Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse A Toolkit for Providers 2d Editio Jue 2008 From the Adolescet Trauma ad Substace Abuse Committee of the Natioal Child Traumatic Stress Network This project was fuded by the Substace Abuse ad Metal Health Services Admiistratio (SAMHSA), US Departmet of Health ad Huma Services (HHS). The views, policies, ad opiios expressed are those of the authors ad do ot ecessarily reflect those of SAMHSA or HHS. Established by Cogress i 2000, the Natioal Child Traumatic Stress Network (NCTSN) is a uique collaboratio of academic ad commuity-based service ceters whose missio is to raise the stadard of care ad icrease access to services for traumatized childre ad their families across the Uited States. Combiig kowledge of child developmet, expertise i the full rage of child traumatic experieces, ad attetio to cultural perspectives, the NCTSN serves as a atioal resource for developig ad dissemiatig evidece-based itervetios, trauma-iformed services, ad public ad professioal educatio.
Ackowledgmets This toolkit was developed by the Adolescet Trauma ad Substace Abuse Committee of the Natioal Child Traumatic Stress Network to raise awareess about the eeds of youth with traumatic stress ad substace abuse problems ad to promote evidece-based practices i cliical settigs. It is meat to serve as a traiig guide for providers workig with this populatio. Toolkit Editor ad Substace Abuse Committee Chair: Liza Suárez, PhD, ow at the Istitute for Juveile Research, Uiversity of Illiois at Chicago Substace Abuse Committee Co-Chairs: Luis Flores, MALPC, LCDC, RPT-S, SCAN s Border Traumatic Stress Respose Ceter, Laredo, TX ad Lucy Zammarelli, MA, NCAC II, Willamette Family Treatmet Services, Eugee, OR Coordiatig Ceter: Adolescet Traumatic Stress ad Substace Abuse Treatmet Ceter, Ceter for Axiety ad Related Disorders at Bosto Uiversity, Bosto, MA NCTSN Adolescet Trauma ad Substace Abuse Committee Ceters Addictio Techology Trasfer Ceter of New Eglad ad Ceter for Alcohol ad Addictio Studies at Brow Uiversity Providece, RI Adolescet Trauma Treatmet Program The Metal Health Ceter of Dae Co., Ic. Madiso, WI Chestut Health Systems Bloomigto, IL Child & Adolescet Traumatic Stress Ceter of Souther Arizoa Tucso, AZ Childre s Hospital Los Ageles Los Ageles, CA Divisio of Child Metal Health Services Wilmigto, DE Natioal Crime Victims Research ad Treatmet Ceter- Medical Uiversity of South Carolia Charlesto, SC Natioal Istitute of Drug Abuse Bethesda, MD SCAN s Border Traumatic Stress Respose Ceter Laredo, TX Substace Abuse ad Metal Health Services Admiistratio Rockville, MD Willamette Family Treatmet Services Eugee, OR Youth Health Services Elkis, WV Natioal Ceter o Family Homelessess Newto Cetre, MA Toolkit Edits Subcommittee Coordiator: Ayme Turbull, PsyD, North Shore-LIJ Health System, Mahasset, NY The NCTSN Adolescet Trauma ad Substace Abuse Committee would like to exted a special thak you to the staff of the Adolescet Traumatic Stress ad Substace Abuse Treatmet Ceter at Bosto Uiversity for providig much of the foudatioal ad coordiatio work for this toolkit. 2 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Cotets I. Makig the Coectio: Trauma ad Substace Abuse... 5 Geeral iformatio about the liks betwee trauma ad substace abuse i adolescets II. III. Uderstadig Traumatic Stress I Adolescets: A Primer for Substace Abuse Providers...13 Iformatio o the prevalece of trauma exposure, the log-term cosequeces of trauma, ad iformatio o specific trauma types Uderstadig Substace Abuse I Adolescets: A Primer for Metal Health Professioals... 25 Iformatio o the prevalece of substace abuse, its log-term cosequeces, ad iformatio o specific substaces of abuse IV. Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems... 49 Iformatio o treatmet recommedatios ad evidece based itervetios for adolescet substace abuse ad traumatic stress, icludig itegrated treatmet strategies for tees with both disorders V. Egagig Adolescets I Treatmet... 67 Strategies for ehacig adolescet egagemet i treatmet The Natioal Child Traumatic Stress Network www.nctsn.org
Makig the Coectio: Trauma ad Substace Abuse Whe Mary was 11, her mother left this ma, Dave to babysit. Dave gave her a joit. It made me happy. It made me feel like othig could touch me ad everythig was OK. So I started stealig my mum s drugs. Of course, she was caught ad locked i a closet. I was i there for almost two days. After that happeed, I guess a part of me chaged. I did t care for aybody. I hated the world after that. 1 Data from the most recet Natioal Survey of Adolescets ad other studies idicate that oe i four childre ad adolescets i the Uited States experieces at least oe potetially traumatic evet before the age of 16 2, ad more tha 13% of 17-year-olds oe i eight have experieced posttraumatic stress disorder (PTSD) at some poit i their lives. 3 Most, if ot all, of these youg people also have access to a wide rage of psychoactive substaces that ca both dull the effects of stress ad place tees at icreased risk of experiecig trauma. It is estimated that 29% of adolescets early oe i three have experimeted with illegal drugs by the time they complete 8th grade, ad 41% have cosumed alcohol. 4 For may adolescets, such early experimetatio evetually progresses to abuse of or depedece o illicit drugs or alcohol. Every year, approximately oe i five America adolescets betwee the ages of 12 ad 17 egages i abusive/depedet or problematic use of illicit drugs or alcohol. 5,6 Although it is uclear exactly how may adolescets who abuse drugs or alcohol also have experieced trauma, umerous studies have documeted a correlatio betwee trauma exposure ad substace abuse i adolescets: I the Natioal Survey of Adolescets, tees who had experieced physical or sexual abuse/assault were three times more likely to report past or curret substace abuse tha those without a history of trauma 3 I surveys of adolescets receivig treatmet for substace abuse, more tha 70% of patiets had a history of trauma exposure 7,8 This correlatio is particularly strog for adolescets with PTSD. Studies idicate that up to 59% of youg people with PTSD subsequetly develop substace abuse problems. 8 11 The Natioal Child Traumatic Stress Network www.nctsn.org
Traumatic Stress ad Substace Use: A Complex Relatioship Multiple pathways have bee proposed to explai the temporal lik betwee trauma ad substace abuse i adolescets. 12 A review of these theories demostrates that the road coectig these disorders rus both ways: trauma icreases the risk of developig substace abuse, ad substace abuse icreases the likelihood that adolescets will experiece trauma. Trauma as a risk factor for substace abuse Accordig to the self-medicatio hypothesis of substace abuse, people develop substace abuse problems i a attempt to maage distress associated with the effects of trauma exposure ad traumatic stress symptoms. This theory suggests that youth tur to alcohol ad other drugs to maage the itese flood of emotios ad traumatic remiders associated with traumatic stress or PTSD, or to umb themselves from the experiece of ay itese emotio, whether positive or egative. Several studies have foud that substace use developed followig trauma exposure (25% 76%) or the oset of PTSD (14% 59%) i a high proportio of tees with substace abuse disorders. 8 11 Recet research i this area also suggests that traumatic stress or PTSD may make it more difficult for adolescets to stop usig, as exposure to remiders of the traumatic evet have bee show to icrease drug cravigs i people with cooccurrig trauma ad substace abuse. 13,14 (For more iformatio o trauma remiders, see Uderstadig Traumatic Stress i Adolescets: A Primer for Substace Abuse Professioals.) Substace abuse as a risk factor for trauma Numerous epidemiological studies have foud that, for may adolescets (45% 66%), substace use disorders precede the oset of trauma exposure. 9 11 Studies have show a direct lik betwee alcohol use ad egagemet i risky behaviors i which adolescets may get hurt 10, such as hitchhikig, walkig i usafe eighborhoods, ad drivig after usig alcohol or drugs. 15 Accordig to the most recet Natioal Survey o Drug Use ad Health, more tha 25% of uderage drikers are bige or heavy drikers, ad approximately 20% oe i five report drivig while uder the ifluece durig the past year. 5 Not surprisigly, adolescets with substace abuse disorders are also sigificatly more likely tha their osubstace abusig peers to experiece traumas that result from risky behaviors, icludig harm to themselves or witessig harm to others. 9 11 There is also evidece that youth who are already abusig substaces may be less able to cope with a traumatic evet as a result of the fuctioal impairmets associated with problematic use. I oe study, ivestigators foud that eve after cotrollig for exposure to trauma, adolescets with substace abuse disorders were two times more likely to develop PTSD followig trauma tha were their o-abusig peers. The researchers suggested that the extesive psychosocial impairmets foud i adolescets with substace abuse 6 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
disorders occurred i part because they lacked the skills ecessary to cope with trauma exposure. 10 Regardless of the pathway describig the oset of trauma exposure or PTSD ad the developmet of substace abuse problems, youth with this co-occurrece experiece difficulties with emotioal ad behavioral regulatio that make it all the more difficult for them to stop usig. A successful treatmet approach must therefore be flexible eough to accommodate the multiple ways i which trauma ad substace abuse may be related. Addressig the Needs of Adolescets with Co-occurrig Trauma ad Substace Abuse For adolescets dealig with the effects of traumatic stress or PTSD, alcohol ad/ or drugs iitially may seem to alleviate distress, either through the icreased pleasurable sesatios or through the avoidace of itese emotios that may follow stressful experieces. I the log ru, however, substace use perpetuates a cycle of problem behaviors that ca make it more difficult to recover after a traumatic evet. For teeagers strugglig with substace abuse ad traumatic stress, the egative effects ad cosequeces of oe disorder compoud the problems of the other. Raphael s* Story Raphael was a 15-year-old boy with a history of truacy ad drug ivolvemet (marijuaa use ad drug dealig). He had bee placed i a group home after Child Protective Services became ivolved with the family ad his mother ad stepfather asserted that they could t cotrol Raphael. I the group home, Raphael was agry, threateig, ad uwillig to cooperate with group activities. He was disruptive durig group therapy sessios ad iitially refused to say much durig idividual treatmet sessios. Through patiece, opeess, ad a willigess to explore Raphael s iterests icludig his flair for developig spotaeous rhymes ad rap-style lyrics Raphael s therapist was gradually able to egage Raphael i the treatmet process. Over time, Raphael opeed up about his difficult relatioship with his mother, beig frequetly hit ad locked i a dark closet by his stepfather, ad his coflicted relatioship with his youger sister. He also talked about his frequet, almost daily, use of marijuaa ad alcohol ad how they made him feel better ad o top of thigs. It became clear that, for Raphael, alcohol ad marijuaa served as tools that eabled him to umb overwhelmig feeligs ad to feel domiat i ucomfortable or threateig social situatios. As Raphael ad his therapist bega to address his trauma ad substace abuse histories, Raphael started to develop better tools for copig with the itese feeligs ad impulses that cotributed to his most pressig problems. * Raphael is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. Although such teeagers eed help, ofte desperately, they frequetly have difficulty eterig or stayig ivolved i treatmet services. Usually teeagers atted such facilities agaist their will because they are either madated to atted treatmet (i.e., by the courts), referred by teachers, or brought i by their parets. The Natioal Child Traumatic Stress Network www.nctsn.org 7
Because the service systems targetig substace abuse ad metal health problems have traditioally bee fragmeted, few teeagers with both traumatic stress ad substace abuse problems receive itegrated treatmet services. Compoudig the problem is that there are few facilities offerig itegrated services, primarily because few professioal traiig programs i substace abuse or metal health provide cliicias with the educatio ecessary to develop expertise i both trauma ad substace abuse treatmet, ad few professioals have traiig ad experiece across both fields. Give the strog lik betwee trauma ad substace abuse amog adolescets, however, the majority of both substace abuse ad metal health professioals have ecoutered this populatio. Providig adequate ad effective care to adolescets who are grapplig with substace abuse ad trauma will require adjustmets o the part of both groups. For metal health providers, it is critical to become familiar with the patters of addictio associated with substaces of abuse, ad to recogize that similar patters are at work i traumatic stress ad addictio. Both are characterized by emotioal ad behavioral dysregulatio, ad are expressed i a rage of symptoms ad behaviors that ca iclude classic posttraumatic stress symptoms, substace abuse, ad other risky behaviors. For substace abuse professioals, it is importat to look beyod the immediate circumstaces of the youth s substace use ad pay attetio to his or her trauma history ad its relatioship to his or her curret emotioal difficulties ad copig patters (icludig substace use). There are may commoalities betwee the ways i which youth respod to substace abuse triggers ad the ways i which they respod to remiders of loss ad trauma. Compilig a list of triggers that may lead to emotioal dysregulatio ad substace use, ad icorporatig possible remiders of previous trauma ad loss ca be helpful. Overcomig Commo Challeges to Care Cliicias, admiistrators, ad other healthcare providers i the substace abuse ad metal health fields ofte face major challeges i providig care to youth with traumatic stress ad substace abuse problems. For example, the fragmetatio that has traditioally existed betwee metal health ad substace abuse systems ofte limits the types of services that youth are eligible to receive. Additioally, service ceters may lack the resources or support ecessary to provide comprehesive services. Although it may ot be possible to fid solutios to may of these challeges, below are some solutios to commo treatmet problems. 8 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
CHALLENGE Lack of istitutioal awareess ad prioritizatio of adolescet trauma ad substace use assessmet ad treatmet Cliicia lack of familiarity with the commo presetatios of posttraumatic stress symptoms i adolescets Time ad costs associated with coductig stadardized assessmets ad traiig staff to use evidece-based itervetios Adolescets with severe co-occurrig disorders ofte require assistace with other practical aspects of life such as trasportatio, schoolig, court advocacy, health isurace that ot all istitutios are equipped to provide Difficulty egagig adolescets with trauma ad substace abuse histories who ofte employ avoidat copig mechaisms i treatmet Lack of local substace abuse ad trauma traiig resources SUGGESTED SOLUTION The materials i this toolkit ca serve as resources to aid i raisig istitutioal awareess of the eed for soud substace abuse ad trauma assessmet ad treatmet. Presetig case material that highlights the relatioships betwee trauma ad substace abuse ca also help raise istitutioal awareess Use the materials i this toolkit to help become familiar with the commo presetatios of posttraumatic stress symptoms i adolescets. Access more iformatio via the Natioal Child Traumatic Stress Network website: www.nctsn.org To covice istitutioal admiistrators to ivest the time ad moey required for the iitial stages of such program developmet, preset them with research o improved treatmet adherece ad treatmet outcomes whe stadardized assessmets ad evidece-based itervetios are employed. Oce the program has bee established ad youth outcomes are improved, workig with youth will be more rewardig, which may ecourage admiistrators to seek additioal fudig opportuities Parterships with local agecies ca ofte go a log way towards meetig the practical eeds of cliets whe they caot be met by a sigle orgaizatio Use the tips i this toolkit to help egage adolescets i treatmet. For cliicias strugglig to egage difficult cliets: access istitutioal support, icludig additioal supervisio Search the Iteret for substace abuse ad trauma traiig resources. To reduce the cost of face-toface traiig sessios, agecies ca sed a sigle represetative to be traied, who ca subsequetly trai his/her colleagues Coclusio Adequate care begis with the recogitio ad accurate idetificatio of the problems these adolescets experiece, whether they preset to a metal health professioal or to a substace abuse specialist. Rather tha referrig a multi-problem teeager to aother provider, cliicias willig to address co-occurrig disorders ca develop the skills ecessary to provide such adolescets with hope of recovery. The Natioal Child Traumatic Stress Network www.nctsn.org 9
Therapists ad couselors ca develop skills to provide a comprehesive ad itegrated treatmet approach. I order to maximize a adolescet s chaces of success, this approach should broadly address the adolescet s cocers ad take ito accout the fuctioal relatioship betwee traumatic stress ad substace abuse problems. Whe developig a idividualized treatmet pla, special attetio should be give to the sigs ad symptoms of posttraumatic stress, substace abuse, ad the relatioship betwee the two. This toolkit has bee developed to assist metal health ad substace abuse professioals i providig comprehesive assessmet ad treatmet to adolescets sufferig from traumatic stress ad substace abuse. It explores the complex coectios betwee traumatic stress ad substace abuse ad provides guidelies for idetifyig, egagig, ad treatig adolescets sufferig from these co-occurrig problems. Trauma ad Substace Abuse: Myths ad Facts MYTH: Sice most adolescets who use drugs ad/or alcohol have experieced some kid of trauma, there is o eed to treat trauma as a uique cliical etity. FACT: Although ot all youth who experiece traumatic evets develop PTSD, it is importat to be prepared to address the multiple ways youth respod to trauma. Traumatic stress ad PTSD are associated with uique (ad challegig) symptoms that require targeted, trauma-iformed treatmet to optimize recovery. (For more iformatio, see Uderstadig Traumatic Stress i Adolescets: A Primer for Substace Abuse Professioals.) Effective treatmet approaches ad itervetios have already bee developed for patiets sufferig from traumatic stress ad PTSD. Makig use of these techiques as part of a comprehesive treatmet pla offers the greatest hope of treatmet success for adolescets dealig with the effects of substace abuse ad traumatic stress. MYTH: Whe dealig with a adolescet who has a history of trauma ad substace abuse, you eed to treat oe set of problems at a time. FACT: Because the symptoms associated with traumatic stress ad substace abuse are so strogly liked, the ideal treatmet approach is to address both coditios. Ufortuately it is ot ucommo for substace abuse programs to dey admissio to patiets with PTSD, ad for trauma treatmet programs to dey admissio to patiets who have ot achieved sobriety. The decisio about which symptoms ad behaviors to address first therefore requires a careful assessmet of the relative threat that each coditio poses to a youth s safety, health, ad immediate well-beig. 10 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Refereces 1. Garder, D. (2002). Skid Row High. The Ottawa Citize. April 21, 2002. 2. Costello, E. J., Erkali, A., Fairbak, J. A., ad Agold, A. (2002). The prevalece of potetially traumatic evets i childhood ad adolescece. J Trauma Stress, 15(2), 99-112. 3. Kilpatrick, D. G., Sauders, B. E., ad Smith, D. W. (2003). Youth Victimizatio: Prevalece ad Implicatios. Washigto, DC: U.S. Departmet of Justice, Office of Justice Programs, Natioal Istitute of Justice. Retrieved April 16, 2008 from http://www.cjrs.gov/pdffiles1/ij/194972.pdf. 4. Johsto, L. D., O Malley, P. M., Bachma, J. G., ad Schuleberg, J. E. (2007). Moitorig the Future: Natioal results o adolescet drug use: Overview of key fidigs, 2006. Bethesda, MD: Natioal Istitute o Drug Abuse. Retrieved April 16, 2008 from http://www.moitorigthefuture. org/pubs/moographs/overview2006.pdf. 5. Substace Abuse ad Metal Health Services Admiistratio. (2007). Results from the 2006 Natioal Survey o Drug Use ad Health: Natioal Fidigs. Rockville, MD: Departmet of Health ad Huma Services. Retrieved April 7, 2008 from http://www.oas.samhsa.gov/sduh/ 2k6sduh/2k6Results.pdf. 6. Kight, J. R., Harris, S. K., Sherritt, L., Va Hook, S., Lawrece, N., Brooks, T., et al. (2007). Prevalece of positive substace abuse scree results amog adolescet primary care patiets. Arch Pediatr Adolesc Med, 161(11), 1035-41. 7. Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), 36-45. 8. Deyki, E. Y., ad Buka, S. L. (1997). Prevalece ad risk factors for posttraumatic stress disorder amog chemically depedet adolescets. Am J Psychiatry, 154(6), 752-7. 9. Clark, D. B., Lesick, L., ad Hegedus, A. M. (1997). Traumas ad other adverse life evets i adolescets with alcohol abuse ad depedece. J Am Acad Child Adolesc Psychiatry, 36(12), 1744-51. 10. Giacoia, R, M., Reiherz, H. Z., Hauf, A. C., Paradis, A. D., Wasserma, M.S., ad Laghammer, D. M. (2000). Comorbidity of substace use ad post-traumatic stress disorders i a commuity sample of adolescets. Am J Orthopsychiatry, 70(2), 253-62. 11. Perkoigg, A., Kessler, R. C., Storz, S., ad Wittche, H. U. (2000). Traumatic evets ad posttraumatic stress disorder i the commuity: Prevalece, risk factors ad comorbidity. Acta Psychiatr Scad, 101(1), 46-59. 12. Giacoia, R. M., Reiherz, H. Z., Paradis, A. D., ad Stashwick, C. K. (2003). Comorbidity of substace use disorders ad posttraumatic stress disorder i adolescets. I Oimette, P. ad Brow, P. J. (Eds.), Trauma ad substace abuse: Causes, cosequeces, ad treatmet of comorbid disorders (pp. 227-242). Washigto, DC: America Psychological Associatio. The Natioal Child Traumatic Stress Network www.nctsn.org 11
