PPT - University of North Dakota

University of North DakotaKids At Risk InRural America Conference“Adolescents AreNOTShort Adults”September 10, 2003 – Minot, ND

Adolescents AreNOTShort Adults”© 2003, 2003, Shulman & Associates, Training & Consulting in in Behavioral l HealthHealth

Aikens a laugh a day *Election 2004

THE SCOPE OF THE PROBLEM• Alcohol and drug use is the leading cause ofdeath in 15 - 24 year olds• Auto accidents• 10% of drivers cause 25% of fatal accidents• Suicide• Homicide• Drug & alcohol overdoses• Non-driving accidents

THE SCOPE OF THE PROBLEMHow incidence & prevalence data iscollected• School based collection• Adolescents with the most severe problemshave:(1) dropped out of school(2) been expelled(3) now worse with “zero tolerance”policies

ISSUES OF VULNERABILITYIN ADOLESCENTS TO SUBSTANCE USEDISORDERS AND PROBLEMS• Psychosocial Risk Factors• Genetics• Family Risk Factors• Drug of Choice• Psychiatric Disorders of Childhood andAdolescence• Societal/Cultural Risk Factors

PSYCHOSOCIAL RISK FACTORS• male gender (but diminishing)• right of passage• fathering a child• becoming pregnant• general adolescent turmoil (true of otherbehaviors)• inability to delay gratification/impulsivity• risk-taking• low self-regulation• no model for deviant drinking in an adolescentpopulation

PSYCHOSOCIAL RISK FACTORS (cont.)• low value and expectation for academic success• peer drinking and peer acceptance of drinking• positive expectancies for the use of A & D• sensation seeking• childhood behavior of impulsiveness,restlessness and distractability• trauma• physical, sexual or emotional abuse• violent victimization• observing violence (e.g., spousal abuse)

GENETICS• child of alcoholic (distinguish betweengenetics & environment)• inheriting those characteristics that makedevelopment more likely

GENETICS• If one is the child of an alcoholic and drinks, thechances of becoming alcohol are 4X greater thana child without an alcoholic parent• With adolescents, high “genetic loading” usuallyresults in:• Earlier onset of a substance use disorder• More rapid progression• Greater severity of the substance use disorder

FAMILY RISK FACTORS• parental drinking behavior• parental attitudes re: drinking• modeling• if a drinking problem for parents, may affectchildhood development• poor parenting practices• early childhood deficits in social skills and selfregulation(e.g., aggressiveness)• rejection from mainstream peer group• association with deviant peer group• Antisocial Personality Disordered parents (environmentalor genetic?)• sibling substance attitude & behaviors

DRUG OF CHOICE• Smoking as a predictor• Problem with the gateway theories• More compulsively used drugs orcompulsive routes of administration• Smoking drugs as the most efficient deliverysystem

PSYCHIATRIC DISORDERSOF CHILDHOOD AND ADOLESCENCE• Conduct Disorder• Oppositional Defiant Disorder• Depression• Anxiety/panic Disorders• Social Phobia• ADHD

SOCIETAL/CULTURALRISK FACTORS• advertising• cultural acceptance of illegal drug use• Parents who are/have been users(1) Role model for children• economics• Issues of supply and demand(1) cost of illicit drugs(2) availability

SOCIETAL/CULTURALRISK FACTORS (cont.)Taking Action About Availability• raising age• raising costs• enforcing lawsAll lead to:• delayed initiation of drinking• lowered rates of use• reduced mortality (esp. drinking/driving)

RISK FACTORS FORSUBSTANCE USE PROBLEMS• Level of emotional and cognitive development• Impulsivity• Perception of invincibility• Vulnerability to peer pressure (external locusof control)• AOD use settings• Immaturity (development of judgment)• lack of experience means cannot be a gooddrinker and/or a good driver• Absence of “deviance” examples• Change in cultural norms & expectations

RISK FACTORS FORSUBSTANCE USE PROBLEMS (cont.)• Cultural acceptance of illegal drug use as thenorm• Parents of many adolescents past/present drugusers• Change in expectations about age for firstexperimentation with alcohol and first drinking

