Inhalant Abuse: Confronting the Growing Challenge

Steve Riedel, M.S. Ed.
Associate Director
Our Home, Inc.

Tim Hebert, M.S.
Paul B. Byrd, Ph.D.
Our Home, Inc.
Huron, South Dakota

Inhalant abuse has been an overlooked and severe form of substance abuse in rural catchment areas. Youths with inhalant abuse problems can be identified, referred to, and retained in treatment. Treatment participation results in positive and objective outcomes. It is recommended that the current policy of nonintervention should not continue. This growing inhalant abuse problem must be challenged. The problem should be given the consideration of governmental, planning, and service providing entities, so that comprehensive approaches responsive to inhalant abuse can be implemented. Finally, the programs implemented should be objectively evaluated, so that comparisons among approaches can be made.

Purpose of the Project

The purpose of the Our Home, Inc. Inhalant Abuse Treatment Program is to challenge the problem of inhalant abuse by making a comprehensive treatment program available to affected youth.

In 1987, H.G. Morton wrote that "solvent abuse appears to be an embarrassment to children's services; rather than accepting the challenge of inhalant abuse, a policy of nonintervention exists and this policy is unacceptable." Dyer (1991) noted that "treatment facilities set up for inhalant abusers are nonexistent." Jumper-Thurman and Beauvais (1992) noted the "lack of even a rudimentary treatment model." Despite such commentaries in the literature, adolescent inhalant abuse has by and large been underacknowledged by the prevention and treatment delivery systems. A specific void has been particularly evident in comprehensive inhalant abuse treatment services.

In an attempt to fill this service void, Our Home, Inc. successfully sought an Office for Treatment Improvement (now the Center for Substance Abuse Treatment [CSAT]) grant. The project sought to "unlock the treatment doors to a population of moderate and severe drug users (inhalant abusers) whose treatment needs have been ignored at national and local levels." This mission continues to be the project's primary purpose.

A critical but coexisting purpose also existed. This second purpose was to develop an inhalant abuse treatment model that would address the wide range of social, psychological, academic, and neuropsychological deficits associated with inhalant abuse. Developing a program in the absence of other models also called for objectively measuring treatment outcomes as part of the model implementation process.

Methods

The discussion of methods addresses two areas. First, we discuss the distinctive treatment and patient identification methods utilized in the project. Second, we review the specific methods applied in measuring treatment outcomes.

Initial Steps

The following steps were taken in establishing the project:

1. First, it was necessary to create a treatment facility. An increased treatment capacity was created through the CSAT grant application process and through support from community economic development funds. A facility with a potential 16-bed capacity was obtained and renovated. As a step toward financial independence, the bed capacity has been managed so that a percentage of the beds are available as prepaid slots and a percentage are available under purchase-of-service agreements.

2. To stimulate systemwide prevention and intervention responses, it was necessary to increase professional awareness of the inhalant abuse problem. Increased awareness was promoted through a variety of methods, including:
   • Formulating an advisory board that represented the service delivery systems which would be impacted.
   • Conducting subject matter workshops at local, national, and international events.
   • Arranging for news releases and media awareness activities throughout the region. Because the program has a target population requirement of 75 percent American Indian youth, a specific radio station targeting Indian audiences was involved.
   • Developing and distributing (via training-of-trainer workshops) a comprehensive educational video curriculum about inhalant abuse and its dangers. As there was a void in resources, this was also done to place an educational resource in the hands of varied professionals across the region. Approximately 300 video curriculums have been released.

