Alcohol and Drug Use in Children and Adolescents

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Alcohol and Drug Use in Children and Adolescents

• Author and Presenter Helen - Kids Helpline
  Counsellor

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Alcohol and Drug Use in Youth

• A social problem
• Earlier initiation of use concerning
• Adolescent drug use into adulthood if intense use
  other factors
• Gender differences - females are more likely to
  use, have earlier use, inject and binge drink
• KHL responds to 2200 calls/year from young people
  with concerns about alcohol or drugs
• KHL A D contacts are made by 54 females 46
  males although males are much more likely to
  contact about their own use

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Alcohol and Drug Use in YouthWhat drugs are
being used?
Warning signs- significant personality change,
mood swings, physical appearance, changes in
school or job performance, secretive
communication, counsellor intuition, an excessive
need or increased supply of money, changing peer
groups, unexplained accidents.
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Alcohol and Drug Use in YouthThe changing
effects of drugs

• Method of administration injecting,
  snorting/smoking, ingestion
• Mood and environment amplify underlying
  emotions, comfortable atmosphere?
• Physical characteristics height, weight, gender
  differences, hormonal
• Tolerance neuroadaptation? Rapid returns to
  level prior to the period of abstinence
• Dependence no drug leads to immediate
  dependence, dependency physical, psychological or
  both. Not generally young people.

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Alcohol and Drug Use in YouthReasons for Use

• Similar to adults reward, taste, increased
  energy, relief from pain, relaxation, social
• Different to adults experimentation/risk taking,
  rapid developmental changes, aspire to be like
  adults
• Peer pressure actually not significant
• The spectrum of drug use non use, experimental,
  recreational, regular, dependent (less common
  amongst youth).

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Alcohol and Drug Use in YouthReasons for use-
risk factors

• More likely to rather than cause
• Social factors availability, media, transition,
  poverty
• School detachment, low commitment, poor
  performance
• Family use history, poor communication family
  management, poor relationships, inconsistent
  parenting
• Peers the norm, friends engage
• Individual abused/neglected, favourable
  attitudes to use, hyperactivity/conduct disorder,
  mental illness, alienation, personality factors
• Minimise risk factors to increase mental
  wellbeing

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Alcohol and Drug Use in YouthReasons for use-
Protective Factors

• Social supportive cultures, stability and
  connection, good relationships with adults
  outside the family
• School belong/connection, achievement
  (recognised!)
• Family belonging/connection, traits are valued
  by family, warm, positive interactions
• Peer factors pro-social peers, peer connection
• Individual temperament, social responsiveness,
  autonomy, special skills/talents, curiosity for
  life, high intelligence

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Alcohol and Drug Use in YouthReasons for use

• Be aware of possible stressors at this period
• Increased conflict with authority
• Torn between peers and family/society
• Loss of childhood
• Body image
• Un/popular
• Fear ridicule or humiliation
• Low confidence and self esteem
• Transition
• Academic performance
• Future?
• Sexuality and sexual behaviours

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Alcohol and Drug Use in YouthImpact of drug on
psychological development

• Being intoxicated interferes
• with a young persons
• ability to adequately
• process situations and
• learn from their experience.
• Chronological age and
• developmental age lag-
• not permanent. For youth may
• be learning these skills for the
• first time not rehabilitation.

Thus limits development of coping skills (social,
cognitive and emotional) and increases
psychological dependence on A D to cope
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Assessment and InterventionEngaging young people

• Explain confidentiality, describe and clarify
  your role counselling
• Remember communication issues
• Expert role and interrogation vs. inquisitive and
  innovative questions
• Changing the young person vs. exploring their
  options
• Crisis can open opportunities for change
• Small goals
• Be creative drawing, games, story telling

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Assessment and InterventionUnderstand adolescent
development

• Often face difficult choices
• Less freedom of expression
• More ridicule comparisons
• Strive for independence but highly dependent on
  others
• Adolescents strive for power (ie control in own
  decision making)
• Non-conformity in society and at home
• Need for peer acceptance (music, clothing,
  mannerisms),
• Freedom vs. structure (push the boundaries to
  find individuality but know there is a secure
  base)
• Self identity self determination
• Ability to form close affectionate bonds
• Sexual identity
• Abstract thought
• These needs can result in immoral and unethical
  behaviour such as substance abuse.

