions It would be inappropriate to generalize from the results of this study due to the small sample size and the methodological limitations. This study does not compare

the ability of the polydrug group to a normal control of age-matched peers. A striking finding, however, was that

the overall impairment ratings based on clinical pattern analysis of individual performance suggested mild to severe neurological impairment for two-thirds of the polydrug group. The research on amphetamine use by adults has not

93 found abuse of stimulants to result in permanent cognitive impairment. This provokes the thought that perhaps the

cognitive ability of the polydrug subjects of this study represents a premorbid level of functioning rather than an effect of drug use. The finding that 81.4% of these poly-

drug using adolescents have a first degree relative with a history of alcohol or drug addiction suggests that consideration of the research supporting genetic transmission of alcohol addiction could be germaine to an understanding of the risk factors for polydrug users. Although alcohol was

not the drug of choice for the subjects of this study it may be that the availability and increased social acceptance of drug use has resulted in polydrug involvement in teenagers who in the past would only have had access to alcohol.

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APPENDIX A MEDICAL HISTORY QUESTIONNAIRE

100

101 MEDICAL HISTORY QUESTIONNAIRE

Screening Items Difficult maternal pregnancy Premature birth Required postnatal observation Hospitalized before age 6 Febrile convulsions Learning difficulties in school Traumatic head injury Posttraumatic amnesia Nontraumatic unconsciousness Diagnostic brain tests History of brain disease Epilepsy Overdose requiring hospitalization Severe headaches Frequent muscular weakness Numbness of extremities Frequent faintness or dizziness General anesthesia

Yes

No

Not Sure

APPENDIX B DEMOGRAPHIC QUESTIONNAIRE

102

103 DEMOGRAPHIC QUESTIONNAIRE

1.

On a scale of 1 to 10 how satisfied are you with your life right now? One represents least satisfied and 10 most satisfied. How would you describe your family? a. b. c. Lower class Middle class Upper class

2.

3.

What is your parents marital status? a. b. c. Married Divored Widowed you describe the quality of your parents'

4.

How would marriage? a. b. c.

Close and warm Cold and distant Angry and hostile

5. 6. 7.

Do you feel that you have experienced brain impairment as the result of your drug use? What is your religious preference? To what extent do you consider yourself religious? a. b. c. d. e. f. Strongly Moderately Fairly Mildly Very Little Not at all

8. 9. 10.

What was the highest grade in school completed by your mother? What was the highest grade in school completed by your father? At what age did you first use drugs?

104 11. Do any of the following members of your family have history of alcohol or drug addiction? a. b. c. d. e. f. g. Father Mother Paternal Paternal Maternal Maternal Siblings

Grandfather Grandmother Grandfather Grandmother

APPENDIX C GLOSSARY

105

106 GLOSSARY

Amnestic - Cognitive problems dealing with recent and remote memory. Focal - The focal effects of brain damage refer to predictable and circumscribed intellectual losses resulting from injury to a specific cite. Impairment - The difference between a person's present level of functioning and the expected level of original ability. Polydrug - Simultaneous or sequential use of multiple categories of drugs. Perseveration - Meaningless repetition of a previous response prohibiting appropriate shifting of responses as task requirements change. Premorbid - Premorbid ability is the intellectual potential or capacity which was present prior to disease, developmental anomalies, emotional disturbance, or any condition that has impaired the expression of these abi1ities.