3. It was necessary to develop and implement a comprehensive treatment model designed for the inhalant abusing patient. Programmatically, this entailed considering the patients' unique needs and problems, especially with regard to neurocognitive functioning. The unique methods ultimately incorporated have been numerous. The provision of individual/group counseling, a history and physical examination, psychological evaluation, balanced diet, recreation, family programming, and aftercare coordination are assumed to be routine and are not discussed in this paper. This discussion is confined to the most distinctive methods implemented and includes:
   • Providing an extended length of stay, allowing for a minimum patient stay of 90 days that can be extended to 120 days.
   • Providing complete neurocognitive assessment based on the procedures and instruments included with the Halstead-Reitan Neuropsychological Test Battery (Reitan 1959). This assessment is given at the approximate 2-week point after intake and is used to assess neurocognitive impairment and to develop an individual prescriptive neurocognitive rehabilitation program. The assessment is repeated at discharge for outcome evaluation purposes. The Kaufman Test of Educational Achievement (K-TEA) is used to assess and retest academic skills.
   • Providing neurocognitive rehabilitation—Reitan Evaluation of Hemispheric Abilities and Brain Improvement Training (REHABIT) (Reitan and Senac 1983)—to those assessed as in the "impaired" range of neurocognitive functioning and to those assessed as in the "normal" range but who may have a specific impairment.
   • Providing a full academic day during the course of treatment. Academic programming has the patient participating in school at any of the three individually assigned levels. Academic attendance assigned levels are assigned as "does not attend school," "attends school part time," or "attends school full time." Another specific method is "video group," in which patients and counselors watch prerecorded classroom behavior in order to assist in behavioral classroom adjustment.
   • Providing specialized inhalant abuse education with other comprehensive health/drug and alcohol education.
   • Providing cultural activities and ceremonies within the customs and beliefs of the American Indian population. In doing so, the first step was to appoint advisory board members reflecting the interest of the Indian Health Service System and the Tribal Court System. Other multiple activities were also undertaken. A consultant was employed to initiate a process of cultural growth and enhancement. Periodic consultation visits stimulated programming. Activities such as "sweat ceremonies," smudge purification rituals, and the use of elders and daily prayer were incorporated. Staff recruitment and employment practices have been enhanced to culturally complement the program.

Enhanced methods applicable to family services, transitional care, community-based aftercare, abuse and neglect counseling, and patient supervision are also used.

Test and Retest Procedures

Objective treatment outcome data have been obtained by test and retest procedures. The methods used, as well as the data handling procedures, are briefly outlined here. A Halstead-Reitan Neuropsychological Test Battery (HRNTB) is administered to all patients at approximately the 14-day point. The Intermediate Booklet Category Test (Byrd 1985) and Booklet Category Test (DeFelipis and McCampbell 1979) are used as opposed to the electromechanical slide versions of the category tests. Through this battery, a Neurocognitive Deficit Score (NDS) (Reitan and Wolfson 1988) is determined for each patient. The NDS reflects the extent of the neurocognitive impairment that each patient is experiencing at admission and discharge. The NDS for each patient population is tabulated and converted to a mean NDS for the total patient population. The difference between the intake and discharge NDS is derived and recorded as improved or regressed neurocognitive functioning. HRNTB norms require that subjects ages 14 and younger be considered "children," and subjects ages 15 or older are considered "adults." Data for each classification are separated by age group. The project restricts admission to those ages 10 through 17.

In addition to the two age groups, clients are also classified as "impaired" or "nonimpaired," based on their NDS. The pretreatment and posttreatment NDS scores for each age group and diagnostic classification (impaired/nonimpaired) are also compared. These comparisons allow the program to assess the differences in the response to treatment between and within the age and diagnostic groups.

A Kaufman Test of Educational Achievement (K-TEA) is also administered at intake and discharge. The individual age-equivalent achievement results are converted into a mean achievement for the patient group. The results reflect the improved or regressed level of academic achievement. Data are handled so that results are presented for the two age groups.

Finally, the project reviews patient functioning at 6 and 12 months after discharge. This followup collects subjective and anecdotal data regarding posttreatment functioning. Inhalant use, other alcohol and drug use, school attendance, legal contacts, and living arrangements are monitored. Data are collected by personal contact, by telephone interview, or in writing. Data are accepted from the patient, the parent/guardian, or the referral/aftercare worker.

Content Area

The 1993 National Institute on Drug Abuse Monitoring the Future Study announced a shifting trend in the drug use patterns of the nation's youth (NIDA Capsules 1993). Between 1992 and 1993, use of inhalants among the nation's eighth graders increased from 17.4 percent to 19.4 percent. Inhalants are now the "most widely abused substance (after alcohol and tobacco) among this age group," and it is now estimated that one in five eighth graders has used inhalants such as glues, aerosols, gasoline, and solvents. The deadly and destructive nature of inhalant abuse is well documented throughout the literature. Death can result from "sudden death syndrome" and other direct causes.