13. Saladi, M. E., Drobes, D. J., Coffey, S. F., Dasky, B. S., Brady, K. T., ad Kilpatrick, D. G. (2003). PTSD symptom severity as a predictor of cue-elicited drug cravig i victims of violet crime. Addict Behav, 28(9), 1611-29. 14. Coffey, S. F., Saladi, M. E., Drobes, D. J., Brady, K. T., Dasky, B. S., ad Kilpatrick, D. G. (2002). Trauma ad substace cue reactivity i idividuals with comorbid posttraumatic stress disorder ad cocaie or alcohol depedece. Drug Alcohol Deped, 65(2), 115-27. 15. Ka, L., Kiche, S. A., Williams, B. I., Ross, J. G., Lowry, R., Grubaum, J.A., et al. (2000). Youth risk behavior surveillace Uited States, 1999. MMWR CDC Surveill Summ, 49(5), 1-96. 12 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Uderstadig Traumatic Stress i Adolescets: A Primer for Substace Abuse Professioals He that coceals his grief fids o remedy for it. Turkish proverb The term traumatic stress geerally refers to the physical ad emotioal respose of a idividual to evets that threate the life or physical/psychological itegrity of that perso or of someoe critically importat to him or her. Traumatic stress characteristically produces itese physical ad emotioal reactios, icludig a overwhelmig sese of terror, helplessess, ad horror, ad a rage of physical sesatios such as a poudig heart, tremblig, dizziess, ausea, dry mouth ad throat, ad loss of bladder or bowel cotrol. I childre ad adolescets, traumatic stress ca be triggered by a wide rage of experieces, icludig: Physical, sexual, or emotioal abuse 1 Neglect (failure to provide for a child s basic physical, medical, educatioal, ad emotioal eeds) Iterpersoal violece or victimizatio (e.g., assault, rape) 2 Commuity violece (e.g., gag violece, riots, school shootigs) 3 6 Natural disasters (e.g., hurricaes, floods, toradoes) 7,8 Terrorism 9,10 Traumatic loss or grief (e.g., murder of a paret or siblig, death of a paret i battle) 9,11 15 Medical trauma (e.g., severe ijury, life-threateig illess) 16 18 Accidets 16 The short- ad log-term impact of ay give traumatic evet depeds partly o the objective ature of the evet, ad partly o the idividual s subjective respose to it. For example, the traumatic impact of iterpersoal evets such as physical or sexual abuse or victimizatio may vary depedig o factors such as the idetity of the perpetrator, the frequecy of the abuse, ad whether force was used. Not every distressig evet results i traumatic stress, ad somethig that is traumatic for oe perso may ot be traumatic for aother. The Natioal Child Traumatic Stress Network www.nctsn.org 13
Types of Traumatic Stress A sigle, time-limited traumatic evet is called a acute trauma. A atural disaster, motor vehicle accidet, physical or sexual assault, or a school shootig are all examples of acute traumas. Over the course of eve a brief evet, a child or adolescet may go through a variety of complicated sesatios, thoughts, feeligs, ad physical resposes that are frighteig i ad of themselves ad cotribute to his or her sese of beig overwhelmed. The loss of someoe critically importat (e.g. a paret, siblig, or close fried) is a acute evet that ca lead to a traumatic stress reactio kow as traumatic grief. Although all adolescets grieve after the death of a loved oe, traumatic grief occurs whe the tee experieces the death/loss as a traumatic evet ad experieces may of the symptoms of PTSD (e.g., itrusive thoughts about the death, icreased physical agitatio, emotioal umbig). 13 15 These symptoms hider the atural bereavemet process, ca cause iterferece i daily fuctioig, ad do ot allow the tee to process ad, evetually, let go of the loss. 13 15 Traumatic grief is ofte complicated by the secodary cosequeces of the loss, such as movig i with gradparets after the loss of a paret. 14 The experiece of multiple traumatic evets is referred to as chroic trauma. Chroic trauma may ecompass several differet evets such as exposure to domestic violece, ivolvemet i a serious car accidet, ad exposure to gag-related violece or logstadig trauma such as physical abuse or war. Oe commo from of chroic trauma is child eglect. The effects of chroic trauma ted to be cumulative, because each evet serves as a remider of the prior trauma ad reiforces its egative impact. A child or adolescet who has bee exposed to a series of traumas may become icreasigly overwhelmed with each subsequet evet ad more coviced that the world is ot a safe place. Over time, he or she may also become less able to tolerate ordiary everyday stress. A Word about Trauma Remiders Trauma remiders are people, situatios, places, or thigs that evoke past traumatic evets. Whe faced with trauma remiders, adolescets may reexperiece the itese ad disturbig feeligs tied to the origial evet. Sometimes adolescets are aware of their reactio ad its coectio to the origial evet. More ofte, however, they are uaware of the root cause of their feeligs, ad may eve feel frighteed by the itesity of their reactio. As a result, traumatized tees may: Respod recklessly, takig more risks or abusig drugs or alcohol Withdraw from activities, places ad frieds i a effort to avoid remiders Fear that their strog reactios mea they are goig crazy Feel stigmatized by havig goe through traumatic evets, ad feel that they caot talk about them 14 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Complex trauma is a term used by some experts to describe both exposure to chroic trauma usually caused by adults etrusted with the child s care, such as parets or caregivers ad the impact of such exposure o the perso. 19 Childre ad adolescets who have experieced complex trauma have edured multiple traumatic evets (such as physical or sexual abuse, profoud eglect, or commuity violece) from a very youg age (typically youger tha age 5). Whe trauma is associated with the failure of those who should be carig for a child, it has profoud effects o early every aspect of the child s developmet ad fuctioig. Childre ad adolescets who have experieced complex trauma ofte display a rage of social, developmetal, ad physical impairmets, icludig: Social isolatio ad difficulty relatig to ad empathizig with others Uexplaied physical symptoms ad icreased medical problems (e.g., asthma, ski problems, ad autoimmue disorders) Difficulty i regulatig emotio ad kowig ad describig their feeligs ad iteral states Poor impulse cotrol, self-destructive behavior, ad aggressio Sleep disturbaces Disturbed body image Low self-esteem, shame, ad guilt I some cases, traumatic stress reaches the level of cliically defied posttraumatic stress disorder (PTSD). Accordig to the America Psychiatric Associatio, PTSD is characterized by episodes of reexperiecig the trauma (e.g., flashbacks, or itrusive thoughts), avoidace of situatios that are remiiscet of the trauma, emotioal umbig, ad icreased arousal (e.g., hypervigilace, irritability). 20 Numerous surveys have show that childre ad adolescets who have experieced trauma are at particularly high risk of developig PTSD: more tha 75% of childre who experiece a school shootig, ad approximately 90% of childre who are sexually abused develop PTSD. 21 They may report ogoig fear that the evet will occur agai, persistet flashbacks ad ightmares, avoidace of thigs that remid them of the evet, beig o edge all the time, ad/or trouble sleepig. The Prevalece of Trauma amog Adolescets Childre ad adolescets i the Uited States are routiely exposed to a wide rage of potetially traumatic evets. Accordig to the Natioal Survey of Adolescets (NSA): 2 The Natioal Child Traumatic Stress Network www.nctsn.org 15
Four out of 10 adolescets have witessed violece Sevetee percet have bee physically assaulted Eight percet have experieced sexual assault The prevalece of trauma exposure is eve higher amog certai high-risk groups. For example, data gathered by the Natioal Child Abuse ad Neglect Data System has show that Native America, Alaska Native, Africa America, ad mixed-race childre have much higher rates of maltreatmet (icludig eglect) as compared to their white (Hispaic or o- Hispaic) peers. 22 The NSA foud that more tha half of Africa America, Hispaic, ad Native America adolescets have witessed violece i their lifetimes. 2 Other groups that are more likely to have experieced various forms of trauma iclude: Homeless youth 23,24 Youth whose parets have a crimial record or history of metal illess 25, or whose older sibligs are ivolved i deviat behaviors such as aggressio, crime, or drug abuse 26 Urba youth who have a high percetage of umoitored ad ustructured time, particularly time spet i the compay of frieds 27 Lesbia, gay, bisexual, ad trasgeder youth 28 Refugee childre ad adolescets 29 32, particularly those ot accompaied by a caregiver adult 33,34 Of course, may adolescets fit ito more tha oe of the above categories, which places them at eve greater risk. The Impact of Trauma o Adolescet Developmet ad Behavior Trauma has bee show to adversely affect may of the eurobiological systems resposible for cogitive developmet ad the regulatio of emotios ad behavior. 35 37 I adolescets, this ca mea delays i the developmetal processes that would ormally eable them to better cosider the cosequeces of their behavior, to make more realistic appraisals of dager ad safety, to moderate daily behavior to meet log-term goals, ad to make icreased use of abstract thikig for academic learig ad problem-solvig. As a result, adolescets sufferig from traumatic stress or PTSD are proe to: Reckless ad risk-takig behavior Livig for today ad ot tomorrow 16 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Uderachievemet ad school failure Makig bad choices I additio to the eurobiological impact of traumatic stress, adolescets who have bee exposed to trauma exped a eormous amout of emotioal ad metal eergy respodig to, copig with, ad tryig to comig to terms with the evet or evets. This ca reduce their capacity to master other age-appropriate developmetal tasks. For example: A youth whose mid is occupied with itrusive images of traumatic evets caot focus o learig, ad so lags behid i school A tee who is emotioally overwhelmed by remiders of traumatic evets caot devote his or her eergies to formig relatioships with peers A tee who is fearful of takig ay risk caot take o the challeges that lead to growth The loger traumatic stress goes utreated, the greater the risk of developig maladaptive ad potetial dagerous copig mechaisms. Implicatios for Substace Abuse Treatmet Adolescets tur to a umber of potetially destructive behaviors i a effort to avoid or defuse the itese egative emotios that accompay traumatic stress, icludig compulsive sexual behavior, self-mutilatio, bigeig ad purgig, ad eve attempted suicide. But arguably the most commo maladaptive copig mechaism amog traumatized adolescets is the abuse of alcohol or drugs. Reported rates of substace abuse followig trauma exposure rage from 25% to 76% 8 11, ad research has show that more tha half of youg people with PTSD subsequetly develop substace abuse problems. 8 11 A history of childhood sexual physical abuse has also bee associated with the developmet ad severity of alcohol disorders. 38 The presece of traumatic stress or PTSD greatly complicates the recovery process i adolescets with substace abuse disorders. I additio to the physically ad psychologically addictig effects of alcohol ad drugs, adolescets with co-occurrig traumatic stress must deal with the sometimes overwhelmig sequelae of their past traumas. For example, exposure to trauma remiders has bee show to icrease drug cravigs i people with co-occurrig trauma ad substace abuse. 39,40 The Natioal Child Traumatic Stress Network www.nctsn.org 17
Available evidece idicates that whe substace abuse ad traumatic stress are treated separately, adolescets with co-occurrig disorders are more likely to relapse ad revert to previous maladaptive copig strategies: I surveys of adolescets receivig substace abuse treatmet, a history of victimizatio has cosistetly bee associated with egative treatmet outcomes 41,42 Tees with a history of physical abuse are less likely to achieve posttreatmet abstiece tha tees without a trauma history 43 Higher iitial symptom severity amog youth with co-occurrig traumatic stress ad substace abuse problems has bee associated with more iteral distress ad violet behavior posttreatmet 42 Research i adults with cooccurrig trauma ad substace abuse supports the same coclusio. I studies of adults receivig substace abuse treatmet, idividuals with cooccurrig PTSD ad substace abuse had higher relapse Toy s Story* Toy is a 17-year-old who lives at home with his mother ad stepfather, who frequetly argue, ad his 14-year-old brother, Mikey. Whe Toy was 15, he saw his best fried, Curtis, shot i the cross-fire of gag-related violece i their eighborhood. After Curtis was atteded to by the paramedics, Toy was allowed to ride i the ambulace to the hospital with Curtis. Curtis died i the ICU several hours later. Toy was devastated, but believed that Curtis would have wated him to stay strog; he tried to get back to his daily routie as quickly as possible. Before Curtis s death, Toy was doig pretty well i his classes ad was o the school basketball team. However, he bega to fid it harder to focus i school ad was havig recurret ightmares about Curtis s death that were makig it difficult for him to sleep. At a basketball party oe weeked, a teammate offered Toy some Vicodi for a game-related ijury. Toy took a couple of extra pills to help him fall asleep. O the way home from the party, he oticed that he o loger had the o-edge feelig he usually had whe walkig through his eighborhood. Durig the ext week he discovered that Vicodi made it easier for him to deal with his brother whe he was gettig o his erves. Whe he ra out of Vicodi, Toy checked aroud for aother source ad foud a teammate who kew someoe who was sellig paikillers. Soo Toy started usig these every day, sometimes skippig school whe he d sleep through his alarm. Whe his dealer offered him OxyCoti, Toy switched ad liked the stroger effect, but soo discovered that it cost a lot more moey, so he started stealig from his parets. Whe the origial amouts did ot cause the same effect, he started crushig ad sortig the pills for a eve stroger effect, ad he evetually tried ijectig morphie. Toy was placed o probatio for missig so much school, ad evetually the courts ordered drug couselig services. He wet to a ipatiet program for oe moth ad the trasitioed to a partial-day program. After beig off drugs for some time, he started thikig more about his fried s horrific death ad bega to experiece survivor guilt. His ightmares ad hyperarousal retured ad felt so ubearable that he soo bega usig agai to gai temporary relief. * Toy is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. 18 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
rates tha those with substace abuse problems aloe 44, ad iitial PTSD severity was a sigificat predictor of relapse. 45,46 Amog adults with cocaie or alcohol depedece, patiets with a history of PTSD were more likely to use followig egative experieces (e.g., upleasat emotios ad/or physical discomfort) tha those without PTSD. 47 Coclusios Although the importace of addressig co-occurrig substace abuse ad traumatic stress is evidet, ways of itegratig these services are ot as clear-cut. For example, some providers may feel that before beig able to address uderlyig issues relatig to trauma, it is importat to treat substace abuse symptoms ad limit the potetial harm ad threat to the idividual. Coversely, some providers may feel that uless the idividual lears strategies to maage distress associated with trauma, the likelihood of substace abuse relapse remais high. Despite these challeges, better care ca be achieved through icreased commuicatio ad coordiatio amog substace abuse professioals ad metal health providers, ad icreased awareess of the liks betwee adolescet traumatic stress ad substace abuse. Substace abuse professioals eed to remai aware of these liks, ad make trauma assessmet a itegral part of the services provided by agecies ad idividuals workig with adolescets, particularly those at high risk of trauma exposure. Trauma ad Substace Abuse: Myths ad Facts Myth: Attributig drug or alcohol use to stress just prevets adolescets from takig resposibility for their actios. Fact: Defiig the relatioship betwee a youth s trauma history ad his or her substace use ca actually ehace his or her ability to take resposibility for his or her actios, particularly i adolescets who are reluctat to ackowledge that their substace use is a problem. I additio, the self-medicatio hypothesis ca be extremely helpful i uderstadig both the origis of a youth s substace abuse ad the factors that may lead to cotiued use or relapse. The Natioal Child Traumatic Stress Network www.nctsn.org 19