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Assessment and Intervention

• Raising the issue
• A D screen as standard in assessment
• Make logical links between lifestyle concerns and
  possible causes
• Ask young person to identify cause of concerns
• 1. Initial assessment process
• Presenting concerns
• Role of drug use in presenting concerns
• Readiness to change
• Other concerns (family, school, peers, partners,
  work, legal, health)

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Assessment and Intervention cont

• 2. Drinking/drug use
• Drugs currently used
• Method
• Amount
• Frequency
• Context
• The effects of drugs
• Past use (useful for intervention planning
  prevention)
• Attempts to cut back/abstain/control use (what
  happened?)
• Previous treatment (what did/did not work)
• Dependence/withdrawal symptoms
• At risk behaviours (injecting, decision making
  ability, mood swings, offending behaviour).

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Assessment and Intervention cont

• 3. Bio/psycho/social areas
• Family issues
• Relationships
• Stability
• Interests/hobbies
• Strengths
• Legal problems
• Childhood experiences (eg trauma)
• Physical wellbeing
• Mental health
• Suicide risk
• With some other serious issues like trauma and
  dual diagnosis referral to others services may be
  required.

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Assessment and Intervention cont

• 4. Goal setting treatment planning
• Young persons goals
• Abstinence? reduced or moderate use? safer
  methods of use, change to a seemingly less
  harmful drug
• Other concerns
• best service provider
• Ask questions as often young people will not
  volunteer information

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Assessment and Intervention - Assessment Tools

• Used for assessment of level, frequency and
  impact of substance abuse
• For awareness raising
• To highlight specific treatment issues
• To monitor progress in treatment (pre/post
  testing)
• Adults tools modified for younger people - be
  careful!
• Rarely meet diagnostic criteria for abuse or
  dependence but becomes a risk
• Little studies to test reliability and validity
• The use of tools can negatively impact on the
  counselling relationship (lower literacy levels
  and dislike forms)

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Assessment and InterventionAssessment Tools
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Assessment and InterventionProcesses of change

• Prochaska DiClemente (1992) stages of change
  model.

Different thoughts/feelings in each stage benefit
from different interventions The model is
transtheoretical
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Assessment and InterventionProcesses of change-
Precontemplation

• No intention to change in near future
• its not a problem, everyone tries it
• Forced to therapy
• Believe that if they wanted to change they could
• Confrontation not helpful
• Establish rapport offer services for when they
  may need it
• Convey that you do not condone the behaviour
• But educate them about drugs harm minimisation
• Raise awareness of link between drug use and
  lifestyle difficulties

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Assessment and InterventionProcesses of change -
Contemplation

• Young person is aware the problem exists and are
  thinking about overcoming it but have not yet
  made a commitment
• See consequences positives
• Importance on change but confidence
• Often present to therapy in this stage but as
  clinicians we assume they are in action.
  Demonstrated when young people find it difficult
  to problem solve and say yes but or nothing
  works.
• Build confidence, empower, setting small
  realistic goals, highlighting previous changes
  and successes.

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Assessment and InterventionContemplation -
Motivational Interviewing

• Directive, client centred counselling style that
  explores ambivalence about change
• What are the good things about A D use?
• What are the LESS GOOD things?
• How would you like things to be?
• How are they now?
• Reflection and summarising, Highlight discrepancy

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Assessment and InterventionProcesses of change -
Contemplation

• Four column diagram (Birmingham, 1986) links
  lifestyle and substance use.