The Situation in Rural South Dakota

While the national trend toward increased inhalant use should serve as a call to attention, the problem has been a longstanding one in many rural areas; this was the case within the project catchment area. In 1990, the South Dakota Senior Survey indicated that 18 percent of the Caucasians and 22 percent of the American Indians surveyed had lifetime experience with inhalants. Also in 1990, 55 percent of the youths in the South Dakota Juvenile Correction System had a history of inhalant use. Eighty-five percent of the youths within the State's most restrictive correctional facility (the South Dakota State Training School) had a history of inhalant use. Finally, given that seven reservations fall within the geographic boundaries of the target area, the estimated inhalant exposure among American Indian populations may be nearly double the national average (Beauvais and Oetting 1985).

Despite such data, professional services directed toward the problem within the catchment area were at best limited. Treatment services were nonexistent and, consistent with Morton's 1987 observation, a policy of "nonintervention" applied. Our Home, Inc. perceived that a significant population of moderate to severe substance abusers were being overlooked and sought to help them.

Record of Unsuccessful Treatment

As early as 1979, Mason suggested in a NIDA monograph that when inhalant abusing patients did enter treatment, they tended to perplex the system rather than be successfully served by it. Specifically, the monograph indicated that "inhalant abusers constitute the greatest dropout rate among substance abusers served." Smart (1986) noted that "probation, foster homes, and training schools were found to be unsuccessful for four of five male sniffers." Dyer (1991) noted that generally "counselors are not equipped to deal with the wide range of problems" presented by inhalant abusers. Jumper and Beauvais (1992) indicated that programs were not adapting to meet the needs of inhalant abusing patients. Our Home, Inc. acted on the need to develop specialized programming conducive to patient retention and successful treatment.

It was also recognized that other sociodemographic factors were likely to affect the delivery of care. These factors were: age (the average age of the patient admitted to date is 13.2 years); income levels (48 percent of the patients have annual family incomes of $5,000 or below); geographic isolation; and the racial composition of the patient population.

Clinical Issues In Providing Treatment

Beyond demographics were clinical issues that raised questions about the delivery of treatment services. Fornazzari (1988) noted that "lack of treatment effectiveness is due to lack of parent/family support, but also because the inhalant abuser is started too early in treatment programs. Detoxification of 2 weeks is recommended to allow for neurocognitive repair." Referring to chronic solvent abusers, Fornazzari stated, "Our experience suggests that the detoxification period be as long as possible. At least 2 weeks of close observation is necessary for the brain of these young persons to be rid of the effect of the solvent." A need for extended lengths of stay was indicated and implemented in the specialized programming.

Mason (1979) estimated that 30 percent of experimental users and 60 percent of regular inhalant users presented with measurable neurocognitive impairment. Other authors, such as Cooper and colleagues (1985), Ron (1986), Allison and Jerrom (1984), and King and colleagues (1985) have acknowledged neurological and neurocognitive consequences of inhalant abuse. Evidence of such neurological and neurocognitive symptoms suggested that any treatment approach developed must consider such matters. In response to this background context, the Our Home, Inc. program incorporated neurocognitive assessment and rehabilitation services.

The neurocognitive implications also held implications in relation to the young person's ability to perform academically. Mitic and McGuire (1987) cited school as a main source of stress for inhalant abusing youths. In 1990, Our Home, Inc. did an internal comparative analysis of 16 patients who had an inhalant abuse history, compared with 16 other substance abuse treatment patients without such a history. The comparison indicated that patients who had an inhalant abuse history came to treatment at a younger age (3.3 years younger than other substance abusing patients). They were also more than 1 year further behind in comprehensive academic achievement as tested by the K-TEA. It was apparent that academic adjustment and academic deficits needed to be considered in the treatment approach.

Objective Measures for Monitoring Outcomes

Finally, and since this project stood as the most comprehensive treatment effort pursued with this special population, Our Home, Inc. sought to evaluate treatment outcomes objectively. Changes in patient neurocognitive functioning and academic achievement were selected as the most objective measures. More subjectively, routine data reflective of patient posttreatment functioning have been pursued. Thus, questions about the benefits of treatment and the project might be considered.

In summary, a variety of questions were evident around the issues of patient treatment readiness and receptiveness. Our Home, Inc. sought to address these questions by modifying the treatment protocol and evaluating objective treatment outcomes.

Findings

The findings must be considered within the context of the patient population served. The following introductory and definitive information about the project catchment area and the patient population provide this context.