Refereces 1. Porter, C., Lawso, J. S., ad Bigler, E. D. (2005). Neurobehavioral sequelae of child sexual abuse. Child Neuropsychol, 11(2), 203 20. 2. Kilpatrick, D. G., Sauders, B. E., ad Smith, D. W. (2003). Youth victimizatio: Prevalece ad Implicatios. Washigto, DC: U.S. Departmet of Justice, Office of Justice Programs, Natioal Istitute of Justice. Retrieved April 16, 2008 from http://www.cjrs.gov/pdffiles1/ij/194972.pdf. 3. Ozer, E. J., ad Weistei, R. S. (2004). Urba adolescets exposure to commuity violece: The role of support, school safety, ad social costraits i a school-based sample of boys ad girls. J Cli Child Adolesc Psychol, 33(3), 463 76. 4. Ozer, E. J., ad McDoald, K. L. (2006). Exposure to violece ad metal health amog Chiese America urba adolescets. J Adolesc Health, 39(1), 73 9. 5. Paxto, K. C., Robiso, W. L., Shah, S., ad Schoey, M. E. (2004). Psychological distress for Africa-America adolescet males: Exposure to commuity violece ad social support as factors. Child Psychiatry Hum Dev, 34(4), 281 95. 6. Fitzpatrick, K. M., Piko, B. F., Wright, D.R., ad LaGory, M. (2005). Depressive symptomatology, exposure to violece, ad the role of social capital amog Africa America adolescets. Am J Orthopsychiatry, 75(2), 262 74. 7. Galea, S., Brewi, C. R., Gruber, M., Joes, R. T., Kig, D. W., Kig, L. A., et al. (2007). Exposure to hurricae-related stressors ad metal illess after Hurricae Katria. Arch Ge Psychiatry, 64(12), 1427 34. 8. Goejia, A. K., Wallig, D., Steiberg, A. M., Karaya, I., Najaria, L. M., ad Pyoos, R. (2005). A prospective study of posttraumatic stress ad depressive reactios amog treated ad utreated adolescets 5 years after a catastrophic disaster. Am J Psychiatry, 162(12), 2302 8. 9. Brow, E. J., ad Goodma, R. F. (2005). Childhood traumatic grief: A exploratio of the costruct i childre bereaved o September 11. J Cli Child Adolesc Psychol, 34(2), 248 59. 10. Calderoi, M. E., Alderma, E. M., Silver, E. J., ad Bauma, L. J. (2006). The metal health impact of 9/11 o ier-city high school studets 20 miles orth of Groud Zero. J Adolesc Health, 39(1), 57 65. 11. Dyregrov, K., ad Dyregrov, A. (2005). Sibligs after suicide the forgotte bereaved. Suicide Life Threat Behav, 35(6), 714 24. 12. Cohe, J. A., Maario, A. P., ad Staro, V. R. (2006). A pilot study of modified cogitivebehavioral therapy for childhood traumatic grief (CBT-CTG). J Am Acad Child Adolesc Psychiatry, 45(12), 1465 73. 13. Cohe, J. A., Maario, A. P., ad Kudse, K. (2004). Treatig childhood traumatic grief: A pilot study. J Am Acad Child Adolesc Psychiatry, 43(10), 1225 33. 20 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
14. Cohe, J. A., ad Maario, A. P. (2004). Treatmet of childhood traumatic grief. J Cli Child Adolesc Psychol, 33(4), 819 31. 15. Cohe, J., Goodma, R. F., Brow, E. J., ad Maario, A. (2004). Treatmet of childhood traumatic grief: Cotributig to a ewly emergig coditio i the wake of commuity trauma. Harv Rev Psychiatry, 12(4), 213 6. 16. Wisto, F. K., Kassam-Adams, N., Garcia-Espaa, F., Ittebach, R., ad Caa, A. (2003). Screeig for risk of persistet posttraumatic stress i ijured childre ad their parets. JAMA, 290(5), 643 9. 17. Taieb, O., Moro, M. R., Baubet, T., Revah-Levy, A., ad Flamet, M. F. (2003). Posttraumatic stress symptoms after childhood cacer. Eur Child Adolesc Psychiatry, 12(6), 255 64. 18. El hamaoui, Y., Yaalaoui, S., Chihabeddie, K., Boukid, E., ad Moussaoui, D. (2002). Posttraumatic stress disorder i bured patiets. Burs, 28(7), 647 50. 19. Cook, A., Spiazzola, J., Ford, J., Laktree, C., Blaustei, M., Cloitre, M., et al. (2005). Complex trauma i childre ad adolescets. Psychiatric Aals, 35(5), 390 398. 20. America Psychiatric Associatio. (2000). Diagostic ad Statistical Maual of Metal Disorders, DSM-IV-TR (Text Revisio) (4th ed.). Washigto, DC: America Psychiatric Publishig, Ic. 21. Hamble, J. (1999). Natioal Ceter for PTSD FactSheet: PTSD i Childre ad Adolescets. White River Juctio, VT: Natioal Ceter for PTSD. Retrieved April 10, 2008, from http://www.cptsd. va.gov/cmai/cdocs/fact_shts/fs_childre.html 22. U.S. Departmet of Health ad Huma Services. (2008). Child Maltreatmet 2006. Washigto, DC: U.S. Govermet Pritig Office. Retrieved April 15, 2008 from http://www.acf.hhs.gov/ programs/cb/pubs/cm06/cm06.pdf. 23. Kipke, M. D., Simo, T. R., Motgomery, S. B., Uger, J. B., ad Iverse, E. F. (1997). Homeless youth ad their exposure to ad ivolvemet i violece while livig o the streets. J Adolesc Health, 20(5), 360 7. 24. Gwadz, M. V., Nish, D., Leoard, N. R., ad Strauss, S. M. (2007). Geder differeces i traumatic evets ad rates of post-traumatic stress disorder amog homeless youth. J Adolesc, 30(1), 117 29. 25. Costello, E. J., Erkali, A., Fairbak, J. A., ad Agold, A. (2002). The prevalece of potetially traumatic evets i childhood ad adolescece. J Trauma Stress, 15(2), 99 112. 26. Syder, J., Bak, L., ad Burrasto, B. (2005). The cosequeces of atisocial behavior i older male sibligs for youger brothers ad sisters. J Fam Psychol, 19(4), 643 53. 27. Richards, M. H., Larso, R., Miller, B. V., Luo, Z., Sims, B., Parrella, D. P., et al. (2004). Risky ad protective cotexts ad exposure to violece i urba Africa America youg adolescets. J Cli Child Adolesc Psychol, 33(1), 138 48. The Natioal Child Traumatic Stress Network www.nctsn.org 21
28. Kosciw, J. G., ad Diaz, E. M. (2006). The 2005 Natioal School Climate Survey: The experieces of lesbia, gay, bisexual ad trasgeder youth i our atio s schools. New York, NY: Gay, Lesbia ad Straight Educatio Network (GLSEN). Retrieved April 16, 2008 from http://www.glse.org/ biary-data/glsen_attachments/file/585-1.pdf. 29. Hooberma, J. B., Rosefeld, B., Lhewa, D., Rasmusse, A., ad Keller, A. (2007). Classifyig the torture experieces of refugees livig i the Uited States. J Iterpers Violece, 22(1), 108 23. 30. Ellis, B. H., Lhewa, D., Charey, M., ad Cabral, H. (2006). Screeig for PTSD amog Somali adolescet refugees: Psychometric properties of the UCLA PTSD Idex. J Trauma Stress, 19(4), 547 51. 31. Keller, A., Lhewa, D., Rosefeld, B., Sachs, E., Aladjem, A., Cohe, I., et al. (2006). Traumatic experieces ad psychological distress i a urba refugee populatio seekig treatmet services. J Nerv Met Dis, 194(3), 188 94. 32. Thabet, A. A., Abed, Y., ad Vostais, P. (2004). Comorbidity of PTSD ad depressio amog refugee childre durig war coflict. J Child Psychol Psychiatry, 45(3), 533 42. 33. Bea, T. M., Eureligs-Botekoe, E., ad Spihove, P. (2007). Course ad predictors of metal health of uaccompaied refugee miors i the Netherlads: Oe year follow-up. Soc Sci Med, 64(6), 1204 15. 34. Bea, T., Derluy, I., Eureligs-Botekoe, E., Broekaert, E., ad Spihove, P. (2007). Comparig psychological distress, traumatic stress reactios, ad experieces of uaccompaied refugee miors with experieces of adolescets accompaied by parets. J Nerv Met Dis, 195(4), 288 97. 35. De Bellis, M. D. (2001). Developmetal traumatology: the psychobiological developmet of maltreated childre ad its implicatios for research, treatmet, ad policy. Dev Psychopathol, 13(3), 539 64. 36. De Bellis, M. D., ad Keshava, M. S. (2003). Sex differeces i brai maturatio i maltreatmet-related pediatric posttraumatic stress disorder. Neurosci Biobehav Rev, 27(1 2), 103 17. 37. De Bellis, M. D., Keshava, M. S., Clark, D. B., Casey, B. J., Giedd, J. N., Borig, A. M., et al. (1999). A.E. Beett Research Award. Developmetal traumatology. Part II: Brai developmet. Biol Psychiatry, 45(10), 1271 84. 38. Zlotick, C., Johso, D. M., Stout, R. L., Zywiak, W. H., Johso, J. E., ad Scheider, R. J. (2006). Childhood abuse ad itake severity i alcohol disorder patiets. J Trauma Stress, 19(6), 949 59. 39. Saladi, M. E., Drobes, D. J., Coffey, S. F., Dasky, B. S., Brady, K. T., ad Kilpatrick, D. G. (2003). PTSD symptom severity as a predictor of cue-elicited drug cravig i victims of violet crime. Addict Behav, 28(9), 1611 29. 22 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
40. Coffey, S. F., Saladi, M. E., Drobes, D. J., Brady, K. T., Dasky, B. S., ad Kilpatrick, D. G. (2002). Trauma ad substace cue reactivity i idividuals with comorbid posttraumatic stress disorder ad cocaie or alcohol depedece. Drug Alcohol Deped, 65(2), 115 27. 41. Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), 36 45. 42. Titus, J. C., Deis, M. L., White, W. L., Scott, C. K., ad Fuk, R. R. (2003). Geder differeces i victimizatio severity ad outcomes amog adolescets treated for substace abuse. Child Maltreat, 8(1), 19 35. 43. Grella, C. E., ad Joshi, V. (2003). Treatmet processes ad outcomes amog adolescets with a history of abuse who are i drug treatmet. Child Maltreat, 8(1), 7 18. 44. Read, J. P., Brow, P. J., ad Kahler, C. W. (2004). Substace use ad posttraumatic stress disorders: Symptom iterplay ad effects o outcome. Addict Behav, 29(8), 1665 72. 45. Brow, P. J. (2000). Outcome i female patiets with both substace use ad post-traumatic stress disorders. Alcoholism Treatmet Quarterly, 13(3), 127 135. 46. Ouimette, P. C., Brow, P. J., ad Najavits, L. M. (1998). Course ad treatmet of patiets with both substace use ad posttraumatic stress disorders. Addict Behav, 23(6), 785 95. 47. Waldrop, A. E., Back, S. E., Verdui, M. L., ad Brady, K. T. (2007). Triggers for cocaie ad alcohol use i the presece ad absece of posttraumatic stress disorder. Addict Behav, 32(3), 634 9. The Natioal Child Traumatic Stress Network www.nctsn.org 23
Uderstadig Substace Abuse i Adolescets: A Primer for Metal Health Professioals Metal health programs desiged to reduce commo psychological problems associated with child ad adolescet victimizatio are commo, but few iclude specific itervetios delayig the oset of substace use ad reducig substace abuse... 1 Dea Kilpatrick, Bejami Sauders & Daiel Smith Youth Victimizatio: Prevalece ad Implicatios O ay give day, approximately 8% of America adolescets betwee the ages of 12 ad 17 meet the America Psychiatric Associatio s diagostic criteria for substace abuse or depedece 2, more tha 5% meet the criteria for alcohol abuse or depedece 2, ad more tha 11% show sigs of problematic use of alcohol or drugs, defied as more tha oe substace-related problem durig the past year. 3 Take together, these data idicate that oe i five America adolescets is egaged i maladaptive or dagerous use of alcohol or drugs. 2,3 Numerous studies have documeted a strog correlatio betwee trauma exposure ad substace abuse i youg people. The most recet Natioal Survey of Adolescets revealed that tees who had experieced physical or sexual abuse/assault were three times more likely to report past or curret substace abuse tha those without a history of trauma 1, ad surveys of adolescets receivig treatmet for substace abuse have show that more tha 70% had a history of trauma exposure. 4,5 The lik betwee trauma ad substace abuse is eve more strikig amog adolescets with PTSD: studies idicate that up to 59% of youg people with PTSD subsequetly develop substace abuse problems. 5 8 Although recreatioal alcohol ad drug use are more commo i adults, studies have show that youth who egage i drug ad alcohol use are at greater risk for lifelog egative cosequeces, especially whe they start usig at a youg age. Because the teeage brai is still growig ad chagig, alcohol ad drug use at a early age have a greater potetial to disrupt ormal brai developmet. The most affected brai regios iclude the hippocampus which is related to learig ad memory ad the prefrotal cortex, which is resposible for critical thikig, plaig, impulse cotrol, ad emotioal regulatio. 9,10 Drug ad alcohol use also iterfere with may other physiological processes ad have bee show to destabilize mood. Thus, adolescet substace use is associated with higher rates of depressio, aggressio, violece ad suicide. 11 These fidigs are particularly disturbig give that, for most tees, iitiatio of substace use teds to be at a early age. Oe The Natioal Child Traumatic Stress Network www.nctsn.org 25
atioal survey foud that by the time they fiish 8th grade, early oe i three (29%) adolescets has experimeted with illegal drugs, ad 41% have cosumed alcohol. 12 The earlier oset the age of first drikig, the greater the risk for lifetime alcohol abuse or depedece. 13 Give these fidigs, it is clear that substace abuse screeig should be a itegral part of the services provided by agecies ad idividuals workig with adolescets. This is particularly importat i metal health service systems, where adolescets i treatmet for traumatic stress ad other emotioal problems could beefit greatly from receivig care from cliical staff that uderstads the strog fuctioal relatioship betwee substace abuse ad traumatic stress. Substace Abuse ad Trauma: Makig the Coectio May researchers ad providers poit to the self-medicatio hypothesis to explai the coectio betwee trauma exposure ad substace abuse, suggestig that youth tur to psychoactive drugs ad alcohol i a attempt to cope with traumatic stress or remiders of loss. Although there is much evidece to support this pathway studies evaluatig the frequecy of substace abuse followig trauma exposure have reported rates as high as 76% 8 11 it is also true that substace abuse ca icrease a adolescet s risk of trauma exposure ad of experiecig traumatic stress symptoms. Epidemiological studies have foud that for may adolescets (up to 66% i some studies) substace use disorders precede the oset of trauma exposure. 6,7 This may be due to the fact that substace abusig adolescets are more likely to egage i risky activities that could lead to harm to themselves or others. 6 8 For example, tees with substace abuse disorders are more likely to drive while uder the ifluece, hitchhike, or walk i usafe eighborhoods. 2,14 There is also evidece that substace use disorders decrease youths ability to appropriately cope with ew distressig ad traumatic evets, thus leadig to the icreased likelihood of developig PTSD. I oe study, adolescets with substace abuse disorders were two times more likely to develop PTSD followig trauma tha were their osubstace abusig peers. 7 Whatever the temporal relatioship betwee trauma ad the developmet of substace abuse, it is clear that the egative effects ad cosequeces of oe disorder compoud the problems of the other. All idividuals with substace abuse disorders are at risk of experiecig itese cravigs for their substace(s) of abuse whe exposed to stimuli associated with use (e.g., substace-usig peers, places where they obtai drugs, time of day). I substace abusig tees with a history of trauma, such cravigs ca also be triggered by people, situatios, places, or thigs that evoke past traumatic evets. Research 26 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
with substace abusig adults has show that cravig icreases whe idividuals with co-occurrig trauma ad substace abuse are exposed to cues of the traumatic evet. 15,16 Amog adults with cocaie depedece, for example, idividuals with PTSD are more likely to use followig egative experieces (such as upleasat emotios ad physical discomfort) whe compared with those without PTSD. 17 Successful treatmet of adolescets with co-occurrig traumatic stress ad substace abuse therefore requires itervetios that address the challeges of both disorders. Failure to provide such comprehesive treatmet may sigificatly impair these tees likelihood of log-term recovery. I the absece of copig strategies to maage distress associated with trauma, adolescets with co-occurrig disorders are more likely to relapse ad revert to maladaptive copig strategies tha tees with substace abuse aloe: I surveys of adolescets receivig substace abuse treatmet, a history of victimizatio has cosistetly bee associated with egative treatmet outcomes 4,18 Tees with a history of physical abuse are less likely to achieve posttreatmet abstiece tha tees without a trauma history 19 Higher iitial symptom severity amog youth with co-occurrig traumatic stress ad substace abuse problems has bee associated with more iteral distress ad violet behavior posttreatmet 18 Research i adults with co-occurrig trauma ad substace abuse supports the same coclusio. I studies of adults receivig substace abuse treatmet, idividuals with cooccurrig PTSD ad substace abuse had higher relapse rates tha those with substace abuse problems aloe 20, ad iitial PTSD severity was a sigificat predictor of relapse. 21,22 These fidigs illustrate the eed for icreased awareess amog metal health professioals of the strog ad complex relatioship betwee substace abuse ad traumatic stress. Tees battlig the effects of traumatic stress ad substace abuse eed to acquire copig skills to maage the distress associated with either type of problem. Improvemets i the ability to maage substace abuse cravigs, for example, may ehace the youth s readiess to lear how to maage trauma ad loss remiders. Why Do Adolescets Use? Uderstadig the reasos youth start usig drugs or alcohol as well as their reasos for cotiuig or discotiuig use is crucial to developig effective substace abuse itervetios. A recet 30-moth study of 923 teeagers receivig outpatiet ad residetial substace abuse treatmet has provided some isight ito the motivatios behid adolescets substace abuse ad evetual recovery. 23 The Natioal Child Traumatic Stress Network www.nctsn.org 27
I this study, three quarters of the tees cited social pressures ad experimetatio as their reasos for iitiatig drug or alcohol use. Tees may use because they see everyoe else doig it ad wat to bled i, because it s a way of spedig time with frieds, of beig accepted, of becomig popular, of ehacig social ad other activities, or because they fear that if they refuse, they might alieate potetial frieds. May If I do t do drugs, I feel like I m goig to go isae. Because I have all these thoughts ad all this pai i my heart ad I ca t get rid of it, you kow? Drugs is the oly thig that takes that away. That s why I do drugs. Because it keeps me, ot happy, but it keeps me from beig so sad that I wat to die. 24 adolescets reported that curiosity led to first use, while others reported that they decided to start after witessig use by a paret or relative. Of ote, oly 7% reported iitiatig use to cope with difficulties. 23 This situatio chages whe it comes to tees reasos for cotiuig use. Whe asked why they cotiue to use, more tha half reported usig drugs because it feels good (29%) or because it helps them cope with difficulties (23%). Aother 7% reported that it was a addictio or habit, ad 4% felt that drug or alcohol use ehaced their sese of self i some way (greater cofidece, self esteem, etc.). 23 I light of these fidigs, it is likely that, for tees experiecig traumatic stress, cotiued substace use may serve as a copig strategy to deal with stress, forget upleasat experieces, avoid egative emotios, do away with worries, or feel umb or idifferet to the challeges of daily life or the remiders of past trauma. Amog tees who quit usig drugs or alcohol, the most frequetly reported reasos accoutig for 57% of resposes had to do with the egative effect that usig had or could have o the adolescets lives. Some respodets said they had tired of usig (22%), others were cocered about the effect drug use could have o their overall life path (21%), ad others were worried about the egative physical ad psychological effects of their drug or alcohol use (14%). By compariso, exteral pressures accouted for less tha oe quarter of tees reasos for quittig: 14% of respodets idicated they had quit i respose to exteral factors such as jail or madated treatmet, 4% reported quittig for family ad frieds, ad 3% reported quittig to avoid trouble. 23 Recogizig Substace Abuse ad Depedece i Adolescets Although the reasos for iitiatig ad cotiuig drug ad alcohol use are varied, the sigs of abuse ad depedece are remarkably cosistet. Accordig to the America Psychiatric Associatio 25, substace abuse is a patter of use that leads to sigificat impairmet or distress, maifested as oe or more of the followig occurrig durig a 12-moth period: 28 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Recurret use resultig i a failure to fulfill major obligatios at work, school, or home Recurret use i situatios i which it is physically hazardous (e.g., drivig while high or druk) Recurret substace-related legal problems Cotiued use despite persistet or recurret social or iterpersoal problems caused or exacerbated by the effects of the substace (e.g., argumets with parets, fights) Substace depedece (more commoly referred to as addictio) ivolves the same problems, with the additio of clear sigs of physical ad psychological depedece, as maifested by three or more of the followig occurrig at ay time over a 12-moth period: 25 Tolerace, defied as the eed for icreased amouts of the substace to achieve the desired effect, or markedly dimiished effects with cotiued use of the same amout of the substace Withdrawal, maifested as either the characteristic withdrawal sydrome for the substace or cotiued use of the substace (or a closely related drug) to relieve or prevet withdrawal symptoms Takig the substace ofte i larger amouts or over a loger period tha iteded A persistet desire or usuccessful efforts to cut dow or cotrol substace use Spedig a great deal of time i activities ecessary to obtai or use the substace or to recover from its effects Givig up social, occupatioal, or recreatioal activities because of substace use Cotiued use with the kowledge that it is causig or exacerbatig a persistet or recurret physical or psychological problem Some researchers have added aother category problematic use to describe adolescets who do t meet the strict diagostic criteria for alcohol abuse or depedece, but who show two or more symptoms of alcohol depedece. The most commo symptoms see i these diagostic orphas are: 26 Tolerace Usig more or loger tha iteded Usuccessful attempts to quit or cut dow A cosiderable amout of time spet usig The Natioal Child Traumatic Stress Network www.nctsn.org 29
