Transcript Assessment and Intervention

Alcohol and Drug Use in Children and
Adolescents
Author and Presenter Helen - Kids Helpline Counsellor
Alcohol and Drug Use in Youth
• A social problem
• Earlier initiation of use concerning:
o Adolescent drug use into adulthood if intense use & other factors
o Gender differences - females are more likely to use, have earlier
use, inject and binge drink
o KHL responds to 2200 calls/year from young people with concerns
about alcohol or drugs
o 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 Youth
What drugs are being used?
Depressants
Hallucinogens
Stimulants
Alcohol
Magic mushrooms
Amphetamines
Tranquillisers
LSD
Nicotine
Heroin
Caffeine
Benzodiapines
Cocaine
Cannabis
Ecstasy
Inhalants/volatile substances (aerosols, glues, petrol)
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 Youth
The 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 Youth
Reasons 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 Youth
Reasons for use- risk factors
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More likely to rather than cause
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Social factors: availability, media, transition, poverty
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School: detachment, low commitment, poor performance
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Family: use history, poor communication & family management, poor
relationships, inconsistent parenting
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Peers: the norm, friends engage
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Individual: abused/neglected, favourable attitudes to use,
hyperactivity/conduct disorder, mental illness, alienation, personality factors
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Minimise risk factors to increase mental wellbeing
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Alcohol and Drug Use in Youth
Reasons 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 Youth
Reasons for use
Be aware of possible stressors at this period:
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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 Youth
Impact of drug on psychological development
Being intoxicated interferes
with a young persons
ability to adequately
process situations and
learn from their experience.
Thus limits development
of coping skills (social,
cognitive and
emotional) and
increases psychological
dependence on A & D to
cope
Chronological age and
developmental age lagnot permanent. For youth may
be learning these skills for the
first time not “rehabilitation”.
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Assessment and Intervention
Engaging 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 Intervention
Understand adolescent development
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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
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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
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cont…
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
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cont…
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 person’s goals
• Abstinence? reduced or moderate use? safer methods of use, change
to a seemingly less harmful drug
• Other concerns
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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 Intervention
Assessment Tools
Measures of general use
Measures of specific drugs
Impact/measures/dependency
Mental & physical health measures
Diagnostic criteria
DrugCheck
Drug Abuse Screening Test (DAST-A
adolescent version)
AUDIT/AusAUDIT
Severity of Opiate Dependency Scale
WHO criteria (dependency)
Severity of Dependence Scale
Maudsley Addiction Profile (1998)
General Health Questionnaire
Psycheck
Self report questionnaire
Depression, anxiety & Stress scale
DSM-IV
ICD-10
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Assessment and Intervention
Processes 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 Intervention
Processes of change- Precontemplation
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No intention to change in near future
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“it’s not a problem”, “everyone tries it”
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“Forced” to therapy
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Believe that if they wanted to change they could
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Confrontation not helpful
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Establish rapport & offer services for when they may need it
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Convey that you do not condone the behaviour
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But educate them about drugs & harm minimisation
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Raise awareness of link between drug use and lifestyle difficulties
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Assessment and Intervention
Processes 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 Intervention
Contemplation - 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 Intervention
Processes of change - Contemplation
Four column diagram (Birmingham, 1986) links lifestyle and substance use.
Straight
Out of it
Like
Dislike
Like
Dislike
Helpful to friends
Emotional
Relax
Abnoxious
Healthy
Highly strung
Fun
Expensive
Confident
Sick
Solution
Outcome
In control
Opposites
Problems
Helpful to see what stage of change youth in
Helpful to demonstrate why the young person drinks
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Assessment and Intervention
Processes 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 Intervention
Processes 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 Intervention
Processes 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 Intervention
Processes 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 Intervention
Processes 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 Intervention
Processes of change - Relapse
• Can occur
at any stage
 Relapse is more
common
• Phrase relapse
as “slip up”
 Relapse failure but =
valuable learning
experience
• Relapse when behaviour that
is being changed resumes
for extended time
 Counsellors role- to
prevent or minimise the
effect of relapse,
alternatives to drug use,
triggers? influencing
factors?
• Lapse occurs when there is
an isolated incident of using again
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Assessment and Intervention
Referral 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 Intervention
Harm minimisation
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Accidents, illness, absenteeism, premature death, crime, violence, antisocial
behaviour, personal & social destruction
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Conveys non-judgement
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Young people respond more positively if you respect their own decision
making ability
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Assessment and Intervention
Harm minimisation cont…
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Education
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Not sharing syringes
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Health promotion
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Supply control - reduce or
restrict access
Recovery
position/resuscitation
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Demand reduction- focus on
strategies to reduce the need for
youth to use drugs
Provide details for
ambulance and ADIS
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Encourage health checks
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Encourage non injection
methods
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Water at raves
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Needle exchanges
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Standard drink education
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Safe sex
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Law enforcement
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Assessment and Intervention
Intervention
• 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 Intervention
Intervention
• 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 Factors
Dual 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 Factors
Dual 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 Factors
Dual diagnosis - clinician challenge
• More difficult engagement
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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 Factors
Management/treatment of dual diagnosis
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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 Factors
Managing resistance
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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 Factors
Risk 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 Factors
Intoxication/ Withdrawal
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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 Factors
Family 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 Factors
Family 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 child’s 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
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