While the project's referral base has included a limited number of patients from across the United States, most of the patients served have been from the project's primary catchment area: South Dakota. CSAT defines South Dakota as a "Frontier State." (Note that the terms "frontier" and "rural" are used interchangeably throughout this paper). Seven Indian reservations have boundaries that overlap with South Dakota, and some of these reservation communities constitute the most impoverished areas in the United States.

Referral patterns suggest that older and chronic inhalant abusers have not been referred to the treatment program. Rather, younger patients who have a less progressed but regular pattern of use have been referred. In the process of determining intake appropriateness, the histories of all patients admitted have been compared to the American Psychiatric Association's Diagnostic and Statistical Manual criteria for inhalant abuse or dependence. The patient sample has been 75 percent male and 25 percent female.

Finally, because of project funding mandates, the findings are based on an 85 percent American Indian sample. Sample size is 101 unless otherwise specified. Project findings are presented below in general as they relate to the identified project purposes.

Project Findings

Section 1

Purpose 1. "Unlocking the treatment doors to a population of moderate to severe drug abusers" (inhalant abusers).

Program utilization findings.

During the initial 25-month project period to date, the project has provided treatment services to 101 youths. The utilization of the 16-bed capacity has progressively increased. For years 1, 2, and 3, respectively, the average census has been 10.0, 11.4, and 14.1.

It should be noted that we have received numerous generic program inquiries. During the 25-month project period, the project has handled 344 documented inquiries from across the United States and Canada. The patient treatment retention ratio for the project has been 80 percent. The most often-noted deterrent to patient retention has been parents' withdrawing of voluntary placements. This withdrawal takes place after the patient has disclosed a pretreatment history of physical or sexual abuse (usually inflicted by a family member). While this trend is difficult to quantify objectively, it is estimated that it applies in 50 percent of the nonretention cases. By the time treatment is completed, 60 percent of the patients have reported a pretreatment history of physical abuse and 52 percent a history of sexual abuse. Average length of treatment stay has been 97 days.

Severity of drug use patterns.

The severity of the patient drug use patterns also needs to be defined. Indications of early chronicity among this population of rural inhalant abusers should be identified. Age of first use stands as one pointed indicator. The average age of first use has been 10.2 years of age, and average age at admission has been 13.4 years. Thus, a "typical" patient has used inhalants for an estimated 3.2 years before entering treatment. During that 3.2-year time span, the typical patient is likely to have used five different inhalants.

Preferred products have been:

• Gasoline (43 percent)

• Rubber cement (22 percent)

• Spray paint (16 percent)

• Correction fluid (7 percent)

• Other (12 percent)

Frequency of use is as follows:

• Binge use (3.9 percent)

• Daily use (15.8 percent)

• 3 to 6 times weekly (28.7 percent)

• 1 to 2 times weekly (18.8 percent)

• 1 to 3 times monthly (14.8 percent)

• No use in the past month or unknown (17.7 percent)

This final percentage is related to referrals from detention and other holding facilities. Eighty-six percent of the youths treated indicate that they have made unsuccessful efforts to stop inhaling before treatment. Ninety-seven percent of the youths report having experimented with alcohol or other drugs.

Neurocognitive impairment.

Evidence of morbidity in the form of neurocognitive impairment is a critical indication of problem severity. While it is not entirely possible to rule out other causative factors, such as head injuries, fetal alcohol effects, or inadequate diet, the project assumes significant impairment is related to inhalant use. To date, the project has collected neurocognitive assessment and retest data from 50 youths. From this total, 44 percent have tested with measurable impairment. The insidious nature of the problem is evident in the fact that 36.1 percent of the younger group (ages 10 to 14) have fallen within the impaired range, while 64.2 percent of the older youth (ages 15 to 17) have been within the impaired range. Academic findings also reflect the severity of impairment. Based on K-TEA findings, the average admitted patient has a composite deficit of 2.5 years in reading and of 3.1 years in math.

These findings suggest that the project has clearly unlocked the treatment doors for a population of moderate to severe substance abusers.

Section 2

Purpose 2. Constructing a comprehensive model of treatment specifically designed for the inhalant abusing patient.

Project findings focus on project outcomes as measured by neurocognitive test and retest measures, academic test and retest measures, and on the posttreatment followup data collected. The project has conducted complete neurocognitive test/retest procedures on a total patient group of 50 youths. Findings are presented in two subsamples for "children" (table 1) and "older youths" (table 2).