Helpful to see what stage of change youth in
Helpful to demonstrate why the young person
drinks
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Assessment and InterventionProcesses of change -
Preparation

• Young person realises the costs outweigh the
  benefits
• Preparing on what they want to do to change
• Goal setting and planning (How much change?)
• Highlighting barriers to success
• Identify supports
• Plan strategies and alternatives for managing
  situations for when at most at risk of using
  whilst empowering client

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Assessment and InterventionProcesses of change -
Action

• Young people change their behaviour, experiences
  and environment
• Initiate reduction or abstinence
• Avoid situations or people
• Difficult stage because withdraws, cravings and
  psychological distress
• Action change. Interventions should not overlook
  the importance of preparation maintenance
  planning
• Support, encourage and assist with strategies to
  overcome difficulties

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Assessment and InterventionProcesses of change -
Action

• Managing cravings normal, not failure, time
  limited, longer abstinence less severe
  cravings, 5Ds
• ABC model
• challenging negative thoughts (adapted from
  Ellis)
• A- Activating event (situation or experience)
• B- beliefs (thoughts about this)
• C- Consequences (feelings and behaviours)
• Problem solving - POOCH
• P (problem) O (options) O (outcomes of each
  option) C (choose the best option for themselves)
  H (how did it go)

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Assessment and InterventionProcesses of change
Action cont

• Identify high risk situations (past experiences)
• Explore alternatives to drug use
• Self monitoring (feelings before and after use,
  situations, cost consequence)
• refusal skills and social skills (with humour,
  look in eyes, exit, excuse, invitation to do
  something else)

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Assessment and InterventionProcesses of change -
Maintenance

• Preventing relapse and consolidate their gains in
  action stage
• Less cravings and difficulties
• Counsellor help affirm and help them build upon
  positive changes
• Review and monitor potential risk of relapse
• Counsellors role changed from emphasise on drug
  use to lifestyle maintenance issues

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Assessment and InterventionProcesses of change -
Relapse

• Can occur
• at any stage
• Phrase relapse
• as slip up
• Relapse when behaviour that
• is being changed resumes
• for extended time
• Lapse occurs when there is
• an isolated incident of using again

• Relapse is more
• common
• Relapse failure but
• valuable learning
• experience
• Counsellors role- to
• prevent or minimise the
• effect of relapse,
• alternatives to drug use,
• triggers? influencing
• factors?

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Assessment and InterventionReferral options

• Alcohol and Drug Information Service
• Community health centres
• Child and Youth Mental Health Services
• GPs
• Accident and emergency departments
• Ambulance and police
• Support groups- for both youth and significant
  others

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Assessment and InterventionHarm minimisation

• Accidents, illness, absenteeism, premature death,
  crime, violence, antisocial behaviour, personal
  social destruction
• Conveys non-judgement
• Young people respond more positively if you
  respect their own decision making ability

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Assessment and InterventionHarm minimisation
cont

• Not sharing syringes
• Recovery
• position/resuscitation
• Provide details for
• ambulance and ADIS
• Encourage health checks
• Encourage non injection
• methods
• Standard drink education
• Law enforcement

• Education
• Health promotion
• Supply control - reduce or
• restrict access
• Demand reduction- focus on
• strategies to reduce the need for
• youth to use drugs
• Water at raves
• Needle exchanges
• Safe sex

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Assessment and InterventionIntervention

• Longer treatment the better
• Individual counselling/ therapy (skills for
  change, various therapies including CBT and
  supportive methods)
• Family therapy (substance use effects the family
  and vice versa. Focus on communication, conflict
  management/resolution, coping strategies)
• Group therapy (Positive peer pressure
  identification, role models, provides hope,
  mutual support)
• 12 steps program (complex for level of
  development so need to simplify)

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Assessment and InterventionIntervention

• Pharmacotherapies (Medical model intervention.
  Better outcomes when used with counselling)
• Detoxification (physically withdraws from the
  substance, In-patient, ambulatory, cold turkey)
• Residential rehabilitation (Safe drug free
  environment where young person can stay for
  several weeks to months to maintain abstinence
  from drugs. Supportive and structured environment
  including counselling, therapy, group work and
  learning life skills)

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Complicating FactorsDual diagnosis/Co-morbidity