The specific sigs ad symptoms of itoxicatio, depedece ad abuse may vary depedig o the substace used (See Table 1 ad Table 2); however, major idicators that a adolescet may be egaged i problematic use or depedece iclude: 25,27,28 Difficulty sleepig Disruptive behavior Depressio Maria s Story* Maria is a 14-year-old girl who has bee physically ad sexually abused by her 22-year-old stepbrother for five years. The first icidet of abuse happeed whe she ad her mother moved i with the ew stepfamily, after havig bee evicted from their old apartmet. I additio, Maria has see her stepfather severely beat her mother several times, ad is ow costatly worried about her mother s safety. She also fears that someoe will fid out about the abuse ad that she will be take away from her mother. School avoidace Declie i academic performace Axiety Rapid chages i mood or hostile outbursts Chages i peer group or failig to itroduce peers to parets Chages i physical appearace or poor hygiee Secretive behaviors such as seakig out, lyig, ad lockig doors Maria has become withdraw at school ad o loger participates i activities she oce ejoyed. Oce very popular with her peers, she has isolated herself from may of her frieds ad speds most of her time aloe. The oly perso Maria speds time with is a older cousi who lives i the eighborhood. Lately, they have bee skippig school to smoke marijuaa ad drik alcohol. Maria used to be a hoor-roll studet, but her grades have bee spiralig dowward. Her favorite teacher is extremely cocered ad has bee tryig to get Maria to talk to her about what is causig such a chage. * Maria is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. Alcohol ad Illicit Drugs: Prevalece Rates ad Geeral Iformatio Alcohol Adolescets use alcohol more frequetly tha they do all other drugs combied. The Natioal Logitudial Study of Adolescet Health foud that more tha 30% of surveyed adolescets had druk more tha five driks i a row i the past 12 moths ad more tha 30% reported gettig druk durig that same period. 31,32 Similarly, the most recet Natioal Survey o Drug Use ad Health foud that more tha 25% of uderage drikers are bige or heavy drikers, ad approximately 20% oe i five report drivig while uder the ifluece durig 30 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
the past year. 2 I 2006, 63% of 8th graders ad more tha 80% of high-school age tees reported that alcohol was easy or very easy to obtai. 12 Caabioids The caabioids are the most commoly used illegal drugs i the Uited States. Accordig to the 2006 Natioal Survey o Drug Abuse, every day 6,000 people try marijuaa for the first time ad more tha 63% of them some 3,800 people are uder the age of 18. Overall, 6.7% of adolescets betwee the ages of 12 ad 17 are curret marijuaa users. 2 I 2006, approximately 40% of 8th graders ad three quarters of high school studets reported that marijuaa was easy or very easy to obtai. 12 Cocaie Cocaie is a powerfully addictive cetral ervous system stimulat. Oce the secodmost commoly used illicit drug i the Uited States, it has recetly bee overtake by prescriptio paikillers (see Opioids, below). Accordig to the 2005 Youth Risk Behavior Surveillace Survey 33, 7.6% of high school studets surveyed had used cocaie at least oce, ad 3.4% had used withi the last 30 days. Of ote, the percetage of tees who report that cocaie (i ay form) is easy or very easy to obtai rises with age: from approximately 20% i 8th grade to more tha 50% i seior year of high school. Cocaie use i combiatio with alcohol is especially dagerous because it facilitates the productio of cocaethylee, a cocaie metabolite that is more toxic tha cocaie aloe. Gamma hydroxybutyrate (GHB) GHB was sythesized i 1960 for use as a aesthetic. I the Uited States, GHB has bee widely abused sice the early 1990s. It is ofte used by youg ad predomiatly white partygoers i combiatio with various other drugs or alcohol at raves ad other gatherigs. It has bee used i a umber of sexual assaults ad, like the drug Rohypol (fluitrazepam), is kow as a date-rape drug because of its ability to sedate ad impair the memory of potetial victims. Because it metabolizes quickly, there are ofte o traces of it i a victim s bloodstream by the time the assault is remembered. GHB geerally comes mixed with water or i powder form. It is commoly sold i small bottles (the size of complimetary shampoo cotaiers supplied by hotels), which are geerally iexpesive ad cotai about 10 hits. GHB use has greatly icreased i recet years, with the most prevalet use observed i the southeaster ad wester Uited States. I 2006, 0.8% of 8th graders, 0.7% of 10th graders, ad 1.1% of 12th graders reported usig GHB at least oce i the prior year. 12 Accordig to data gathered by the Drug Abuse Warig Network (DAWN), i 2002 early 5,000 emergecy room visits were related to use of GHB. 37 The Natioal Child Traumatic Stress Network www.nctsn.org 31
Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 Category ad Name Examples of Commercial ad Street Names Alcohol Booze, brew, hooch, sauce, forty, brewsky, hard stuff, hard A, liquor, spirits, various brad ames DEA Schedule* How Admiistered** Not scheduled Swallowed Relaxatio, decreased cocetratio, impaired judgmet, coordiatio, ad reactio time, loss of cosciousess, blackouts, ad memory lapses Itoxicatio Effects Potetial Health Cosequeces Caabioids Class effects Hashish Boom, chroic, gagster, hash, hash oil, hemp Marijuaa Blut, dope, gaja, grass, herb, joits, Mary Jae, pot, reefer, sisemilla, skuk, weed I Swallowed, smoked Euphoria, slowed thikig ad reactio time, cofusio, impaired I Swallowed, smoked balace ad coordiatio Depressats Class Effects Liver disease, ulcers, cacer (esophageal, oral, hepatic), hypertesio, hypoglycemia, depedece, addictio Cough, frequet respiratory ifectios, impaired memory ad learig, icreased heart rate, axiety, paic attacks, tolerace, addictio Barbiturates Amytal, Nembutal, Secoal, Pheobarbital: barbs, reds, red birds, pheies, tooies, yellows, yellow jackets Bezodiazepies (other tha fluitrazepam) Ativa, Halcio, Librium, Valium, Xaax: cady, dowers, sleepig pills, traks Fluitrazepam*** Rohypol: forget-me pill, Mexica Valium, R2, Roche, roofies, roofiol, rope, rophies Reduced axiety, feelig of wellbeig, lowered ihibitios, slowed pulse ad breathig, lowered blood pressure, poor cocetratio Fatigue, cofusio, impaired coordiatio, memory, judgmet, addictio, respiratory depressio ad arrest, depedece, addictio, death II, III, V Ijected, swallowed Sedatio, drowsiess Depressio, uusual excitemet, fever, irritability, poor judgmet, slurred speech, dizziess, lifethreateig withdrawal IV Swallowed, ijected Sedatio, drowsiess Dizziess IV Swallowed, sorted Visual ad gastroitestial disturbaces, uriary retetio, memory loss for the time uder the drug s effects Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008 32
Category ad Name Examples of Commercial ad Street Names GHB*** gamma-hydroxybutyrate: G, Georgia home boy, grievous bodily harm, liquid ecstasy Methaqualoe Quaalude, Sopor, Parest: ludes, madrex, quad, quay DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces I Swallowed Drowsiess, ausea Vomitig, headache, loss of cosciousess, loss of reflexes, seizures, coma, death I Ijected, swallowed Euphoria Depressio, poor reflexes, slurred speech, coma Dissociative Aesthetics Class Effects Ketamie Ketalar SV: cat Valiums, K, Special K, vitami K PCP ad aalogs Phecyclidie: agel dust, boat, hog, love boat, peace pill III Ijected, sorted, smoked I, II Ijected, swallowed, smoked Icreased heart rate ad blood pressure, impaired motor fuctio At high doses, delirium, depressio, respiratory depressio ad arrest Possible decrease i blood pressure ad heart rate, paic, aggressio, violece Hallucioges Class Effects LSD Lysergic acid diethylamide: acid, blotter, boomers, cubes, microdot, yellow sushies I Swallowed, absorbed through mouth tissues Altered states of perceptio ad feelig, ausea Icreased body temperature, heart rate, ad blood pressure, loss of appetite, sleeplessess, umbess, weakess, tremors, persistet metal disorders Mescalie Buttos, cactus, mesc, peyote I Swallowed, smoked Icreased body temperature, heart rate, ad blood pressure, loss of appetite, sleeplessess, umbess, weakess, tremors Psilocybi Magic mushroom, purple passio, shrooms I Swallowed Nervousess, paraoia Memory loss, umbess, ausea. vomitig Loss of appetite, depressio Persistig perceptio disorder (flashbacks) The Natioal Child Traumatic Stress Network www.nctsn.org 33
Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 (cotiued) Category ad Name Examples of Commercial ad Street Names DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces Opioids ad Morphie Derivatives Class Effects Codeie Empiri with Codeie, Fiorial with Codeie, Robitussi A-C, Tyleol with Codeie: Captai Cody, Cody, schoolboy (with glutethimide), doors & fours, loads, pacakes ad syrup Fetayl ad fetayl aalogs Actiq, Duragesic, Sublimaze: Apache, Chia girl, Chia white, dace fever, fried, goodfella, jackpot, murder 8, TNT, Tago ad Cash Heroi diacetylmorphie: brow sugar, dope, H, horse, juk, skag, skuk, smack, white horse Morphie Roxaol, Duramorph: M, Miss Emma, mokey, white stuff Opium laudaum, paregoric: big O, black stuff, block, gum, hop II, III, IV, V Ijected, swallowed Less aalgesia, sedatio, ad respiratory depressio tha morphie I, II Ijected, smoked, sorted I Ijected, smoked, sorted II, III Ijected, swallowed, smoked II, III, V Swallowed, smoked Oxycodoe HCL OxyCoti: Oxy, O.C., killer II Swallowed, sorted, ijected Hydrocodoe bitartrate, acetamiophe Vicodi: vike, Watso-387 II Swallowed Pai relief, euphoria, drowsiess Nausea, costipatio, cofusio, sedatio, respiratory depressio ad arrest, tolerace, addictio, ucosciousess, coma, death Staggerig gate Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008 34
Category ad Name Examples of Commercial ad Street Names DEA Schedule* How Admiistered** Itoxicatio Effects Potetial Health Cosequeces Stimulats Class Effects Amphetamie Biphetamie, Dexedrie: beies, black beauties, crosses, hearts, LA turaroud, speed, truck drivers, uppers Cocaie Cocaie hydrochloride: blow, bump, C, cady, Charlie, coke, crack, flake, rock, sow, toot MDMA (methyleedioxymethamphetamie) Adam, clarity, ecstasy, Eve, lover s speed, peace, STP, X, XTC Methamphetamie Desoxy: chalk, crak, crystal, fire, glass, go fast, ice, meth, speed Methylpheidate (safe ad effective for treatmet of ADHD) Ritali: JIF, MPH, R-ball, Skippy, the smart drug, vitami R Nicotie Cigarettes, cigars, smokeless tobacco, suff, spit tobacco, bidis, chew II Ijected, swallowed, smoked, sorted II Ijected, smoked, sorted Icreased heart rate, blood pressure, metabolism; feeligs of exhilaratio, eergy, icreased metal alertess I Swallowed Mild halluciogeic effects, icreased tactile sesitivity, empathetic feeligs II Ijected, swallowed, smoked, sorted II Ijected, swallowed, sorted Not scheduled Smoked, sorted, take i suff ad spit tobacco Rapid or irregular heart beat, reduced appetite, weight loss, ervousess, isomia, heart failure Rapid breathig Tremor, loss of coordiatio, irritability, axiousess, restlessess, delirium, paic, paraoia, impulsive behavior, aggressiveess, tolerace, addictio, psychosis Icreased temperature Chest pai, respiratory failure, ausea, abdomial pai, strokes, seizures, headaches, malutritio, paic attacks Aggressio, violece, psychotic behavior Impaired memory ad learig, hyperthermia, cardiac toxicity, real failure, liver toxicity Memory loss, cardiac ad eurological damage, detal decay ad damage, impaired memory ad learig, tolerace, addictio Additioal effects attributable to tobacco exposure: adverse pregacy outcomes, chroic lug disease, cardiovascular disease, stroke, cacer, tolerace, addictio The Natioal Child Traumatic Stress Network www.nctsn.org 35
Table 1. Commo Drugs of Abuse ad Their Effects 27,29,30 (cotiued) Category ad Name Other Compouds Examples of Commercial ad Street Names Aabolic steroids Aadrol, Oxadri, Duraboli, Depo-Testosteroe, Equipoise: roids, juice Dextromethorpha (DXM) Foud i some cough ad cold medicatios, Robotrippig, Robo, Triple C Ihalats Solvets (pait thiers, gasolie, glues), gases (butae, propae, aerosol propellats, itrous oxide), itrites (isoamyl, isobutyl, cyclohexyl), laughig gas, poppers, sappers, whippets DEA Schedule* How Admiistered** III Ijected, swallowed, applied to ski Not scheduled Swallowed Dissociative effects, distorted visual perceptios to complete dissociative effects Not scheduled Ihaled through ose or mouth Itoxicatio Effects Potetial Health Cosequeces Noe Hypertesio, blood clottig ad cholesterol chages, liver cysts ad cacer, kidey cacer, hostility ad aggressio, ace. I adolescets, premature stoppage of growth. I males, prostate cacer, reduced sperm productio, shruke testicles, breast elargemet. I females, mestrual irregularities, developmet of beard ad other masculie characteristics Stimulatio, loss of ihibitio, headache, ausea or vomitig, slurred speech, loss of motor coordiatio, wheezig For effects at higher doses see dissociative aesthetics Ucosciousess, cramps, weight loss, muscle weakess, depressio, memory impairmet, damage to cardiovascular ad ervous systems, sudde death * Schedule I ad II drugs have a high potetial for abuse. They require greater storage security ad have a quota o maufacturig, amog other restrictios. Schedule I drugs are available for research oly ad have o approved medical use; Schedule II drugs are available oly by prescriptio (urefillable) ad require a form for orderig. Schedule III ad IV drugs are available by prescriptio, may have five refills i six moths, ad may be ordered orally. Some Schedule V drugs are available over the couter. **Takig drugs by ijectio ca icrease the risk of ifectio through eedle cotamiatio with staphylococci, HIV, hepatitis, ad other orgaisms. ***Associated with sexual assaults Sources: Natioal Istitute o Drug Abuse. (2007). Commoly Abused Drugs. Bethesda, MD: Natioal Istitute o Drug Abuse, Natioal Istitutes of Health. Retrieved April 28, 2008 from http://www.ida.ih.gov/drugpages/drugsofabuse.html; Saitz, R. (2007). Treatmet of alcohol ad other drug depedece. Liver Traspl, 13(11 Suppl 2), S59-64; Saitz, R. (2005). Cliical practice. Uhealthy alcohol use. N Egl J Med, 352(6), 596-607. Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008 36
Hallucioges Hallucioges are a class of illicit drugs that alter perceptio ad, i some cases, produce euphoria. Hallucioge use is geerally rare i the overall populatio, although higher amog tees ad youg adults. I 2006, reported lifetime use of ay hallucioge was less tha 4% amog 8th graders, approximately 6% amog 10th graders, ad slightly more tha 8% amog 12th graders. Reported lifetime use was eve lower for LSD: 1.6%, 2.7%. ad 3.3% amog 8th, 10th, ad 12th graders, respectively. Ihalats Ihalats are breathable chemical vapors that produce psychoactive effects. Siffig ihalats is ofte referred to as huffig. Ihalats ca also be used by placig the ihalat i a bag ad the siffig ito the bag or puttig the bag over the head ( baggig ). Ihalats are very easy to fid, are ot illegal, ad are less expesive tha most drugs. Accordig to the most recet Natioal Survey o Drug Use ad Health, ihalats are the secod most frequetly used illicit drug amog 12- to 13-year-olds, third amog 14- ad 15- year-olds, ad fourth amog 16- ad 17-year-olds. 2 Most ihalat users start usig before their 16th birthday. 2 MDMA (Ecstasy) MDMA acts as both a stimulat ad a hallucioge. It is amog the most frequetly reported club drugs. I the 2006 Natioal Survey o Drug Use ad Health, approximately 500,000 tees betwee the ages of 12 ad 17 reported usig MDMA withi the last 30 days. 2 Overall use rates icrease with age, from less tha 2% amog 8th graders to more tha 4% i 12th graders. 12 Perceived availability of MDMA also icreases with age: less tha 15% of 8th graders report that it is easy or very easy to obtai, versus approximately 25% of 10th to 12th graders. 12 Methamphetamie Methamphetamie is a addictive stimulat closely related to amphetamie. It has loger lastig ad more toxic effects o the cetral ervous system tha amphetamie, ad is ofte made i small, illegal laboratories called meth labs, usig relatively iexpesive overthe-couter igrediets. Methamphetamie has a high potetial for abuse ad addictio. Methamphetamie users may experiece upredictable mood swigs, as well as tooth decay caused by dry mouth ad excessive tooth gridig. Users commoly have the sesatio that isects are crawlig o their ski, ad may users will scratch themselves raw, causig laceratios o their face ad arms. Durig 2006, 731,000 people age 12 or older i the Uited States reported curret use of methamphetamie, with highest rates of use amog older adolescets ad youg adults. 2 Less tha 2% of 8th ad 10th graders reported usig durig the past year, versus 2.5% of 12th graders. 12 The Natioal Child Traumatic Stress Network www.nctsn.org 37