Table 1. Treatment pretest and posttest neurocognitive
performance among children ages 10 to 14
Current sample size = 36

Table 1 details the treatment pretest and posttest of neurocognitive performance among children ages 10 to 14. Findings indicate that a mean average reduction (improvement) of 28 percent in NDS has been measured during the treatment stay.

Table 2 details findings for the older youth group, ages 15 to 17. While the older group has not reached the level of improvement attained by the children's group, a 23 percent improvement in NDS has been noted.

The neurocognitive deficit score is obtained from the entire sample group; therefore, these percentages reflect a total patient population outcome measure. Findings that compare impaired patients to their nonimpaired counterparts have also been considered. These findings indicate that impaired children have been found to show a slightly greater reduction (7 percent) in NDS as compared with those children who are not impaired, as depicted in tables 3 and 4.

Tables 5 and 6 demonstrate that impaired older youth show a 9 percent greater reduction in NDS than do nonimpaired youth. However, in comparing impaired older youth to impaired children, the impaired older youth demonstrate 5 percent less improvement during the course of treatment. During the course of treatment, 30 percent of the patients tested progress enough that they move from an impaired level of functioning to the normal range.

In order to determine if there were statistically significant differences between the impaired and nonimpaired clients' NDS before and after treatment, a multivariate analysis of variance was conducted. As shown in table 7, the pre- and posttreatment NDS was compared for the two age groups and within each age group. The results indicate that for the children ages 10 to 14, there is a significant difference between the impaired and nonimpaired clients (F=59.398, p<.000). The results also indicate a statistically significant difference between the pre- and posttreatment NDS for clients ages 10 to 14 (F=61.029, p=.000).

When the clients ages 15 to 17 were compared, the results indicate that again there is a significant difference between NDS of those clients who are impaired and nonimpaired (F=12.867, p<.003). The results also indicate a significant difference between the pre- and posttreatment NDS for this age group (F=10.790, p<.006). Although there is a significant difference between the impaired and nonimpaired pre- and posttreatment NDS for children ages 10 to 14 (F=11.131, p<.002), no significant difference was found between the impaired and nonimpaired pre- and posttreatment NDS for the 15- to 17-year-old clients. This is likely due to the limited number of clients served so far in the 15- to 17-year-old group (n=14).

Academic outcome findings are presented in Tables 8 and 9. The results indicate that the average composite academic gain of the children's group is 1.01 years during the course of treatment. The older group has gained 1.06 in academic years.

Followup findings (based on 35 youths to date) suggest that 34 percent of the patients have not used inhalants 6 months after discharge. An additional 12 percent report that they "use less often than before attending treatment." Patient tracking has been difficult, and the project has not been able to track 54 percent of the discharged patients. The status of these youths must be viewed as unknown. Followup findings are presented in brief form in table 10.

Tracking problems appear to be related to the frequent moving of project participants. Project intake data suggest 81 percent of the patients have moved one or more times in the 3 years prior to treatment. Twenty-nine percent of the discharges indicate no use of alcohol or other drugs following treatment, and 14 percent indicate that they use other chemicals less often. Such data have helped the project act constructively in that it has secured funding through the Single State Agency to enhance aftercare services in two target communities. This is being accomplished through contracts for service with community providers. The impact of this approach is yet to be determined. Arrest data, school attendance data, and participation in aftercare service data can be made available to the interested reader.

Conclusions

Wide-ranging conclusions can be made from this comprehensive treatment project. The following significant conclusions are based on project experience. Project experience has established that:

1. Inhalant abuse stands as a frequent and severe form of substance abuse within the rural catchment area served. National trends and project experience strongly suggest that similar rural communities are likely to have a comparable or greater problem.
2. The frequency and severity of the inhalant abuse problem merits heightened attention in the rural areas served. In view of the frequency and severity of the problem, a policy of nonintervention is truly unacceptable. The social, emotional, and financial consequences of failing to act on a form of substance abuse so clearly associated with mortality and morbidity need to be addressed.
3. A policy of nonintervention is simply not necessary. These youths can be identified, referred to, and placed in treatment before they shift predominant using patterns to other chemicals or congest correctional facilities. In a similar vein, it seems a logical conclusion that the earlier the intervention the better. The earliest possible intervention is likely to forestall adverse consequences and enhance the likelihood of favorable treatment outcomes, especially in relation to neurocognitive impairment. Given the severity and frequency of physical and sexual abuse among the patient population, treatment and child protection networks must be enhanced to serve these children adequately and to reduce continued risk factors.
4. Inhalant abuse patients can be retained in treatment for lengths of stay that are conducive to patient detoxification and to the demonstrated reduction of impairment in neurocognitive functions, along with improved academic performance and emotional behavioral stabilization.
5. The comprehensive treatment model utilized results in multiple and favorable treatment outcomes. The patient recovery and treatment outcomes with this population go far beyond the basic question of posttreatment substance use. Residential care appears to be central to patient stabilization and early recovery. Aftercare is likely to require extensive enhancement because of current resource limitations and patient demands. The project has also established objective measures that can be utilized to implement and compare other approaches used with similar populations.