RISK FACTORS FORDIAGNOSABLESUBSTANCE USE DISORDERS• Early onset• Earlier onset correlated with greater likelihood ofdependence and more rapid progression• More rapid progression• Family history of substance use disorders and geneticvulnerability• Perception of invincibility• Adolescent smoking• Level of emotional and cognitive development• Primary psychiatric comorbidity• Absence of skills for independent living• Victimization

Victimization HistoryPhysical AbuseSexual AbuseEmotionalAbuseAny Abuse0% 20% 40% 60% 80% 100%

Mental Heath Problemand Mental Health Disorders• Mental health problems exist on a continuumwhich includes sub-diagnostic thresholdsymptoms and traits• At some point there are enough symptoms andtraits to meet diagnostic criteria• In common use, “mental health problems”includes both sub-threshold and diagnosableproblems• Generally, the more criteria an individual meetsbeyond what is necessary to meet the diagnosis,the more severe the problem.

CONTINUUM OFADOLESCENT SUBSTANCE USE• Abstinence• Use (minimal or experimental use, with minimalconsequences)• Abuse (regular use or abuse, with several andmore severe consequences• Abuse/Dependence (regular use over anextended period, with continued severeconsequences)• Recovery (return to abstinence, with a relapsephase in which some adolescents cycle throughthe stages again)• Secondary Abstinence

SCREENING

THE THREE BEST INDICATORS OFALCOHOLISM IN ADOLESCENTS• drinking while truant from school• drinking on school property before, duringor after school• absence from school due to intoxication orthe after effects of drinking

Screening instruments are“quick, cheap and easy”and their purpose is to:• Rule individuals “out” or• Rule individuals “in” for furtherassessment

CRAFFTBrief Screening Test for Adolescent SubstanceAbuse*YESNOC-Have you ever ridden in a CAR w driven by someone(including yourself) who was “high” or had been usingalcohol or drugs?____ ____R -So you ever use alcohol drugs to RELAX, feel betterabout yourself or fit in?____ ____A -Do you ever use alcohol/drugs while you are byyourself, ALONE?____ ____F -Do your family or FRIENDS ever tell you that youshould cut down on your drinking or drug use? ________F -Do you ever FORGET things that you did whileusing alcohol or drugs?____ ____T -Have you gotten into TROUBLE while you were usingalcohol or drugs?____ ____* 2 or more yes answers suggests a significant problem

DIAGNOSIS

A diagnostic assessment isperformed:• After completion of a substance usedisorder screen which rules the individual“in” for further assessment• As a result of collateral information (e.g.,a DUI with a BAC of 0.25; a positive UDS;a crime committed under the influence ofa psychoactive substance, clearlyintoxicated at school)

Diagnostic Assessment• Substance Dependence• Substance Abuse• Those individuals who do not meet thecriteria for abuse, but whose drinking/druguse might still create problems (“sub-threshold” abuse) - Dimension 0.5

DSM-IV CRITERIA FOR SUBSTANCE DEPENDENCEA maladaptive pattern of substance use, leading to clinicallysignificant impairment or distress, as manifested by three(or more) of the following, occurring at any time in thesame 12-month period:(1) tolerance(2) withdrawal(3) the substance is taken in larger amounts or over alonger period of time than was intended(4) there is a persistent desire or unsuccessful attempts tocut down or control substance use(5) a great deal of time is spent in activities necessary toobtain the substance, use the substance, or recoverfrom its effects(6) important social, occupational or recreational activitiesare given up or reduced because of substance use(7) the substance use is continued despite knowledge ofhaving a persistent or recurrent physical orpsychological problems that is likely to have beencaused or exacerbated by the substance

DSM-IV CRITERIA FOR SUBSTANCE DEPENDENCESpecify If:• With Physiological Dependence: evidence of toleranceor withdrawal (i.e., either item 1 or 2 is present)• Without Physiological Dependence: no evidence oftolerance or withdrawal (i.e., neither item 1 or 2 ispresent)• Course Specifiers• Early Full Remission• Early Partial Remission• Sustained Full Remission• Sustained Partial Remission• On Agonist Therapy• In A Controlled Environment

Consider theDescription of Dependenceas Comprised of:(1) Loss of control(2) Compulsive use(3) Continued use in spiteof adverse consequences