Nicotie Nicotie is oe of the most frequetly used addictive drugs. I the 2006 Natioal Survey o Drug Use ad Health, 12.9% of 12- to 17-year-olds 3.3 millio tees reported usig some form of tobacco durig the past moth. The umber of curret cigarette smokers icreases with age, from a low of 2% amog 12- to 13-year-olds to a high of 20% amog 16- ad 17-year-olds. 2 Such high prevalece rates may be accouted for by research that suggests adolescets are more susceptible to rapid developmet of icotie addictio, with measurable symptoms of depedece observable after oly a few weeks of casual use. 38 Opioids Opioids are the most powerful kow pai relievers, ad their aalgesic ad euphoric effects have bee kow sice 4000 BC. I the Uited States, heroi use has icreased over the last decade, particularly amog adolescets, although overall heroi use remais low. I 2006, 1.4% of 8th graders, 10th graders, ad 12th graders reported usig heroi at least oce i their lifetime. The same survey foud that less tha 1% of youth i each of these grades reported usig heroi i the year prior to the survey. 12 By cotrast, the abuse of prescriptio paikillers particularly arcotics such as Vicodi, OxyCoti, Percocet, Demerol, ad Darvo has rise dramatically. The overall icidece of emergecy departmet visits related to arcotic abuse has bee icreasig i the U.S. sice the mid-1990s ad has more tha doubled betwee 1994 ad 2001. 39 Accordig to emergecy departmet data, i 2005 early 50,000 youth betwee the ages of 12 ad 17 preseted to the emergecy departmet because of o-medical uses of prescriptio paikillers. Natioally, a estimated 14% of high school seiors have used prescriptio drugs for omedical reasos at least oce i their lifetime, makig prescriptio drugs the secodmost commoly abused illegal substace by teeagers, after marijuaa. 2 Steroids Aabolic steroids were origially developed i the late 1930s to treat hypogoadism (a coditio i which the testes do ot produce sufficiet testosteroe for ormal growth, developmet, ad sexual fuctioig); steroids are legal by prescriptio but are ofte abused. Accordig to the 2006 Moitorig the Future survey, most tee aabolic steroids users are male. 12 Amog male studets, use of steroids durig the past year was reported by approximately 1% of 8th graders ad 10th graders, ad early 2% of 12th graders. Adolescets may be more likely to abuse aabolic steroids if they have experieced muscle dysmorphia, a history of physical or sexual abuse, or a history of egagig i high-risk behaviors. 40 38 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Table 2: Sources of Additioal Iformatio o Specific Drugs of Abuse Drug Class/Drug Source URL Alcohol Caabioids Depressats NIAAA Leadership to Keep Childre Alcohol Free DEA NIDA http://www.iaaa.ih.gov http://www.alcoholfreechildre.org/ http://www.usdoj.gov/dea/cocer/marijuaa.html http://www.drugabuse.gov/pdf/ifofacts/marijuaa06.pdf Rohypol/GHB DEA http://www.usdoj.gov/dea/cocer/ghb_factsheet.html Hallucioges NIDA http://www.drugabuse.gov/pdf/ifofacts/rohypol06.pdf Geeral DEA http://www.usdoj.gov/dea/cocer/hallucioges.html NIDA http://www.drugabuse.gov/pdf/rrhalluc.pdf LSD DEA http://www.usdoj.gov/dea/cocer/lsd.html Ihalats Opioids DEA NIDA http://www.usdoj.gov/dea/cocer/ihalats.html http://www.ida.ih.gov/ifofacts/ihalats.html Heroi DEA http://www.usdoj.gov/dea/cocer/heroi.html NIDA http://www.ida.ih.gov/ifofacts/heroi.html OxyCoti DEA http://www.usdoj.gov/dea/cocer/oxycoti.html Prescriptio Pai Medicatios Stimulats NIDA http://www.ida.ih.gov/ifofacts/paimed.html Cocaie/crack DEA http://www.usdoj.gov/dea/cocer/cocaie.html NIDA http://www.ida.ih.gov/ifofacts/cocaie.html MDMA (Ecstasy) DEA http://www.usdoj.gov/dea/cocer/mdma.html NIDA http://www.ida.ih.gov/ifofacts/ecstasy.html Methamphetamie DEA http://www.usdoj.gov/methawareess/ NIDA http://www.ida.ih.gov/ifofacts/methamphetamie.html Nicotie NIDA http://www.ida.ih.gov/ifofacts/tobacco.html Steroids DEA NIDA http://www.usdoj.gov/dea/cocer/steroids.html http://www.ida.ih.gov/ifofacts/steroids.html DEA=Drug Eforcemet Agecy, NIAAA=Natioal Istitute o Alcohol Abuse ad Alcoholism, NIDA=Natioal Istitute o Drug Abuse The Natioal Child Traumatic Stress Network www.nctsn.org 39
Recogizig Withdrawal Regular users of alcohol ad drugs may evetually develop tolerace ad eed larger amouts of the substace to achieve the same effect. Whe the body adjusts to havig the substace preset, users may feel emotioally ad physically ill whe they discotiue use (withdrawal). Substace use iitially may serve as a meas to fid pleasure or relief from emotioal distress, but oce physiological depedece develops, substace use becomes a way to maage cravigs ad withdrawal symptoms (see Table 3 below). Adolescets exhibitig sigs of withdrawal require medical as well as metal health itervetio to prevet severe (or, i the case of alcohol, potetially fatal) physiological reactios. Table 3. Sigs ad Symptoms of Withdrawal Alcohol Substace Caabioids (marijuaa, hashish) Cocaie (crack) GHB (date rape drug) Ihalats (pait thier, gasolie, glues, laughig gas, poppers, sappers, whippets) Methyleedioxymethamphetamie (MDMA, Ecstasy, X, XTC, etc.) Methamphetamie Nicotie Opioids ad Morphie Derivatives (codeie, fetayl, heroi, morphie, opium, oxycodoe, hydrocodoe) Steroids Withdrawal Symptoms Cravig for alcohol, isomia, vivid dreams, axiety, hypervigilace, agitatio, irritability, loss of appetite (i.e., aorexia), ausea, vomitig, headache, sweatig, tremors, tactile ad auditory halluciatios, seizures, delirium tremes Irritability, axiety ad physical tesio, decreases i appetite ad mood Agitatio/irritability, depressio ad/or axiety, itese cravigs, agry outbursts, lack of motivatio, fatigue, ausea/vomitig, shakig Profuse sweatig, axiety attacks, high blood pressure ad pulse, halluciatio, rapid pulse Had tremors, excess sweatig, costat headaches, ervousess Depressio, axiety, icludig paic attacks, depersoalizatio/ derealizatio, paraoid delusios, sleeplessess Irritability, moderate-to-severe depressio, psychotic reactios, axiety Irritability/aggressio, depressio, poor cocetratio, icreased appetite, light-headedess, restlessess, ight-time awakeigs, cravig Nausea/vomitig, isomia, diarrhea, irritability, loss of appetite, shakig, tremors, paic, chills or profuse sweatig Nausea/vomitig/diarrhea, joit/muscle pai or weakess, weight loss, fever, headache ad fatigue, low blood pressure 40 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Substace Use Problems: Risks ad Protective Factors I order to provide appropriate, effective care to tees with or at risk for substace abuse disorders, it is importat to recogize ad evaluate the various factors that ca ehace or mitigate risk. These factors ca have a profoud impact o how teeagers cope with difficulties, ad o log-term treatmet outcomes. For example, studies have show that adolescets who use positive copig strategies such as good decisio-makig skills, assertiveess, ad cogitive mastery, are less likely to use substaces or egage i deliquet behavior. 41 Coversely, adolescets who egage i avoidat stress copig ad have difficulty i maagig temptatios are more likely to use drugs ad alcohol. 42 Geder is a importat factor i the use ad effects of alcohol ad other drugs of abuse. Boys ted to have opportuities for use earlier i life ad thus ted to iitiate at youger ages. 43 However, oce girls have the opportuity to experimet, they are just as likely as boys are to use. 44 Data from the 2006 Moitorig the Future survey suggest that there are similar treds for substace use amog boys ad girls, but that boys are more likely to cosume marijuaa, steroids, ad smokeless tobacco, whereas girls are more likely to abuse amphetamies ad methamphetamie. 12 Rates of drug use for both geders have bee covergig over the past decade. 45 Research idicates that there are few differeces i the type or amout of substaces that male ad female adolescets use; however, the effects of substaces o their emotioal ad physiological health ca vary. Substace abuse stemmig from traumatic evets ad/ or psychological problems is more commo i females tha i males. Additioally, female substace abusers are more vulerable to some of the physiological effects ad psychological difficulties that ca result from substace use. Research has also show that females have a greater chace of developig eurological problems associated with alcohol abuse. 46 I additio to varyig by geder, adolescet drug ad alcohol use also teds to vary by populatio. For example, rates of curret drug use amog America Idia/Alaska Native Youth are approximately twice the rate amog tees overall. 2 Much research has bee devoted to idetifyig commo risks ad protective factors associated with adolescet substace use. Table 4 outlies some of the factors that are associated with the idividual, family, peer, school, ad commuity domais of a adolescet s life. I geeral, tees are less likely to succumb to exteral pressures toward drug use if they have a strog sese of attachmet to parets who clearly commuicate their disapproval of substace use ad atisocial behaviors 47 49 ad a strog commitmet to doig well i school. 50,51 Coversely, associatig with substace abusig peers 41,48,52 55, ad limited availability of educatioal ad recreatioal opportuities 56 are associated with icreased risk of substace abuse. The Natioal Child Traumatic Stress Network www.nctsn.org 41
Table 4: Risks ad Protective Factors Associated with Adolescet Substace Use Domai Risk Factors Protective Factors Idividual Family Peer School Commuity Aggressive behavior Geetic vulerability Low self-esteem Academic failure Risk-takig propesity Impulsivity Lack of paretal supervisio Family member with a history of alcohol or other drug abuse Lack of clear rules ad cosequeces regardig alcohol ad other drug use Family coflict/abuse Loss of employmet Substace abuse Ties to deviat peers/gag ivolvemet Iappropriate sexual activity amog peers Drug availability Studets lack commitmet or sese of belogig at school High umbers of studets who fail academically at school Parets ad commuity members ot actively ivolved Poverty Alcohol ad other drugs readily available Laws ad ordiaces uclear or icosistetly eforced Norms uclear or ecourage use of drugs Lack of sese of coectio to commuity High uemploymet Youths activities ot moitored Self-cotrol Positive relatioships with adults (e.g., parets, teachers, doctors, law eforcemet officers, etc.) Ivolvemet i extracurricular activities Positive future plas Paretal moitorig Close family relatioships Educatio valued ad ecouraged; parets actively ivolved Clear expectatios ad limits regardig alcohol ad other drug use Shared family resposibilities icludig chores ad decisio makig Nurturig family members who support each other Academic competece Ivolvemet i substace-free activities Negative view of alcohol ad other drug use amog peers Atidrug use policies Positive attitudes toward school ad regular school attedace promoted Goal-settig, academic achievemet, ad positive social developmet ecouraged Tutorig made available Leadership ad decisio-makig opportuities for studets provided Substace-free evets sposored Laws ad ordiaces cosistetly eforced Norms ad policies ecourage ouse of drugs Strog sese of coectio to eighborhood Jobs ad other resources (e.g., housig, healthcare, childcare, commuity service opportuities, recreatio; religious orgaizatios) available 42 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Coclusio Youth services providers should always be aware of the liks betwee adolescet traumatic stress ad substace abuse problems. The traditioal divisio betwee metal health ad substace abuse service systems, the limited availability of evidece-based itegrated approaches, ad the difficulties associated with havig separate sources of fudig available for these types of problems all ca pose may challeges to providig itegrated ad coordiated care. However, a coordiated approach offers the best hope of lastig recovery i tees strugglig with the effects of traumatic stress ad substace abuse. The Natioal Child Traumatic Stress Network www.nctsn.org 43
Refereces 1. Kilpatrick, D. G., Sauders, B. E., ad Smith, D. W. (2003). Youth victimizatio: Prevalece ad implicatios. NIJ research i brief. Washigto, DC: U.S. Departmet of Justice, Office of Justice Programs, Natioal Istitute of Justice. Retrieved April 16, 2008 from http://www.cjrs.gov/ pdffiles1/ij/194972.pdf. 2. Substace Abuse ad Metal Health Services Admiistratio. (2007). Results from the 2006 Natioal Survey o Drug Use ad Health: Natioal fidigs. Rockville, MD: Departmet of Health ad Huma Services. Retrieved April 7, 2008 from http://www.oas.samhsa.gov/sduh/ 2k6sduh/2k6Results.pdf. 3. Kight, J. R., Harris, S. K., Sherritt, L., Va Hook, S., Lawrece, N., Brooks, T., et al. (2007). Prevalece of positive substace abuse scree results amog adolescet primary care patiets. Arch Pediatr Adolesc Med, 161(11), 1035 41. 4. Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), 36 45. 5. Deyki, E. Y., ad Buka, S. L. (1997). Prevalece ad risk factors for posttraumatic stress disorder amog chemically depedet adolescets. Am J Psychiatry, 154(6), 752 7. 6. Clark, D. B., Lesick, L., ad Hegedus, A. M. (1997). Traumas ad other adverse life evets i adolescets with alcohol abuse ad depedece. J Am Acad Child Adolesc Psychiatry, 36(12), 1744 51. 7. Giacoia, R. M., Reiherz, H. Z., Hauf, A. C., Paradis, A. D., Wasserma, M. S., ad Laghammer, D. M. (2000). Comorbidity of substace use ad post-traumatic stress disorders i a commuity sample of adolescets. Am J Orthopsychiatry, 70(2), 253 62. 8. Perkoigg, A., Kessler, R. C., Storz, S., ad Wittche, H. U. (2000). Traumatic evets ad posttraumatic stress disorder i the commuity: Prevalece, risk factors ad comorbidity. Acta Psychiatr Scad, 101(1), 46 59. 9. De Bellis, M. D., Narasimha, A., Thatcher, D. L., Keshava, M. S., Soloff, P., ad Clark, D. B. (2005). Prefrotal cortex, thalamus, ad cerebellar volumes i adolescets ad youg adults with adolescet-oset alcohol use disorders ad comorbid metal disorders. Alcohol Cli Exp Res, 29(9), 1590 600. 10. Zeigler, D. W., Wag, C. C., Yoast, R. A., Dickiso, B. D., McCaffree, M. A., Robiowitz, C. B., et al. (2005). The eurocogitive effects of alcohol o adolescets ad college studets. Prev Med, 40(1), 23 32. 11. Diamod, G., Paichelli-Midel, S. M., Shera, D., Deis, M., Tims, F., ad Ugemack, J. (2006). Psychiatric sydromes i adolescets with marijuaa abuse ad depedecy i outpatiet treatmet. Joural of Child & Adolescet Substace Abuse, 15(4), 37 54. 44 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
12. Johsto, L. D., O Malley, P. M., Bachma, J. G., ad Schuleberg, J. E. (2007). Moitorig the Future: Natioal results o adolescet drug use: Overview of key fidigs, 2006. Bethesda, MD: Natioal Istitute o Drug Abuse. Retrieved April 16, 2008 from http://www.moitorigthefuture. org/pubs/moographs/overview2006.pdf. 13. DeWit, D. J., Adlaf, E. M., Offord, D. R., ad Ogbore, A. C. (2000). Age at first alcohol use: A risk factor for the developmet of alcohol disorders. Am J Psychiatry, 157(5), 745 50. 14. Ka, L., Kiche, S. A., Williams, B. I., Ross, J. G., Lowry, R., Grubaum, J. A., et al. (2000). Youth risk behavior surveillace Uited States, 1999. MMWR CDC Surveill Summ, 49(5), 1 96. 15. Coffey, S. F., Saladi, M. E., Drobes, D. J., Brady, K. T., Dasky, B. S., ad Kilpatrick, D. G. (2002). Trauma ad substace cue reactivity i idividuals with comorbid posttraumatic stress disorder ad cocaie or alcohol depedece. Drug Alcohol Deped, 65(2), 115 27. 16. Saladi, M. E., Drobes, D. J., Coffey, S. F., Dasky, B. S., Brady, K. T., ad Kilpatrick, D. G. (2003). PTSD symptom severity as a predictor of cue-elicited drug cravig i victims of violet crime. Addict Behav, 28(9), 1611 29. 17. Waldrop, A. E., Back, S. E., Verdui, M. L., ad Brady, K. T. (2007). Triggers for cocaie ad alcohol use i the presece ad absece of posttraumatic stress disorder. Addict Behav, 32(3), 634 9. 18. Titus, J. C., Deis, M. L., White, W. L., Scott, C. K., ad Fuk, R. R. (2003). Geder differeces i victimizatio severity ad outcomes amog adolescets treated for substace abuse. Child Maltreat, 8(1), 19 35. 19. Grella, C. E., ad Joshi, V. (2003). Treatmet processes ad outcomes amog adolescets with a history of abuse who are i drug treatmet. Child Maltreat, 8(1), 7 18. 20. Read, J. P., Brow, P. J., ad Kahler, C. W. (2004). Substace use ad posttraumatic stress disorders: Symptom iterplay ad effects o outcome. Addict Behav, 29(8), 1665 72. 21. Brow, P. J. (2000). Outcome i female patiets with both substace use ad post-traumatic stress disorders. Alcoholism Treatmet Quarterly, 13(3), 127 135. 22. Ouimette, P. C., Brow, P. J., ad Najavits, L. M. (1998). Course ad treatmet of patiets with both substace use ad posttraumatic stress disorders. Addict Behav, 23(6), 785 95. 23. Titus, J. C., Godley, S. H., ad White, M. K. (2006). A post-treatmet examiatio of adolescets reasos for startig, quittig, ad cotiuig the use of drugs ad alcohol. Joural of Child & Adolescet Substace Abuse, 16(2), 31 49. 24. Garder, D. (2002). Skid Row high. The Ottawa Citize. April 21, 2002. 25. America Psychiatric Associatio. (2000). Diagostic ad Statistical Maual of Metal Disorders, DSM-IV-TR (Text Revisio) 4th ed. Washigto, DC: America Psychiatric Publishig, Ic. The Natioal Child Traumatic Stress Network www.nctsn.org 45
26. Pollock, N. K., ad Marti, C. S. (1999). Diagostic orphas: Adolescets with alcohol symptoms who do ot qualify for DSM-IV abuse or depedece diagoses. Am J Psychiatry, 156(6), 897 901. 27. Natioal Istitute o Drug Abuse. (2007). Commoly Abused Drugs. Bethesda, MD: Natioal Istitute o Drug Abuse, Natioal Istitutes of Health. Retrieved April 28, 2008 from http://www. ida.ih.gov/drugpages/drugsofabuse.html. 28. Hawkis, J. D., Catalao, R. F., ad Miller, J. Y. (1992). Risk ad protective factors for alcohol ad other drug problems i adolescece ad early adulthood: Implicatios for substace abuse prevetio. Psychol Bull, 112(1), 64 105. 29. Saitz, R. (2007). Treatmet of alcohol ad other drug depedece. Liver Traspl, 13(11 Suppl 2), S59 64. 30. Saitz, R. (2005). Cliical practice. Uhealthy alcohol use. N Egl J Med, 352(6), 596 607. 31. Udry, J. R. E. (2003). The Natioal Logitudial Study of Adolescet Health (Add Health), Waves I & II, 1994 1996; Wave III, 2001 2002. Chapel Hill, NC: Carolia Populatio Ceter, Uiversity of North Carolia at Chapel Hill. Retrieved from http://www.cpc.uc.edu/projects/addhealth. 32. Bartlett, R., Holditch-Davis, D., ad Belyea, M. (2007). Problem behaviors i adolescets. Pediatr Nurs, 33(1), 13 18. 33. Eato, D. K., Ka, L., Kiche, S., Ross, J., Hawkis, J., Harris, W. A., et al. (2006). Youth risk behavior surveillace Uited States, 2005. MMWR Surveill Summ, 55(5), 1 108. 34. Lepere, B., ad Charbit, B. (2002). Cardiovascular complicatios of cocaie use: Recet poits o cocaethylee toxicity. A Med Itere (Paris), 153(3 Suppl), 1S45 6. 35. McCace-Katz, E. F., Koste, T. R., ad Jatlow, P. (1998). Cocurret use of cocaie ad alcohol is more potet ad potetially more toxic tha use of either aloe a multiple-dose study. Biol Psychiatry, 44(4), 250 9. 36. Wilso, L. D., Jeromi, J., Garvey, L., ad Dorbadt, A. (2001). Cocaie, ethaol, ad cocaethylee cardiotoxity i a aimal model of cocaie ad ethaol abuse. Acad Emerg Med, 8(3), 211 22. 37. Drug Abuse Warig Network. (2004). The DAWN Report: Club drugs, 2002 update. Rockville, MD: Substace Abuse ad Metal Health Services Admiistratio, Office of Applied Studies. Retrieved May 1, 2008 from http://dawifo.samhsa.gov/old_daw/pubs_94_02/shortreports/files/ DAWN_tdr_club_drugs02.pdf. 38. Natioal Istitute o Drug Abuse. (2006). NIDA research report series: Cigarettes ad other tobacco products. Rockville, MD: Natioal Istitute o Drug Abuse, US Departmet of Health ad Huma Services, Natioal Istitutes of Health. Retrieved from http://www.ida.ih.gov/pdf/ ifofacts/tobacco06.pdf. 46 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
39. Substace Abuse ad Metal Health Services Admiistratio Office of Applied Studies. (2007). Drug Abuse Warig Network, 2005: Natioal Estimates of Drug-Related Emergecy Departmet Visits. Rockville, MD: U.S. Departmet of Health & Huma Services. Retrieved May 1, 2008 from http://dawifo.samhsa.gov/files/dawn-ed-2005-web.pdf. 40. Natioal Istitute o Drug Abuse. (2007). NIDA Ifo Facts: Steroids (Aabolic-Adrogeic). Rockville, MD: Natioal Istitute o Drug Abuse. Retrieved April 28, 2008, from http://www.ida. ih.gov/pdf/ifofacts/steroids07.pdf. 41. Griffi, K. W., Botvi, G. J., Scheier, L. M., Doyle, M. M., ad Williams, C. (2003). Commo predictors of cigarette smokig, alcohol use, aggressio, ad deliquecy amog ier-city miority youth. Addict Behav, 28(6), 1141 8. 42. Wager, E. F., Myers, M. G., ad McIich, J. L. (1999). Stress-copig ad temptatio-copig as predictors of adolescet substace use. Addict Behav, 24(6), 769 79. 43. Va Ette, M. L., Neumark, Y. D., ad Athoy, J. C. (1999). Male-female differeces i the earliest stages of drug ivolvemet. Addictio, 94(9), 1413 9. 44. Va Ette, M. L., ad Athoy, J. C. (2001). Male-female differeces i trasitios from first drug opportuity to first use: Searchig for subgroup variatio by age, race, regio, ad urba status. J Womes Health Ged Based Med, 10(8), 797 804. 45. Wallace, J. M., Jr., Bachma, J. G., O Malley, P. M., Schuleberg, J. E., Cooper, S. M., ad Johsto, L. D. (2003). Geder ad ethic differeces i smokig, drikig ad illicit drug use amog America 8th, 10th ad 12th grade studets, 1976 2000. Addictio, 98(2), 225 34. 46. Brady, T., ad Ashley, O. E. (2005). Wome i substace abuse treatmet: Results from the Alcohol ad Drug Services Study (ADSS). Rockville, MD: Substace Abuse ad Metal Health Services Admiistratio, Office of Applied Studies. Retrieved May 1, 2008 from http://www.oas.samhsa. gov/wometx/wometx.htm. 47. Kostelecky, K. L. (2005). Paretal attachmet, academic achievemet, life evets ad their relatioship to alcohol ad drug use durig adolescece. Joural of Adolescece, 28, 665 669. 48. Bahr, S. J., Hoffma, J. P., ad Yag, X. (2005). Paretal ad peer iflueces o the risk of adolescet drug use. Joural of Primary Prevetio, 26, 529 551. 49. Herrekohl, T. I., Tajima, E. A., Whitey, S. D., ad Huag, B. (2005). Protectio agaist atisocial behavior i childre exposed to physically abusive disciplie. Joural of Adolescet Health, 36, 457 465. 50. Kumpfer, K. L., ad Turer, C. W. (1990 1991). The social ecology model of adolescet substace abuse: Implicatios for prevetio. The Iteratioal Joural of the Addictios, 25, 435 463. 51. O Doell, J., Hawkis, J. D., ad Abbott, R. D. (1995). Predictig serious deliquecy ad substace use amog aggressive boys. Joural of Cosultig ad Cliical Psychology, 63, 529 437. The Natioal Child Traumatic Stress Network www.nctsn.org 47