• Mental health concerns are commonly associated
  with alcohol and drug use
• Adolescents with a substance use are more likely
  to have a co-morbid psychiatric diagnosis
• Adolescents with substance abuse are at higher
  risk of having a psychiatric illness than are
  adults
• Daily cannabis use in youth predicts later
  depression and anxiety. Females four times as
  likely
• Cannabis doubles the risk of schizophrenia and
  increases risk in proportion to the amount used

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Complicating FactorsDual diagnosis/Co-morbidity

• Mental health concerns are commonly associated
  with alcohol and drug use
• Adolescents with a substance use are more likely
  to have a co-morbid psychiatric diagnosis
• Adolescents with substance abuse are at higher
  risk of having a psychiatric illness than are
  adults
• Daily cannabis use in youth predicts later
  depression and anxiety. Females four times as
  likely
• Cannabis doubles the risk of schizophrenia and
  increases risk in proportion to the amount used

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Complicating FactorsDual diagnosis - clinician
challenge

• More difficult engagement
• non-compliance and standard interventions less
  beneficial
• Unclear primary diagnosis and assessment
• A lack of clear evidence based practice to guide
  clinicians in providing treatment
• Lack of dual diagnosis services information for
  young people

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Complicating FactorsManagement/treatment of dual
diagnosis

• Little evidence of effective treatment
• Strengths based approach
• Be aware of underlying mental illness
• Psychoeducation and support for family/carers
• Prevention and early intervention
• Medical management to enable counselling
  interventions
• Program that treats both
• Treated by one clinician trained in both areas
• Trust understanding and learning vs
  confrontation, criticism and expression
• Reduction of harm emphasised
• rather than abstinence

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Complicating FactorsManaging resistance

• Often occurs when - counsellor cannot apply
  empathy, humour - encouragement and
  reinforcement.
• - counsellor directive confronting
• - client is nervous and lacks understanding
• - client uncomfortable with content and style
  of counselling
• - client coerced into treatment
• - confidentiality concerns
• - past negative experiences with counsellors
• - not yet ready to consider change
• Traps counsellors fall into - overworking
• - confrontation and denial
• - the expert trap
• - labelling trap
• - premature focus on unimportant/2ndry issue
• - allowing the young person to blame others

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Complicating Factors Rolling with resistance
(Miller Rollnick, 1991)
Simple Reflection

• Amplified reflection

• Double sided reflection

• Shifting the focus

Emphasising personal choice and control

• Reframing

Therapeutic paradox
Empathy
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Complicating FactorsRisk assessment

• Substance information- dose, substances used,
  when taken, administration method,
• Contact poisons information
• Safety issues- What are the young persons
  immediate needs? (Medical or emotional
  management), risks to self or others, suicide
  (intent, method, perturbation, history)
• Support systems available
• Monitor youth
• Call ambulance as required

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Complicating FactorsIntoxication/ Withdrawal

• Effects may be masked- sometimes by other drugs
• Intoxication lasts minutes to hours, withdrawal
  days to months
• Organisations should have procedures for managing
  these
• Single staff member care for young person in
  isolation
• Consider noise, lighting
• Complete a risk assessment
• Seek medical advice
• Not helpful to engage in counselling with youth
  if intoxicated
• Calm, reassuring, safe environment, recovery
  position, clear communication

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Complicating FactorsFamily members

• Substance use effects the family and vice versa
• Family may be protective factor or risk factor
• Parents tend to carry much of the blame for the
  use but externally blame child
• Parents view use as crisis- fear for kids life,
  shock guilt anger confusion, vulnerable, fragile,
  powerless

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Complicating FactorsFamily members

• Family therapy- do not focus solely on drug use.
  Focus on communication, positive relationships,
  conflict management/resolution, raise awareness
  of coping strategies
• Educate, management strategies for crisis
  situations, explore challenge parents beliefs
  regarding childs use, explore parenting, self
  care,
• Exploring parenting- do not support drug use
  (finances etc), consistent parenting re verbal
  condemnation then behaviours allow use, parent
  drug use, rescuing may be a disservice, reactive
  parenting bad as leads to anger hostility, do
  not be too controlling