Duration of Substance Use andProblems For Dependent CasesAverage Duration in Years432103.782.031.22First High First Problem ConcernOthers0.88Concern Self

DSM IV Criteria for Substance AbuseA Maladaptive pattern of substance use leading to clinicallysignificant impairment or distress, as manifested by one (ormore) of the following occurring within a 12-month period:(1) Recurrent substance use resulting in failure to fulfillmajor role obligations at work, school, or home(2) Recurrent substance use in situations in which it isphysically hazardous(3) Recurrent substance-related legal problems(4) Continuing substance use despite having persistent orrecurrent social or interpersonal problems caused orexacerbated by the effects of the substanceB The symptoms have never met the criteria for SubstanceDependence for this class of substance

CO-OCCURRINGOCCURRINGMENTAL HEALTH DISORDERSIN ADOLESCENTS WITHSUBTANCE USE DISORDERS

Diagnoses IndicatedPercent of Cases90%80%70%60%50%40%30%20%10%0%Conduct Disorder Major Depression Manic EpisodesPanic Attacks PSD

Possible Current Diagnoses forJuvenile Justice CommitmentsPercent of Cases100%80%60%40%20%0%DiagnosesConduct DisorderSub. DependenceOp. DefiantDepressionManic EpisodePTSDPanic AttacksPsychoses

Some Thoughts About ADHD andPsychiatric Medication• Based on multiple studies over the lastyear, children with ADHD who areappropriately placed on ADHD stimulantdrugs (e.g., Ritalin), have a LOWERincidence of later drug problems thanchildren with ADHD who are not placed onADHD stimulant drugs

(Simon & Schuster, $13)Excerpt fromLearning Outside the LinesIt feels as if our heads are filling up with lukewarm water, ideasfeel abstracted, and they rush to fill the recesses of ourtemples, running behind our eyes, dripping down our neck. It’snot quite a headache, but more of a dull pain buried in a thickfog — crossfire of connections, ideas, synaptic misfires andemotional distress. As we write, the cognitive pain movesthrough our bodies. Our feet fidget and our bodies contort aswe try to force ourselves to focus. We talk to ourselves whenwe write — a pathetic, angry murmur filled with obscenitiesand punctuated by the occasional whimper. We develop ticsfrom nervesand lack of sleep, and we live on the edge of obsessivecompulsivebehavior, from rubbing our eyebrows raw to pickingat our face . . . Why is writing so hard for us? We usedto have an answer: because we were stupid and lazy.But that was simply wrong.

How Have We Historically ViewedCo-Occurring Mental Health ProblemsIn Adolescents?• “Don’t label someone so young with amental health diagnosis”• “The substance HAS TO BE the result ofan underlying mental health problem”• “Is it REALLY a mental health or substanceuse disorder?”

alexithymia“a” – (without)“lexi” – (language)“thymia” – (feelings)

Link Between Psychiatric and AlcoholDisordersSecondary Alcoholism ModelPsychiatricDisorderAlcoholDisorderSecondary Psychiatric Disorder ModelAlcoholDisorderCommonFactorAlcoholDisorderCommon Factor ModelBi-Directional ModelPsychiatricDisorderAlcoholDisorderPsychiatricDisorderPsychiatricDisorder

When should co-occurring occurring disorders beconsidered:PRIMARY? SECONDARY?• “Primacy,” when defined as “Which disordercame first?” alone, is unimportant for thepurposes of treatment• When a mental illness and substance disordercoexist, both diagnoses should be consideredprimary and simultaneous primary treatment forboth disorders is required• A substance use or psychiatric disorder shouldbe considered “secondary” only if it resolveswhen the comorbid disorder is at baseline

AssessCo-occurring occurring Disordersby Looking At:• Mood• Cognition• Behavior

Assessment Instrumentfor Co-OccurringMental Health DisordersIn AdolescentsPADDIPractical AdolescentDual Diagnosis Inventory

PADDI• Covers addictions• Covers 9 major Axis 1 conditions• Assesses personality traits and abusevictimization