52. Kutsche, E., ad Jorda, M. D. (2006). Adolescet alcohol ad caabis use i relatio to peer ad school factors: Results of multilevel aalyses. Drug ad Alcohol Depedece, 84, 167 174. 53. Oettig, E. R., ad Beauvais, F. (1986). Peer cluster theory: Drugs ad the adolescet. Joural of Couselig ad Developmet, 65, 17 22. 54. Brook, J. S., Brook, D. W., Arecibia-Mireles, O., Richter, L., ad Whitema, M. (2001). Risk factors for adolescet marijuaa use across cultures ad across time. Joural of Geetic Psychology, 162, 357 374. 55. Stormshak, E. A., Comeau, C. A., ad Shepard, S. A. (2004). The relative cotributio of siblig deviace ad peer deviace i the predictio of substace use across middle childhood. Joural of Abormal Child Psychology, 32, 635 649. 56. McItosh, J., MacDoald, F., ad McKegaey, N. (2005). The reasos why childre i their pre ad early teeage years do or do ot use illegal drugs. Iteratioal Joural of Drug Policy, 16, 254 261. 48 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems Oe patiet whom I talked to said that she had to lie to be able to get adequate treatmet for both disorders. She was told whe she wet to a PTSD treatmet program that she could t have substace abuse or she would t be able to get treatmet she had to be clea first. 1 Lisa M. Najavits, PhD Assistat Professor of Psychology Harvard Medical School I a ideal world, careful assessmet of traumatic stress ad substace abuse problems ad their effects would be a itegral part of the services provided by all agecies ad idividuals workig with adolescets. Each troubled adolescet would receive a idividualized treatmet pla that took ito cosideratio the liks betwee traumatic stress ad substace abuse, ad treatmet services for each disorder would be itegrated ad coordiated. I reality, although much progress has bee made i the treatmet of both substace abuse ad traumatic stress, these fields have grow idepedetly of each other. As a result, despite the clear lik betwee these two cliical areas, very few attempts have bee made to itegrate the services provided by each group, ad each has developed differet assessmet protocols ad treatmet approaches. Trauma ad Substace Abuse: Myths ad Facts Few treatmet providers are proficiet i the multiple areas of eed amog youth with co-occurrig disorders. Substace abuse providers, for example, may ot have the tools ecessary to idetify the impact of trauma exposure, ad may ot have experiece or traiig i usig trauma-iformed itervetios. Trauma treatmet specialists ad metal health providers i geeral may overlook sigs of icreasig substace abuse. They may ot have a deep uderstadig of the process of addictio, or may ot be familiar with effective strategies to stregthe Myth: Available evidece-based assessmet tools for trauma or substace abuse are too log ad complicated to be implemeted i real cliical practice settigs. Fact: May of the older evidece-based assessmet istrumets do have a reputatio for beig log ad complicated, as well as expesive. However, over the past decade the assessmet field has produced may more assessmet tools that are accessible ad cliicia-friedly i terms of both degree of complexity ad legth. The Natioal Child Traumatic Stress Network www.nctsn.org 49
youths abilities to reduce use or abstai from substaces, ad therefore fail to target these problems as a cetral part of the itervetio. Screeig ad Assessmet of Trauma ad Substace Abuse The sigs ad symptoms of trauma ad substace abuse ca at times be hard to spot, especially amidst the turbulet lives of teeagers today. May of the sigs of both trauma ad substace abuse are similar to problem behaviors that are part of the atural developmetal course of adolescece. For this reaso, it may be hard to recogize these problems early. What is evidet about this group of teeagers is that they ofte experiece a great deal of distress ad eed cosiderable help. Proper assessmet of trauma ad substace abuse is critical i order to provide adequate care. Therefore, all service providers who have regular cotact with adolescets should icorporate screeig ad assessmet istrumets that address trauma ad substace use ito their geeral itake process. Clarissa s Story* Clarissa was oly five years old whe her stepfather started sexually abusig her. She lived i a rural tow where everyoe kew everyoe else. Clarissa s eighbors ad classmates oticed that she always kept to herself ad was usually o edge. She was very scared that her stepfather would hurt her or her mother if she told ayoe about the thigs he did to her whe they were aloe. It was t util Clarissa tured 11 that a school guidace couselor foud out what she was goig through. The Departmet of Social Services was otified, ad Clarissa was removed from her parets home. She wet through several foster placemets before settlig i with a aut ad ucle who lived i a big city i a crowded apartmet with may other relatives. Clarissa started to get ito fights with her cousis ad would ofte refuse to participate i activities with her relatives. Whe she was reprimaded for her failig grades, Clarissa told her aut that she wished she did t exist. Her teachers oticed that Clarissa had trouble maagig her emotios, ofte exhibitig deep sadess, irritability, agitatio, ad/or itese ager. The social worker assiged to the case told her caregivers that he was cocered that Clarissa displayed a lack of regard for her ow safety ad well-beig, as she was gettig ivolved i several risky activities. She was itroduced to marijuaa at school whe she was 13 ad quickly progressed to alcohol use, ad later to OxyCoti. Whe she tured 15, Clarissa told her frieds that she felt worthless ad uimportat. Oe of the ways she respoded to coflict ad tesios i the home was by goig ito her room ad makig superficial cuts o her arms with a razor blade. Her teachers wodered why she wore log sleeves all the time. Clarissa tried to stay away from home as much as possible, spedig a lot of her time with peers i usafe eighborhoods. O her way back from a party with frieds late oe ight, Clarissa was attacked by a group of tees o the trai, but oe of her frieds tried to help her because they were high at the time. She felt betrayed by her frieds, whom she felt had t stood up for her. Clarissa was already failig i school, had lost trust i her frieds ad family, ad did ot feel that she had ayoe to go to. She started cosiderig the possibility of edig her life. * Clarissa is a composite based o real teeage cliets strugglig with traumatic stress ad substace abuse. 50 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Numerous tools are available for the assessmet of traumatic stress ad of substace abuse. Table 1 provides iformatio about some well-validated assessmet resources. A more comprehesive list of trauma assessmet ad screeig tools ca be foud at The Natioal Ceter for Child Traumatic Stress Network s olie Measures Review database (www.nctsn.org/measures). To optimize assessmet accuracy ad esure appropriate treatmet, providers should try to icorporate iformatio from multiple sources. Such a multi-faceted approach will help providers geerate a treatmet pla that is based o complete evaluatio of the sigs ad symptoms of trauma ad substace abuse, as well as the degree of fuctioal impairmet caused by these problems. Treatig Youth with Substace Abuse ad Traumatic Stress There is a dearth of research evaluatig itegrated treatmet approaches for youth with substace abuse ad traumatic stress problems. However, a review of the adolescet substace abuse treatmet literature suggests that traumatized youth do ot do well i treatmet focusig oly o substace use. 7 9 Adolescets who have experieced trauma ad adversity ofte tur to alcohol ad drug use i order to cope with paiful emotios. Youth with both substace abuse ad trauma exposure show more severe ad diverse cliical problems tha do youth who have bee afflicted with oly oe of these types of problems. Whe these problems are treated separately, youth are more likely to relapse ad revert to previous maladaptive copig strategies. Although the research o itegrated treatmet approaches for this populatio is limited, there are guidelies that providers ca follow to better serve this populatio. Give the Trauma ad Substace Abuse: Myths ad Facts Myth: Maualized itervetios are too rigid ad simplistic to address the complex eeds of adolescets sufferig from traumatic stress ad substace abuse problems. Fact: Most of today s evidece-based itervetios are maual-guided rather tha maualized. This distictio reflects a movemet away from scripted, iflexible sessio cotet ad structure ad toward a therapeutic model with flexible sessio cotet ad structure. multiple ad complex eeds of youth with co-occurrig traumatic stress ad substace abuse problems, several ivestigators have proposed the followig recommedatios: 10 13 Iclude assessmets of substace abuse problems ad traumatic stress as part of routie screeig ad assessmet procedures Provide youth ad families with more itese treatmet optios to address the magitude of difficulties ofte experieced by this populatio The Natioal Child Traumatic Stress Network www.nctsn.org 51
Table 1. Validated Assessmet Istrumets for Traumatic Stress ad Substace Abuse Disorders Resource Brief Descriptio Source Adquest 2 This self-report measure allows adolescets to idetify various issues Adolescet Itake Questioaire 2 of cocer, which the therapist ca the use to egage adolescets i discussio o a variety of topics icludig health, sexuality, safety, substace abuse ad frieds. Peake, K., Epstei, I., ad Medeiros, D. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. CANS-TEA Child ad Adolescet Needs ad Stregths-Trauma Exposure ad Adaptatio Versio This cliicia-report istrumet assesses a variety of domais icludig trauma history, traumatic stress symptoms, emotioal ad behavioral regulatio (e.g., axiety, depressio, self-harm, substace abuse), evirometal stability, caregiver fuctioig, attachmet, child stregths ad child fuctioig. For iformatio o the guidelies for use ad developmet cotact Cassadra Kisiel: (312) 503-0459 c-kisiel@orthwester.edu GAIN The GAIN is a series of cliicia-admiistered biopsychosocial assessmets Global Appraisal of Idividual Needs 3 desiged to provide iformatio useful for screeigs, diagosis, treatmet plaig, ad moitorig progress. Domais measured o the GAIN-Iitial (GAIN-I) iclude substace use, physical health, risk behaviors, metal health, eviromet, legal ad vocatioal. Several scales are derived from the GAIN-I, icludig substace problem, traumatic stress, ad victimizatio idices. Deis, M., White, M., Titus, J., ad Usicker, J. (2006). Global Appraisal of Idividual Needs (GAIN): Admiistratio guide for the GAIN ad related measures (Versio 5.4.0). Bloomigto, IL: Chestut Health Systems. Retrieved April 17, 2008, from http://www.chestut.org/li/gai/ GAIN_I/GAIN-I_v_5-4/Idex.html. TSCC Trauma Symptom Checklist for Childre 4 The Trauma Symptom Checklist for Childre is a self-ratig measure used to evaluate both acute ad chroic posttraumatic stress symptoms. Joh Briere, Ph.D. Psychological Assessmet Services http://www3.paric.com/products/product. aspx?productid=tscc UCLA PTSD RI for DSM-IV Uiversity of Califoria Los Ageles Posttraumatic Stress Disorder Reactio Idex 5 This scale is used to scree for exposure to traumatic evets ad DSM-IV PTSD symptoms. Three versios exist: a self-report for school-age childre, a self-report for adolescets, ad a paret report. A abbreviated versio of the UCLA PTSD RI is also available. This ie-item measure provides a quick scree for PTSD symptoms. UCLA Trauma Psychiatry Service 300 UCLA Medical Plaza, Ste 2232 Los Ageles, CA 90095-6968 rpyoos@medet.ucla.edu Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008 52
Resource Brief Descriptio Source Screeig ad Assessig Adolescets for Substace Use Disorders: Treatmet Improvemet Protocol (TIP) Series 31 6 This guide provides iformatio regardig screeig ad assessmet of adolescets with substace use disorders icludig descriptios of specific assessmet istrumets. Substace Abuse ad Metal Health Services Admiistratio. (1999). TIP 31: Screeig ad assessig adolescets for substace use disorders. Rockville, MD U.S. Dept. of Health ad Huma Services. Retrieved April 18, 2008 from http://www.cbi.lm.ih.gov/books/ bv.fcgi?rid=hstat5.chapter.54841. POSIT Problem Orieted Screeig Istrumet for Teeagers This scale was desiged to idetify potetial problems i eed of further assessmet, ad potetial treatmet or service eeds, i 10 areas icludig substace abuse, metal health, physical health, family relatios, peer relatios, educatioal status, vocatioal status, social skills, recreatio, ad aggressive behavior/deliquecy. Natioal Istitute o Drug Abuse (NIDA), Natioal Istitutes of Health Elizabeth Rahdert, Ph.D., 6001 Executive Blvd, Bethesda, MD, 20892 Email: Elizabeth_Rahdert@ih.gov CPSS Child Posttraumatic Stress Disorder Symptom Scale The CPSS was adapted from the adult Posttraumatic Diagostic Scale (PTDS). The CPSS is a self-report measure that assesses the frequecy of all DSM-IV-defied PTSD symptoms ad was also desiged to assess PTSD diagosis. The measure yields a total Symptom Severity score as well as a daily fuctioig ad impairmet score. To obtai the CPSS, cotact: Eda Foa, Ph.D. Ceter for the Treatmet ad Study of Axiety Uiversity of Pe. School of Medicie Departmet of Psychiatry 3535 Market Street, Sixth Floor Philadelphia, PA 19104 CRAFFT The CRAFFT is a six-item measure that assesses adolescet substace use. The measure assesses reasos for drikig or other substace use, risky behavior associated with substace use, peer ad family behavior surroudig substace use, as well as whether the adolescet has ever bee i trouble as a result of his or her substace use. The CRAFFT questios were developed by The Ceter for Adolescet Substace Use Research (CeASAR). To get permissio to make copies of the CRAFFT test, email ifo@crafft.org. The Natioal Child Traumatic Stress Network www.nctsn.org 53
Emphasize maagemet ad reductio of both substace use ad PTSD symptoms early i the recovery process Start relapse prevetio efforts targetig both substace ad trauma-related cues early i treatmet (e.g., problem solvig, drug refusal, ad safety skills ad desesitizatio to trauma remiders) Establish a therapeutic relatioship that is cosistet, trustig, ad collaborative Focus o stress maagemet skills such as relaxatio ad positive self-talk Help cliets develop emotioal regulatio skills such as the idetificatio, expressio, ad modulatio of egative affect Icorporate cogitive restructurig techiques such as recogizig, challegig, ad correctig egative cogitios Provide social skills traiig ad cosider referral to adolescet self-help groups as eeded Provide psychoeducatio for both youth ad their families about trauma ad substace abuse problems, ad ecourage paretal ivolvemet i treatmet with the goal of icreasig paretig skills, commuicatio, ad coflict resolutio Make use of school-based treatmet programs to reach at-risk youth For some adolescets, effective treatmet may also require radom urie drug screes to moitor abstiece from drugs or alcohol, ad adjuct psychopharmacologic treatmet to relieve acute symptoms of drug withdrawal or traumatic stress. Cosiderig Culture ad Cotext It is importat to remember that adolescets with co-occurrig traumatic stress ad substace abuse ca belog to ay umber of cultural commuities. Cultural backgroud goes beyod ethicity ad race, ad ca iclude idetities associated with disability, socioecoomic status, sexual orietatio, homelessess, immigratio/refugee status, spiritual or religious groups, foster care, ad others. Providig services that are culturally competet lays the foudatio for establishig a safe, respectful eviromet that tells adolescets ad families that they are respected ad valued. Culturally competet service providers are specially traied i ad are aware ad respectful of the values, beliefs, traditios, customs, ad paretig styles of the youths ad families they serve. Key characteristics of culturally competet care iclude: 14,15 54 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Uderstadig ad respect for diverse worldviews The presece of staff who reflect the cultural diversity of the commuity served Use of iterpreter services or, preferably, biligual providers for cliets with limited Eglish proficiecy Ogoig cultural competecy educatio ad traiig for staff Use of liguistically ad culturally appropriate educatioal materials A physical eviromet that reflects the diversity of commuities served, icludig artwork, accessibility, ad materials Culturally relevat assessmets Workig withi the family s defied structure (e.g., the family may iclude elders or other relatives) Uderstadig ad respect for the social mores related to iteractios by geder ad age Whatever the cultural or social backgroud of the adolescet, it is importat to adopt a stregth-based approach that capitalizes o idividual, family, ad cotextual factors that ca serve to promote healthy copig ad adjustmet. These factors ca iclude a family s religious or spiritual beliefs, exteded families ad available social support etworks, positive role models i the commuity, opportuities for participatio i positive recreatioal, artistic, or academic activities, ad adolescets built-i capacity to grow ad flourish i the midst of adversity. Special Treatmet Cosideratios Whe Workig with Homeless Youth Give the high rates of trauma exposure ad substace use amog homeless youth 16,17, it is particularly importat to be aware of treatmet cosideratios specific to this populatio. 18 The lives of homeless youth are ofte characterized by high levels of persoal ad evirometal istability, icludig ucertaity about basic eeds such as havig access to a meal or a place to sleep. Eve the most elemetal therapeutic processes, such as egagig youth i treatmet, ad attemptig to develop a trustig relatioship betwee the adolescet ad service providers, ca be quite challegig. I additio, it might also be difficult to safely coduct more ivolved therapeutic strategies such as exposure-based treatmet, particularly whe access to evirometal supports ad the possibility of regular attedace is limited. For this reaso, it is importat to prioritize homeless youths immediate ad primary eeds, ad to provide access to complemetary services that address additioal psychosocial eeds. Brief itervetios employig motivatioal iterviewig 19 as well as skill-based cogitive-behavioral approaches appear to be best suited for this populatio. These approaches are described i the sectios that follow. The Natioal Child Traumatic Stress Network www.nctsn.org 55