Recommendations

While the project has led to certain conclusions, it has also raised broad questions. Seeking answers to such questions might provide further direction on issues such as length of stay, learning and academic approaches to be applied, and patient aftercare planning. Despite a host of unanswered questions, some broad recommendations can be made:

1. Federal, State, and tribal planning jurisdictions must thoroughly assess the inhalant abuse problem in order to:
   • Determine its human and economic impact
   • Plan for sufficient, appropriate, and comprehensive intervention responses, so that a continuum of care extending from prevention through aftercare exists to address the problem.
2. Governmental entities and service providers must cooperate to secure and implement these approaches as they are developed. The general void in services that continues to exist in most areas should be challenged.
3. All approaches should be implemented in conjunction with individual project and systemwide methods of objective measurement, so that approach and impact comparisons may be made.

This problem must not be ignored, given the growing body of evidence about the dangers of inhalant abuse, its impact on youth, and its consequences.

References

Allison, R., and Jerrom, D. Glue sniffing: A pilot study of the cognitive effect of long term use. The International Journal of Addictions 19(4):453-458, July 1984.

Beauvais, F., and Oetting, E. Trends in the usage of inhalants among American Indian adolescents. White Cloud Journal 3(4):3-11, 1985.

Byrd, P.B. The Intermediate Booklet Category Test. Psychological Assessment Resources, Inc. Odessa, FL, 1985.

Cooper, R.; Newton, P.; and Reed, M. Neurophysiological signs of brain damage due to glue sniffing. Electroencephalography Clinical Neurophysiology 60(1):23-26, 1985.

DeFelipis, N., and McCampbell, E. Manual for the Booklet Category Test Research and Clinical Form. Odessa, FL: Psychological Assessment Resources, Inc., 1979.

Dyer, M. "Psychological Aspects of Inhalant Abuse and Its Implications on Treatment." Unpublished, 1991.

Fornazzari, L. Clinical recognition and management of solvent abusers. Internal Medicine for the Specialist 9(6):99-109, 1988.

Jumper-Thurman, P., and Beauvais, F. Treatment of volatile solvent abusers. In: National Institute on Drug Abuse Research Monograph Series, No. 129. Inhalant Abuse: A Volatile Research Agenda. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992.

King, P.; Morris, J.; and Pollard, J. Glue sniffing neuropathy. Australian and New Zealand Journal of Medicine 15:293-299, 1985.

Mason, T. Inhalant Use and Treatment. National Institute on Drug Abuse Research Monograph Series. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1979.

Mitic, W., and McGuire, D. Adolescent inhalant use and perceived stress. Journal of Drug Education 17(2):113-121, 1987.

Morton, H.G. Occurrence and treatment of solvent abuse in children and adolescents. Pharmacological Therapy 33:449-469, 1987.

Reitan, R.M. Manual for Administration of Neuropsychological Test Batteries for Adults and Children. Tucson, AZ: Neuropsychological Press, 1959.

Reitan, R.M., and Sena, D.A. "The Efficacy of the REHABIT Technique in Remediation of Brain Injured People." Paper presented at the meeting of the American Psychological Association, Anaheim, CA, 1983.

Reitan, R.M., and Wolfson D. Traumatic brain injury. Recovery and Rehabilitation. Vol. 2. Tucson, AZ: Neuropsychological Press, 1988.

Ron, M. Volatile substance abuse: A review of possible long term neurological, intellectual and psychiatric sequelae. British Journal of Psychiatry 148:235-246, 1986.

Smart, R. Solvent use in North America: Aspects of epidemiology, prevention and treatment. Journal of Psychoactive Drugs 18(2):87-96, 1986.

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