SYMPTOMS OF ADOLESCENT SUBSTANCEUSE DISORDERS• Change in family social relationships• Change in academic functioning• Change in school behavior• Personality changes• Cognition problems• Antisocial behavior• Unexplained absences• Personal appearance• Availability to others in life• Adolescent's peer group• Physical health• Drinking/drug use• Compulsiveness/Tolerance• Withdrawal symptoms (physical addiction/dependence)

PERSONALITY CHANGES• Emotional Lability• Withdrawal• Depression• Hostility• Anxiety

COGNITION PROBLEMS• Memory• Understanding• Concentration

ANTISOCIAL BEHAVIOR• As typical for adolescents• Problems with feelings• Aggression• Passive - aggressiveness• History of crime• Alcohol/drug related• Non-related

PERSONAL APPEARANCE• Change• Disinterest• Adolescents as conformists

AVAILABILITY TO OTHERS IN LIFE• Secretive• Sleep a lot• Hide in room

ADOLESCENT'S PEER GROUP• How are members of the peer groupusing?• Recent change?• Dating• Close friends

PHYSICAL HEALTH• Major change in weight (plus or minus10%)• Sleeping habits change• Inappropriately falling asleep

DRINKING/DRUG USE• Age of onset/drug• Quantity• Number of different drugs (polydrug)• Drinking/use to intoxication• Problems as results• Review all important areas• Sexual behavior• Self-image• Level of responsibility• Overdose• Violent when intoxicated• Prior treatment

COMPULSIVENESS/TOLERANCE• Unsuccessful attempts to stop• Unsuccessful attempts to control• Longest periods of abstinence• Preoccupation• Daydreaming {obsession?}• Anticipation• Money spent• How obtained?• BAC (tolerance)• Drunkenness

WITHDRAWAL SYMPTOMS(PHYSICAL ADDICTION/DEPENDENCE)• Morning shakes• Break in eating or sleeping patterns• Increased irritability• Blackouts• Inexplicable episodes of fear and panic• Depression (post cocaine use)• Daily use• Need to function?

Need to Distinguish Above from:• Normal adolescent alcohol and drugexperimentation• Normal adolescent behavior• Acting-out of parental alcoholism• Using drugs as a symptom of comorbidpsychopathology• Depression• Anxiety/panic disorders• Conduct/Antisocial personality disorder• ADD/ADHD

SPECIAL ISSUES OF ADOLESCENTS• Denial• Adolescent's Bar• Impulsivity/Risk-Taking• Feelings of Invincibility• Children of Alcoholics• Parental Issues• Multiple Issues of Adolescents• Adolescent's Subcultural Values

• By Adolescents• Too young• Not deviant from peersDENIAL• Helped in denial by rest of system• By Parents - Codependence at its most striking• "Failure" as a parent• Looking at their own chemical use• Non-routine discharges of adolescents• "Code word" situation• By Mental health, social service personnel• Denial of chemical dependence• Acting out of underlying psychiatric problem• Old approach to adult alcoholism

DENIAL (cont.)• By school systems• Similar to companies, particularly before advent ofEAP• Similar to parents - failure• By governmental agencies and voluntary associations• Incidence and prevalence figures did not includeadolescents• In determining need• By Chemical Dependence treatment programs• Did not admit• Set lower age limit for admission• Need to meet certain requirements• "Be adult"• Overlooking comorbid psychiatric problems,primary or secondary

ADOLESCENT'S BAR• Refer an adult to a bar for 6 hours/day?• School is the adolescent's bar• Where drugs and alcohol are• Pressure to use• Need to teach adolescents how to survive in ahostile environment•Teaching refusal skills

IMPULSIVITY/RISK-TAKING• Related to high level of auto accidents• More likely to relapseFEELINGS OF INVINCIBILITY• Len Bias story• HIV/AIDS prevention• The "future" for adolescents - next ten minutes• Adolescent females and smoking

CHILDREN OF ALCOHOLICSIf COA:• No adequate role model at home for:• Use of alcohol• Response to use• Responsibility• Adequate functioning• Effective communications• Coping skills• Positive self-image• Have learned to accept pathological as norm, asexpected, as appropriate• Not only not learned necessary skills, have not observedthem• Recovering parents trying to “make them well”