Itegrated Treatmet Approaches for Adolescets Although there is strog evidece to support the eed for itegrated treatmet models, there are few treatmet models available that address both trauma ad substace abuse problems amog adolescets. Some of these models are highlighted below: Seekig Safety Seekig Safety 20,21 is a maualized treatmet for co-occurrig substace abuse disorder ad PTSD i adults developed by Lisa Najavits, PhD at Harvard Medical School/McLea Hospital. The focus of Seekig Safety is to elimiate or reduce risky or dagerous behaviors, situatios, or symptoms, icludig substace abuse, dagerous relatioships, severe psychological symptoms, ad self-harm behaviors. The treatmet model posits a meaigful coectio betwee past trauma ad curret self-abusig behaviors, ad it utilizes 25 topics or modules divided amog cogitive, behavioral, ad iterpersoal themes that ca be selected based o the idividual s eed. 20 Applyig Seekig Safety to a adolescet populatio ivolves mior modificatios of the origial maual to suit the developmetal level of adolescets. Modificatios iclude offerig the iformatio verbally if a adolescet refuses to read the hadouts, usig hypothetical third-perso examples to discuss situatios, limited paretal ivolvemet with the adolescet s permissio, ad discussig details of the trauma oly if the adolescet chooses to do so. 21 I radomized cliical trials, Seekig Safety has show sigificat improvemets over treatmet as usual i both icarcerated 22 ad commuity 23 adult females. Whe implemeted with adolescet girls, Seekig Safety showed greater improvemets tha did treatmet as usual i substace abuse domais, PTSD cogitios, ad levels of deviat behavior, as well as aorexia ad somatizatio ratigs. 21 Risk Reductio through Family Therapy (RRFT) RRFT is a itervetio developed to reduce the risk of substace abuse ad other highrisk behaviors, revictimizatio, ad trauma-related psychopathology i adolescets who have bee sexually assaulted. RRFT itegrates several existig empirically supported treatmets, such as Trauma Focused-Cogitive Behavioral Therapy, Multisystemic Therapy, ad other risk reductio programs for revictimizatio ad risky sexual behaviors. Adolescets participatig i this treatmet may be heterogeeous with regard to symptom expressio; thus a cliical pathways approach is take i the RRFT maual. The maual cosists of six primary compoets: Psychoeducatio, Copig, Substace Abuse, PTSD, Sexual Educatio ad Decisio Makig, ad Sexual Revictimizatio ad Risk Reductio. A pilot trial of RRFT is curretly uderway. 24 56 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Trauma Systems Therapy for Substace Abuse i Adolescece TST-SA 25 applies Trauma Systems Therapy (TST) 26 to the problem of adolescet traumatic stress ad substace abuse, utilizig existig promisig practices for treatig adolescet substace abuse, traumatic stress, ad emotioal regulatio problems. The applicatio of TST to adolescet substace abuse icludes several modificatios to the existig itervetio. Motivatioal iterviewig strategies are icluded to egage youth i treatmet ad to establish a commitmet to chage. Additioally, parets ad tees are provided with psychoeducatio about substace abuse ad its iteractio with symptoms of traumatic stress. This approach icorporates a strog emphasis o behavior maagemet strategies for parets to utilize i order to icrease moitorig ad appropriate limit settig, particularly aroud drug use ad high-risk behaviors. The model also icorporates substace abuse treatmet strategies such as paret-tee commuicatio skills, recogizig ad plaig for substace abuse cues or trigger situatios, cogitive ad iterpersoal problemsolvig techiques, ad other relapse-prevetio techiques. Careful attetio is give to the coectio betwee substace abuse ad the egative emotios associated with the experiece of trauma. I additio, youth lear skills to maage emotios, behavior, ad substace abuse cravigs. A ope trial of TST-SA is curretly uderway. Trauma-Focused Itervetios for Adolescets Several successful treatmet programs have bee developed or adapted from adult models to help adolescets process traumatic memories ad maage distressig feeligs, thoughts, ad behaviors. These empirically supported mauals are described i detail below. Trauma-Focused Cogitive Behavioral Therapy (TF-CBT) TF-CBT is a short-term idividual treatmet that ivolves sessios with the youth ad parets as well as paret-oly sessios. TF-CBT is for youth aged 4 to 18 who have sigificat behavioral or emotioal problems related to traumatic life evets, eve if they do ot meet the full diagostic criteria for PTSD. 27 Utilizig weekly cliic-based, idividual treatmet, TF- CBT helps youth process traumatic memories ad maage distressig feeligs, thoughts, ad behaviors. TF-CBT also uses joit paret ad youth sessios to provide paretig ad family commuicatio skills traiig. Compared to a odirective supportive therapy, sexually abused youth aged 8 to 15 treated with TF-CBT demostrated sigificatly greater improvemet o levels of axiety, depressio, ad dissociatio at six-moth follow up. Youth treated with TF-CBT also showed a sigificat improvemet i PTSD symptoms ad dissociatio at 12-moth follow-up. 28 Olie traiig for TF-CBT is curretly available at http://tfcbt.musc.edu. The Natioal Child Traumatic Stress Network www.nctsn.org 57
Cogitive-Behavioral Itervetio for Trauma i Schools (CBITS) CBITS is a itervetio program for youth exposed to traumatic evets, which ca be delivered o school campuses by school-based cliicias. It was developed i collaboratio with the Los Ageles Uified School District for studets ad their families. CBITS utilizes idividual ad group sessios to teach youth relaxatio techiques ad social problemsolvig skills, as well as how to challege upsettig thoughts ad process traumatic memories. CBITS also icludes a paret ad teacher psychoeducatio compoet. I a radomized cotrolled trial comparig this itervetio with a three-moth wait-list coditio, those receivig CBITS reported lower PTSD, depressio, ad psychological dysfuctio symptom scores after three moths. 29 Structured Psychotherapy for Adolescets Respodig to Chroic Stress (SPARCS) SPARCS is a group itervetio specifically desiged to address the eeds of chroically traumatized adolescets who may still be livig with ogoig stress, are curretly experiecig stress, ad are experiecig problems i areas of fuctioig such as impulsivity, affect regulatio, self-perceptio, dissociatio, relatios with others, somatizatio, ad struggles with their ow purpose ad meaig i life. The 16-sessio program ca be provided i a variety of settigs, icludig school, outpatiet, ad residetial, ad icorporates compoets of three existig itervetios. These compoets iclude midfuless, iterpersoal, ad emotio regulatio skills derived from Dialectical Behavior Therapy for Adolescets 30, problem-solvig skills from Trauma Adaptive Recovery Group Educatio ad Therapy (TARGET) 31, ad social support ehacemet ad skills for plaig for the future from the School Based Trauma/Grief Group Psychotherapy. 32 Trauma Systems Therapy (TST) Developed at the Ceter for Medical ad Refugee Trauma at Bosto Medical Ceter 33, TST ackowledges the complexity of the social eviromet that surrouds a idividual, ad the ways i which disruptios i oe area of the social ecology may create problems i aother. The social ecological model of huma behavior i which the cotexts of family, school, peer group, eighborhood, ad culture all iteract with a idividual s developmet 34 is applied to youth exposed to traumatic stress, who ofte live i eviromets characterized by child maltreatmet, paretal illess ad substace abuse, ad domestic violece. TST itervetios are desiged to work i two dimesios: strategies that operate through ad withi the social eviromet to promote chage, ad strategies that ehace the idividual s capacity to self-regulate their emotios. The TST model ivolves choosig a series of itervetios that correspod to the fit betwee the traumatized youth s ow emotioal regulatio capacities ad the ability of the youth s social eviromet ad system-of-care to help him or her maage emotios or to protect him or her from threat. TST begis with a assessmet of both the youth s 58 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
level of emotioal regulatio ad the degree of evirometal stability i the youth s world. Prelimiary data from a ope trial of TST demostrate a sigificat reductio of trauma symptoms ad icreased emotioal regulatio skills amog youth, as well as a more stable social eviromet, after three moths of treatmet. 33 A cotrolled trial of TST is curretly i progress. Substace Abuse Itervetios for Adolescets Several successful treatmet programs have bee developed or adapted from adult models i order to focus o the uique cogitive chages, developmetal trasitios, ad peer ad family issues that typically occur durig adolescece. Treatmets for adolescets icorporate these developmetal cosideratios i differet ways. Described below are the curret approaches utilized withi various types of itervetios, as well as empirically supported treatmet mauals available for substace-abusig adolescets i a outpatiet settig. Brief Itervetios Itervetios that are of shorter duratio ad less extesive tha more traditioal substace abuse treatmets ca be appealig to cosumers, service providers, ad maaged care providers. These treatmets have the overarchig goal of addressig ad ehacig the motivatio to chage problem behaviors, as well as providig skills to meet these goals. Geerally, brief itervetios cotai betwee oe ad five sessios ad ca be delivered virtually aywhere by a variety of professioals. Two of the most widely used brief itervetio approaches iclude cogitive-behavioral therapy ad motivatioal iterviewig. Cogitive-Behavioral Therapy (CBT) Cogitive-behavioral models, based o social learig theory, coceptualize substace use ad related problems as leared behaviors that are iitiated ad maitaied i the cotext of evirometal factors. This treatmet approach icorporates the priciple that uwated behavior ca be chaged by clear demostratio of the desired behavior, ad cosistet reward of icremetal steps toward achievig it. CBT may icorporate emotioal exposure to iteral cues i order to ioculate idividuals agaist future relapse. Therapeutic activities iclude completig specific assigmets, rehearsig desired behaviors, experiecig imagied ad real exposures to emotios ad situatios to ehace emotioal tolerace, ad recordig ad reviewig progress. Praise ad privileges are give for meetig assiged goals. This model ca be implemeted via idividual sessios as well as withi a group treatmet approach. Accordig to research studies, idividual ad group CBT ca help adolescets become drug free ad icrease their ability to remai drug free after treatmet eds. The Natioal Child Traumatic Stress Network www.nctsn.org 59
Motivatioal Iterviewig (MI) This treatmet approach ivolves usig specific iterviewig ad discussio techiques to ehace the idividual s motivatio to chage their problematic behavior. MI pertais to both a style of relatig to the cliet as well as to the therapeutic techiques that facilitate the process. Its mai teets iclude: 1) takig a empathetic, ojudgmetal stace while listeig reflectively, 2) developig discrepacy, rollig with the cliet s resistace, ad avoidig argumetatio, ad 3) supportig self-efficacy for chage. Motivatioal iterviewig has bee foud to sigificatly reduce drikig ad drivig i tees with iitial low motivatio to chage. Motivatioal Ehacemet Therapy ad Cogitive Behavioral Therapy for Caabis Users The Caabis Youth Treatmet Collaborative developed a empirically tested five-sessio treatmet maual that combies the motivatioal iterviewig treatmet approach ad cogitive behavioral therapy. The treatmet cosists of two iitial idividual sessios desiged to icrease the adolescet s motivatio to deal with their drug use, followed by three group CBT sessios desiged to help adolescets develop skills useful for stoppig or reducig marijuaa use. This brief therapy has bee prove effective i reducig marijuaa use i adolescets. There is also a optio for therapists to utilize a additioal sevesessio CBT compoet to provide additioal skills traiig. The complete mauals for both the brief five-sessio treatmet as well as the exteded treatmet with 12 CBT sessios are available at: http://www.chestut.org/li/cyt/products/. Family-Based Therapies Family-based treatmet is the most thoroughly studied treatmet modality for adolescet substace use. Cosiderable research uderscores the ifluetial role played by family relatioships ad family eviromets i the developmet of adolescet alcohol ad drug problems. The more thoroughly researched family approaches are outlied below. Multidimesioal Family Therapy (MDFT) This is a outpatiet family-based drug abuse treatmet for teeagers. MDFT views adolescet drug use i terms of a etwork of iflueces (made up of idividual, family, peer, ad commuity) ad utilizes this etwork to reduce uwated behavior ad icrease desirable behavior i differet settigs. Treatmet icludes idividual ad family sessios held i the cliic, i the home, or with family members at family court, school, or other commuity locatios. Multidimesioal Family Therapy for Adolescet Caabis Users This maual-based treatmet itegrates family therapy ad substace-abuse treatmet ad has bee prove effective with a caabis-usig adolescet populatio. The treatmet 60 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
focuses o the adolescet ad the parets, as well as o patters of family iteractio, both withi the family ad with other systems such as schools, courts, ad other support etworks. The maual is available at: http://www.chestut.org/li/cyt/products/. Brief Strategic Family Therapy (BSFT) This itervetio is used to treat adolescet drug use that occurs with other problem behaviors such as coduct problems, oppositioal behavior, deliquecy, associatig with atisocial peers, aggressive ad violet behavior, impaired family fuctioig, ad risky sexual behavior. BSFT is a family systems approach based o the premise that the drug-usig adolescet is displayig problem behaviors that are idicative of what is goig o withi the family system. BSFT holds the priciple that patters of iteractio i the family ifluece the behavior of the adolescet. The role of the BFST couselor is to pla itervetios that carefully target ad provide practical ways to chage the patters of iteractio (e.g., failig to establish rules ad cosequeces) that are directly liked to the adolescet s drug use. Brief Strategic Family Therapy for Adolescet Drug Abuse The Natioal Istitute of Drug Abuse has made a olie versio of the BSFT maual available at: http://www.ida.ih.gov/txmauals/bsft/bsft2.html. Multisystemic Therapy (MST) This treatmet approach targets multiple systems that cotribute to the developmet of deliquet behavior i adolescets, icludig family, peers, school, ad the eighborhood. MST is tailored to each idividual s eeds ad may iclude idividual, family or marital therapy, peer group couselig, ad case maagemet. Services are provided withi the adolescet s atural eviromet, such as the home or school, which facilitates both the applicatio to ad the maiteace of treatmet gais i the real world. MST also helps adolescets ad their families develop social support etworks through such meas as makig coectios with exteded family or religious commuities. MST has bee show to sigificatly reduce adolescet drug use durig treatmet ad for at least six moths after treatmet. More iformatio regardig the MST approach is available olie at: http://www. mstservices.com/text/treatmet.html. Commuity-Based Itervetios Commuity-based itervetios provide metal health services withi the ormal eviromet of a idividual or populatio. Service sites may iclude the home, school, or other eighborhood settigs, which icreases access to care for uderserved populatios, particularly for idividuals who do ot have the resources to travel to specialty cliics. Because teeagers are iflueced by may aspects of their eviromet (such as family, The Natioal Child Traumatic Stress Network www.nctsn.org 61
peers, teachers, cultural orms), commuity itervetios ofte take place across a umber of settigs to maximize the social ecological validity of the itervetio ad to support practice of skills leared i treatmet. Commuity itervetios may target specific idividuals who have already begu to display high-risk behaviors such as drug ad alcohol abuse, deliquet behavior, ad usafe sexual behaviors or they may target select groups who may be at greater risk for egagig i these behaviors such as athletes who are at greater risk for steroid use ad teeagers who live i a commuity with a lot of gag violece. I may commuity itervetios, a social support compoet for adolescets ad their parets is importat ad may decrease the likelihood of relapse. Three itervetios for adolescets displayig high-risk behaviors, which iclude a commuity-based compoet, are described below: Adolescet Commuity Reiforcemet Approach (ACRA) This treatmet approach recogizes the powerful role the eviromet plays i ecouragig or discouragig drug use. It attempts to rearrage evirometal cotigecies to make substace use a less rewardig behavior. ACRA bleds a operat model with a social systems approach to teach tees ew ways of hadlig life s problems without drugs or alcohol. It focuses o the iterpersoal iteractio betwee idividuals ad those i their commuities. ACRA teaches adolescets whe ad where to implemet the techiques leared i treatmet as well as how to build o positive reiforcemets ad use existig commuity resources that will support positive chage. ACRA also guides adolescets i developig a positive support system. The Adolescet Commuity Reiforcemet Approach for Adolescet Caabis Users This 14-sessio treatmet model cosists of 10 idividual sessios with the youth, two sessios with oe or two caregivers, ad two sessios with both the youth ad caregiver(s). This treatmet uses fuctioal aalyses to idetify triggers for drug use as well as other prosocial activities that compete with drug use, skills traiig i a variety of areas icludig relapse prevetio, ad the Happiess scale to moitor progress. The maual is available olie at: http://www.chestut.org/li/cyt/products/acra_cyt_v4.pdf. Studet Assistace Program (SAP) This substace abuse itervetio is a school-based program for idetifyig, assessig, ad treatig studets with alcohol ad/or substace abuse problems. There are more tha 1,500 studet assistace programs i the coutry; however, these programs vary widely. For example, some SAPs refer all idetified alcohol ad drug users to cliics for treatmet, while other programs brig traied cliicias to the school to provide itervetio o-site. The most effective school-based substace abuse itervetios are empirically guided ad maualized, ad focus o providig psychoeducatio ad skills traiig to adolescets. I 62 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
additio, effective programs eforce school-wide policies regardig alcohol ad drug use. Prelimiary aalyses of certai programs suggest that adolescets who participate i SAPs ca show reduced substace use. The Residetial Studet Assistace Program (RASP) RASP is a residetial substace abuse prevetio program for high-risk adolescets, modeled after the Westchester Studet Assistace Model. More iformatio is available at: http://www.sascorp.org/residesap.htm or http://www.sascorp.org. Psychiatric Care ad Psychotropic Medicatio The commoalities betwee posttraumatic stress disorder ad substace use disorders suggest that pharmacotherapies targetig a specific eurotrasmitter or euroedocrie system might be particularly beeficial. 35 A importat goal of pharmacotherapies for this populatio is to decrease PTSD symptoms so that the adolescet does ot utilize substaces of abuse i order to distace himself/herself from the traumatic evet. Some atidepressats have bee show to improve the itrusive ad depressive symptoms of PTSD. Furthermore, stadard pharmacotherapeutic treatmets for substace abuse disorders may be useful for idividuals with co-occurrig PTSD. Itegratio of pharmacotherapy ad psychotherapy may be beeficial i order to maximize treatmet outcomes i this populatio. For More Iformatio o Treatmet Optios for Substace Abuse, see Substace Abuse ad Metal Health Services Admiistratio (SAMHSA) Model Programs http://modelprograms.samhsa.gov/ Society for Adolescet Substace Abuse Treatmet Effectiveess (SASATE) http://www.chestut.org/li/apss/sasate/ The Natioal Istitute of Drug Abuse (NIDA) http://www.ida.ih.gov The Natioal Istitute o Alcohol Abuse ad Alcoholism (NIAAA) http://www.iaaa.ih.gov The Natioal Child Traumatic Stress Network www.nctsn.org 63