PARENTAL ISSUESPower and control held by parents• Permission to go to AA/NA meetings• Ride to self-help or aftercare groups• If adolescent changes and parents do not, creates stress• True with adult alcoholics also• Power/control issues with adolescent• Sending the adolescent back into a dysfunctional home• Treating adolescents and not the system, likely toincrease stress and possibly the rate of adolescentsuicide.• Requiring parental involvement in treatment• What if parents won't agree to admission?• What if parents won't agree to cooperate?• Threats on part of parents who are alcoholic• Early discharge• Sabotage of treatment

MULTIPLE ISSUES OF ADOLESCENTS• While attempting to deal with CD, adolescentalso trying to resolve normal developmentaladolescent tasks:• Dependence/Independence (individuation)• Personal relationships• Developing an identity (pimples as a crisis)• Sexuality• Normal difficult adolescent issues• Now complicated by a chemical dependence

ADOLESCENT'S SUBCULTURAL VALUES• Adult move toward health• Abstinence for health and weight reasons• Move to "light" drinks• Becoming O.K. for adult not to drink• Not so for adolescents• Also, impact of advertising on undevelopedpersonalities• Need to identify• Need for survival skills

DIFFERENCES FROM ADULTS HAVE DIRECTIMPLICATIONS FOR THE FOLLOWING• Severity inhibits the ability of adolescents toarrest their addiction and address essentialdevelopmental tasks without external assistanceand supports• Assessment• damage due to volatile solvents• absence of withdrawal syndrome• Diagnosis• dependence vs. abuse• situational abuse

DIFFERENCES HAVE DIRECT IMPLICATIONSFOR THE FOLLOWING(cont.)• Treatment• Intensity• Duration• Type•to meet level of emotional and cognitivedevelopment•absence of physiological deterioration dueto chronic use• Setting

GOALS OF TREATMENT• For all: REDUCE RISK• For the Adolescent• Abstinence• Harm reduction and moderation management vs.abstinence for adolescents• Resolution (elimination or stabilization) of cooccurringmental health problems• Enhanced functioning in all major life areas• family/caretaker• school• Social• Legal• self-image• Enhanced ability to communicate

GOALS OF TREATMENT• For Family/Caretaker• Reduction of enabling behaviors•ability to set and keep limits• Detachment• Enhanced communication• Enhanced parenting skills (as necessary)• For Schools• Avoidance of “throwaway” mentality• Avoidance of “walking on eggshells” response• Expectations of adolescent in outpatient orreturning from residential treatment

To assess progress/outcomefor MH and AOD disorders look fora reduction in the:• intensity/severity of symptoms• frequency of symptoms• duration of symptoms

HABILITATION vs. REHABILITATION• “Rehabilitation”• “A return to an earlier level of successful functioning”• Assumption: 2-5 year problem before entrance intoresidential treatment, somewhat less into outpatient:• Predicted psychological and emotional growth not takenplace because of addiction with resultant deficits.• Contrast with adult alcoholics• Identify through maturation and achievement• No base to build on when they stop drinking/using• Therefore, habilitation, not rehabilitation.• Teaching people to function effectively for the first time:• More difficult• More arduous• More time consuming

ISSUES OF CHEMICAL DEPENDENCYTREATMENT• Separate programming to meet adolescentspecific needs• Required family involvement in treatment• Scholastic evaluation and treatment• Outpatient versus inpatient• Should residential units be locked orunlocked?• Levels of care• Irregular discharges

ISSUES OF CHEMICAL DEPENDENCYTREATMENT (cont.)• Length of stay issues• Presence, extent and purpose ofeducational services• Age range• Handling behavior in treatment• Mixing socioeconomic groups• Continuing care• Working with school personnel

ISSUES OF CHEMICAL DEPENDENCYTREATMENT (cont.)• Separate programming to meet adolescentspecific needs:• Need for more concrete information• Need for more age-specific information• Inappropriate adolescent/adult behaviors• Regulations• Required family involvement in treatment:• Power issues• Communication• Recovery of the family system

ISSUES OF CHEMICAL DEPENDENCYTREATMENT (cont.)• Scholastic Evaluation and Treatment• Educational deficits• ADD/ADHD• Learning disabilities• Use of C.D.-specific assignments• Scholastic treatment plan• During treatment• Aftercare• Goals• Not get further behind• Work with home school• Enhance ability• Enhance self-esteem

ISSUES OF CHEMICALDEPENDENCY TREATMENT (cont.)• Outpatient versus inpatient• Need for structure• The disruption advantage of inpatient• Parental resistance• Disruption advantage and disadvantage of inpatient• New ASAM PPC-2R• Should residential units be locked or unlocked?• Locked unit "making kids crazy“• What do you do with the acting-out adolescentwithout enough control to function in an unlockedprogram?

ISSUES OF CHEMICALDEPENDENCY TREATMENT (cont.)• Irregular discharges• What do irregular discharges mean• Act like adult• Act like not sick• Adolescent split in "groups"• Parents pulling kids out of treatment• Contracting problems• Length of stay issues• If we are really talking about "rehabilitation" ratherthan habilitation, does it not mean greater intensityand length of stay?• Convincing reimbursers that adolescents are adifferent treatment population• Two years in a treatment “continuum”

ISSUES OF CHEMICALDEPENDENCY TREATMENT (cont.)• HANDLING BEHAVIOR IN TREATMENT• Sexual behavior•Actual•Flirtation and seductiveness• Physical acting out•When is it assault?•Pushing another patient against a wall(zero tolerance?)• What should level of expectation be in thisage group• Lack of acceptance of adolescent patients'behavior because it is adolescent?

ISSUES OF CHEMICALDEPENDENCY TREATMENT (cont.)• AGE RANGE• Age only criteria for adolescent program?•18 year olds•Married, working, with children• Young adults (18 to 22)•Fall through the cracks• Bottom of age range, 13?, 12?

ISSUES OF CHEMICALDEPENDENCY TREATMENT (cont.)• MIXING SOCIOECONOMIC GROUPS• Inner city/rural• CONTINUING CARE• How and when to use halfway house? When?• Continued structure• Continued disruption• How long for continuing care groups?• Require family?• Separate from adults in continuing care?• Support systems for kids returning to schools?• WORKING WITH SCHOOL PERSONNEL• Expectation of counselors and teachers• Support groups for students

STRATEGIES FOR WORKINGEFFECTIVELY WITH ADOLESCENTS• Recognize that part of being adolescent is challengingauthority• Listen to what they are NOT saying• Remain calm and in control of our reactions• Stay out of power struggles• Be consistent• Respect them as people and their culture even when youdon’t agree with it• Be aware that you communicate with your bodylanguage and vocal tone AND THEY ARE WATCHINGCLOSELY• Show concern for their needs and feelings• Be genuine• Encourage them to express themselves, explore newideas and take responsibility for their own actions andbehavior

STRATEGIES FOR WORKINGEFFECTIVELY WITH ADOLESCENTS (cont.)• Empower them to take risks• Understand adolescent development• Be aware of existence of problems in addition tothe substance use and address• Keep the focus on responsible behavior• Utilize educational and experiential treatments• Utilize interactive learning relevant to their ownexperience• Have fun with them• Provide structure so they will be safe• REMEMBER, ADOLESCENTS ARE NOT SHORTADULTS

LEARNING ABOUT ADOLESCENTSFROM THE RESEARCHBeginning around age 11 the brain undergoes majorreorganization in the prefrontal cortex, responsible for“executive function” (UNC-Chapel Hill)• social behavior• impulse control• goal setting• Planning• organization• Above is part of the reason why adolescents are notgood at risk-taking: (UC-San Francisco)• accidents are the leading cause of adolescent death• more likely to become crime victims than any otherage group• 1/4 of individuals contracting HIV before 21 areadolescents

LEARNING ABOUT ADOLESCENTSFROM THE RESEARCH (cont.)• In hamster experiments, an adolescent hamsterplace in a cage with an aggressive adult onehour/day, the hamster will grow up to be a“bully,” picking on animals smaller then itself butcowering in fear around hamsters its own size(U of MA Medical Center)• Subjected adolescent and adult rats to bingedrinking (10 grams of alcohol/kg of body weight4 times/day for 4 days) - finding that adolescentrats sustained more brain damage than adultsand in brain areas associated with addiction(UNC)

Treating AdolescentsLike They Are Short AdultsWill ResultIn ABridgestone/Firestone Outcome