Refereces 1. Cavalcade Productios. (1998). A video series o substace abuse treatmet: Trauma ad substace abuse. Nevada City, CA: Cavalcade Productios, Ic. Retrieved April 12, 2008, from http://www.cavalcadeproductios.com/substace-abuse-treatmet.html. 2. Peake, K., Epstei, I., ad Medeiros, D. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. 3. Deis, M., White, M., Titus, J., ad Usicker, J. (2006). Global Appraisal of Idividual Needs (GAIN): Admiistratio guide for the GAIN ad related measures (Versio 5.4.0). Bloomigto, IL: Chestut Health Systems. Retrieved April 17, 2008, from http://www.chestut.org/li/gai/gain_ I/GAIN-I_v_5-4/Idex.html. 4. Briere, J., Johso, K., Bissada, A., Damo, L., Crouch, J., Gil, E., et al. (2001). The Trauma Symptom Checklist for Youg Childre (TSCYC): Reliability ad associatio with abuse exposure i a multi-site study. Child Abuse Negl, 25(8), 1001 14. 5. Steiberg, A. M., Brymer, M. J., Decker, K. B., ad Pyoos, R. S. (2004). The Uiversity of Califoria at Los Ageles Post-traumatic Stress Disorder Reactio Idex. Curr Psychiatry Rep, 6(2), 96 100. 6. Substace Abuse ad Metal Health Services Admiistratio. (1999). TIP 31: Screeig ad assessig adolescets for substace use disorders. Rockville, MD U.S. Dept. of Health ad Huma Services. Retrieved April 18, 2008 from http://www.cbi.lm.ih.gov/books/ bv.fcgi?rid=hstat5.chapter.54841. 7. Fuk, R. R., McDermeit, M., Godley, S. H., ad Adams, L. (2003). Maltreatmet issues by level of adolescet substace abuse treatmet: The extet of the problem at itake ad relatioship to early outcomes. Child Maltreat, 8(1), 36 45. 8. Titus, J. C., Deis, M. L., White, W. L., Scott, C. K., ad Fuk, R. R. (2003). Geder differeces i victimizatio severity ad outcomes amog adolescets treated for substace abuse. Child Maltreat, 8(1), 19 35. 9. Grella, C. E., ad Joshi, V. (2003). Treatmet processes ad outcomes amog adolescets with a history of abuse who are i drug treatmet. Child Maltreat, 8(1), 7 18. 10. Back, S., Dasky, B. S., Coffey, S. F., Saladi, M. E., Soe, S., ad Brady, K. T. (2000). Cocaie depedece with ad without post-traumatic stress disorder: A compariso of substace use, trauma history ad psychiatric comorbidity. Am J Addict, 9(1), 51 62. 11. Giacoia, R. M., Reiherz, H. Z., Paradis, A. D., ad Stashwick, C. K. (2003). Comorbidity of substace use disorders ad posttraumatic stress disorder i adolescets. I Oimette, P., ad Brow, P. J. (Eds.), Trauma ad substace abuse: Causes, cosequeces, ad treatmet of comorbid disorders (pp. 227 242). Washigto, DC: America Psychological Associatio. 12. Oimette, P., & Brow, P. J. (Eds.). (2003). Trauma ad substace abuse: Causes, cosequeces, ad treatmet of comorbid disorders. Washigto, DC: America Psychological Associatio. 64 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
13. Cohe, J. A., Maario, A. P., Zhitova, A. C., ad Capoe, M. E. (2003). Treatig child abuserelated posttraumatic stress ad comorbid substace abuse i adolescets. Child Abuse Negl, 27(12), 1345 65. 14. Aderso, L. M., Scrimshaw, S. C., Fullilove, M. T., Fieldig, J. E., ad Normad, J. (2003). Culturally competet healthcare systems. A systematic review. Am J Prev Med, 24(3 Suppl), 68 79. 15. Cross, T., Bazro, B., Deis, K., ad Isaacs, M. (1999). Toward a culturally competet system of care. Washigto, DC: Georgetow Uiversity Child Developmet Ceter. 16. Gwadz, M. V., Nish, D., Leoard, N. R., ad Strauss, S. M. (2007). Geder differeces i traumatic evets ad rates of post-traumatic stress disorder amog homeless youth. J Adolesc, 30(1), 117 29. 17. Johso, K. D., Whitbeck, L. B., ad Hoyt, D. R. (2005). Substace abuse disorders amog homeless ad ruaway adolescets. Joural of Drug Issues, 35(4), 799 816. 18. Thompso, S. J., McMaus, H., ad Voss, T. (2006). Posttraumatic Stress Disorder ad substace abuse amog youth who are homeless: Treatmet issues ad implicatios. Brief Treatmet ad Crisis Itervetio 6(3), 206 217. 19. Baer, J. S., Peterso, P. L., ad Wells, E. A. (2004). Ratioale ad desig of a brief substace use itervetio for homeless adolescets. Addictio Research ad Theory, 12(4), 317 334. 20. Najavits, L. (2001). Seekig Safety: A treatmet maual for PTSD ad substace abuse. New York, NY: The Guilford Press. 21. Najavits, L. M., Gallop, R.J., ad Weiss, R. D. (2006). Seekig safety therapy for adolescet girls with PTSD ad substace use disorder: A radomized cotrolled trial. J Behav Health Serv Res, 33(4), 453 63. 22. Zlotick, C., Najavits, L. M., Rohseow, D. J., ad Johso, D. M. (2003). A cogitive-behavioral treatmet for icarcerated wome with substace abuse disorder ad posttraumatic stress disorder: Fidigs from a pilot study. J Subst Abuse Treat, 25(2), 99 105. 23. Hie, D. A., Cohe, L. R., Miele, G. M., Litt, L. C., ad Capstick, C. (2004). Promisig treatmets for wome with comorbid PTSD ad substace use disorders. Am J Psychiatry, 161(8), 1426 32. 24. Daielso, C. (2006). Risk Reductio Through Family Therapy treatmet maual. Charlesto, SC: Natioal Crime Victims Research & Treatmet Ceter. 25. Suarez, L., Saxe, G., Ehrereich, J., ad Barlow, D. (2006). Trauma Systems Therapy for Substace Abuse i Adolescece (Upublished). Bosto, MA: Ceter for Axiety ad Related Disorders, Bosto Uiversity. 26. Saxe, G., Ellis, B., ad Kaplow, J. (2006). Collaborative treatmet of traumatized childre ad tees: The trauma systems therapy approach, 1st ed. New York, NY: The Guilford Press. The Natioal Child Traumatic Stress Network www.nctsn.org 65
27. Cohe, J., Maario, A., Berlier, L., ad Debliger, E. (2000). Trauma-focused cogitive behavioral therapy for childre ad adolescets: A empirical update. Joural of Iterpersoal Violece, 15, 1202 1223. 28. Cohe, J. A., Maario, A. P., ad Kudse, K. (2005). Treatig sexually abused childre: 1 year follow-up of a radomized cotrolled trial. Child Abuse Negl, 29(2), 135 45. 29. Stei, B. D., Jaycox, L. H., Kataoka, S. H., Wog, M., Tu, W., Elliott, M. N., et al. (2003). A metal health itervetio for schoolchildre exposed to violece: A radomized cotrolled trial. JAMA, 290(5), 603 11. 30. Wager, E., Rathus, J., ad Miller, A. (2006). Midfuless skills i dialectical behavior therapy. I Baer, R. (Ed.), Midfuless-based treatmet approaches: Cliicia s guide to evidece base ad applicatios. Burligto, MA: Elsevier, Ic. 31. Ford, J. D., ad Russo, E. (2006). Trauma-focused, preset-cetered, emotioal self-regulatio approach to itegrated treatmet for posttraumatic stress ad addictio: Trauma Adaptive Recovery Group Educatio ad Therapy (TARGET). Am J Psychother, 60(4), 335 55. 32. Laye, C., Pyoos, R., Saltzma, W., Arslaagic, B., Savjak, N., ad Popovic, T. (2001). Trauma/ grief focused group psychotherapy: School based postwar itervetio with traumatized Bosia adolescets. Group Dyamics: Theory, Research, ad Practice, 5, 277 290. 33. Saxe, G., Ellis, H., Fogler, J., Hase, S., ad Sorki, B. (2005). Comprehesive care for traumatized childre: A ope trial examies treatmet usig Trauma Systems Therapy. Psychiatric Aals, 35(5), 443 448. 34. Brofebreer, U. (1979). Cotexts of child rearig: Problems ad prospects. America Psychologist, 34, 844 850. 35. Brady, K., Back, S., ad Coffey, S. (2004). Substace abuse ad posttraumatic stress disorder. Curret Directios i Psychological Sciece, 13, 206 209. 66 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Egagig Adolescets i Treatmet Assistig adolescets to reflect o their curret situatio ad experieces ad helpig them to evisio a positive future may promote motivatio to chage, especially amog those who have bee there, doe that ad are willig to look ahead. Jaet C. Titus, Susa H. Godley, ad Michelle K. White A Post-Treatmet Examiatio of Adolescets Reasos for Startig, Quittig, ad Cotiuig the Use of Drugs ad Alcohol To successfully idetify ad treat adolescets with traumatic stress ad substace abuse, cliicias must cotiually explore better ways to ecourage their participatio i treatmet. This is particularly importat i metal health ad substace abuse service systems, where these tees preset a uique set of challeges. Adolescets with both traumatic stress ad substace abuse ofte have complex histories ad umerous additioal problems that make them particularly difficult to treat. Although empirically-based treatmet itervetios offer adolescets a good chace of success i overcomig a variety of psychological problems, may youth fail to obtai treatmet, ad those who eter treatmet ofte termiate prematurely. Cliicias who work with adolescets ecouter a series of challeges whe tryig to egage youth who have histories of traumatic stress ad substace abuse. Most adolescets do ot eter treatmet volutarily ad are ofte apprehesive about the process. Furthermore, substace abusig adolescets, much like their adult couterparts, ofte have a hard time makig positive chages i their use patters. To provide effective services, these challeges ad barriers must be addressed. Idetifyig ad Ecouragig Youth to Seek Help Tees ted ot to seek out professioal help for a variety of reasos. They may ot believe they eed help. They ofte are ot aware of the rage of services available. They may be cocered about the stigma of obtaiig metal health services or hesitat to seek out a adult for assistace. Researchers ad cliicias have developed a variety of ways to overcome these iitial hurdles. The Natioal Child Traumatic Stress Network www.nctsn.org 67
Offer multiple types of assistace Tees are far more likely to seek assistace for problems with employmet, relatioships, ad family tha they are for metal health or emotioal issues like posttraumatic stress or substace abuse. Agecies that ca act as resource ceters ad offer a variety of services that might be sought by tees themselves are more likely to be i a positio to help a adolescet with multiple problems, icludig those related to trauma ad/or substace abuse. Idetify youth i schools Schools are a key access poit for early idetificatio of at-risk youth. Outreach ca be coducted i school usig peer etworks, stadardized screeig programs, or a combiatio of the two. Peer etworks utilize studet leaders who have bee traied to provide assistace to at-risk tees. By makig use of i-school studet support resources, cliicias are more likely to idetify youth who would otherwise ot have approached a adult for treatmet. Programs that employ peer support etworks should provide close adult supervisio to peer supporters ad have couselors readily available to provide assistace to at-risk youth idetified by their peer supporters. At-risk studets ca also be idetified through screeigs ad evaluatios coducted i school or after-school settigs. Cliicias admiisterig aual or semiaual metal health or substace abuse screeigs at a school ca help Breda s Story* Breda, a 16-year-old mother of a 10-mothold boy, was madated to treatmet after a marijuaa-related arrest. Bor ito a chaotic family, Breda has lived at various times with her mother, her father, ad other family members; she ow speds most of her time with the father of her so at his parets home. Breda bega drikig ad smokig marijuaa whe she was 10. At age 12, she bega sellig marijuaa ad other drugs ad became ivolved i a loosely orgaized gag. She has atteded school oly sporadically sice she was 14 years old. Illegal substaces were commo i the eviromet where Breda was raised. Both of Breda s parets have bee itermittet users of heroi ad other drugs, ad her father spet a sigificat amout of time i jail durig Breda s childhood. Breda was sexually assaulted by a adult fried of her father s at age ie. Breda prided herself o ever usig heroi, ad o just usig marijuaa ad alcohol. Eve the occasioal use of cocaie was of very little cocer either to her or to most of the importat figures i her persoal life. Breda is a watchful, cautious, strog-willed, ad outwardly cofidet girl. She speaks quietly about feelig old, feelig resposible for her youger sibligs ad her so, ad about feelig disillusioed with the world, particularly with her father. Attedig school, followig the rules, ad meetig the expectatios that are typical for girls her age hold little meaig for her, ad she has few dreams for her future. She is highly suspicious of other people s itetios, ad experieces a sese of profoud iterpersoal distace. It is ot likely that Breda would have etered treatmet without havig bee madated by the court. * Breda is a composite represetatio based o real teeage cliets strugglig with traumatic stress ad substace abuse. 68 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
idetify youth who would ot have sought treatmet or otherwise bee idetified, thus facilitatig youths egagemet i treatmet or services. May schools scree their adolescet studets for substace abuse problems usig the CRAFFT questioaire, a brief (six-item) screeig test that ca idetify adolescets who are egaged i risky behaviors with alcohol or drugs. 1 3 Programs that employ the Cogitive- Behavioral Itervetio for Trauma i Schools (CBITS) have also successfully screeed large umbers of studets for traumatic stress withi high school populatios. (For more iformatio o screeig tools, see Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems.) Gettig Adolescets i the Door No-show rates for iitial sessios at substace abuse cliics are reported at about 50%. 4 Factors associated with missed appoitmets iclude active substace abuse, youg age, ad atisocial behavior. Listed below are some of the ways cliicias ca icrease the likelihood that a adolescet will atted the first sessio ad cotiue comig thereafter: Make remider calls. Call the adolescet s home prior to the appoitmet ad speak with both the youth ad a paret. Tell them that you look forward to meetig them. Discuss the importace of arrivig at the sessios o time; metio a couple of success stories with previous cliets, ad ask about ay obstacles to attedace they aticipate Be especially welcomig at the first sessio. Praise the tee ad family for just makig it to the first sessio Be culturally aware ad sesitive. Whe egagig youths ad especially their caregivers from diverse backgrouds, it is essetial to be aware of cultural values ad expectatios that guide social iteractio, metal health/substace abuse treatmet, ad saliet themes i their commuities. Establishig the trust of youths ad families from diverse backgrouds is a importat factor i determiig whether they will cotiue to show up for appoitmet, ad the quality of the iitial iteractio will greatly ifluece this decisio. If ay staff members are uaware of the cultural backgrouds of the youths ad families they are likely to assist, make sure they receive traiig i cultural competece; this will greatly cotribute to successful treatmet egagemet ad delivery (For more o this topic, see Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems.) Reach out to the family. Make a itese outreach effort startig with the very first sessio. Obtai several ways to get i touch with the youth ad the family ad The Natioal Child Traumatic Stress Network www.nctsn.org 69
get cotact iformatio for those ivolved i their care. Make follow-up phoe calls, lettig them kow that you care ad that you wat to cotiue to see them. This is particularly importat for adolescets who are madated for treatmet Egagig Homeless Youth Drug use by homeless youth is reported to be double that of youth i school. 5 Furthermore, homeless adolescets who abuse substaces egage i more high-risk behaviors, are more resistat to treatmet, ad have higher rates of psychopathology ad family problems tha substace-usig adolescets who are ot homeless. While egagig this overlooked populatio i treatmet is particularly importat, it is also a especially challegig edeavor. Homeless youth are very ulikely to self-refer to treatmet ad, as they are frequetly ot i touch with caregivers, are rarely referred by motivated family members who may have otherwise iitiated treatmet. Although shelters are the primary itervetio for these adolescets, may are ot equipped to provide treatmet for the multiple areas of eed ad diverse co-occurrig coditios characterizig this populatio. Strategies to egage substace-abusig homeless adolescets ad their families i treatmet iclude: 6 Stay at their level whe makig the first cotact. Showig the adolescet that you uderstad his or her laguage ad culture will facilitate egagemet. Let him or her kow that you are kowledgeable about the issues faced by may homeless adolescets, such as a history of abuse Preset treatmet optios i a o-threateig, appealig maer. Avoid askig persoal questios, ad stress that tees similar to him or her have participated i ad beefited from the program Avoid blamig. Reframe curret situatios (e.g., drug behavior, livig i a shelter) i terms of relatioal factors rather tha persoal failure Covey hope ad empowermet. Commuicate that chage is possible ad that the tee will have cotrol over his or her participatio i treatmet Respect his or her cocers, such as those surroudig cofidetiality or egagig primary caregivers, ad beig ope to egotiatio Addressig Practical Barriers to Care May adolescets ecouter real barriers to accessig treatmet, ad it is sometimes ecessary to provide guidace ad assistace to help parets, caregivers, ad adolescets overcome them. 70 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Schedulig Both parets ad adolescets may have difficulty with schedulig appoitmets. If a family is workig with other treatmet team members, try to coordiate with these members to schedule as may appoitmets as possible o the same day, so that the family has to make oly oe trip to your locatio. Discuss the possibility of holdig sessios before or after usual busiess hours to eable families to schedule appoitmets aroud work ad school commitmets. Trasportatio Discuss with the youth ad family ay potetial obstacles they might have to gettig to appoitmets regularly. Wheever possible, offer to provide bus or trasit passes if your ceter is ear public trasportatio. Address child care limitatios Families may have youg childre to care for ad may ot be able to afford child care durig family sessios or paret sessios. If your agecy has access to voluteers, ask them to assist with child care while parets are i sessio. Address caregivers treatmet issues Caregivers may eed referrals for treatmet themselves. Providig idepedet referrals for caregiver treatmet may help to alleviate stress o a family. Gettig Families Ivolved Adolescets whose caregivers are ivolved ad egaged i treatmet are more likely to have better outcomes tha those whose caregivers do ot believe that treatmet will help ad/or who are uwillig to work with treatmet providers. 7 Specific strategies for ivolvig families i treatmet iclude: Foster family motivatio. Determie what chages each family member would most like to see ad icorporate those chages ito treatmet goals to icrease the family s motivatio ad egagemet Validate parets. Validate parets past ad ogoig efforts to help their adolescet Ackowledge paretal stress. Ackowledge parets stress ad sese of burde (both as parets ad as idividuals) Be a ally for the paret. I additio to tryig to maage their tee s emotioal ad behavioral problems, parets are ofte overwhelmed by difficulties i their ow lives. Be sure to provide active support ad guidace The Natioal Child Traumatic Stress Network www.nctsn.org 71
Provide educatio about the ature of metal health problems. Families may prefer to see their adolescet s symptoms solely as a medical ad/or behavioral problem, ad ot as a metal health problem. I the case of substace abuse, for example, families may believe that oce the adolescet is sober, all emotioal ad/or behavioral problems will disappear. Psychoeducatio regardig the ature of substace abuse ad emotioal problems may help family members better uderstad their adolescet s issues Address complex family dyamics. Adolescets ofte come to treatmet with complex family backgrouds. It is importat to idetify the family members ad/or caretakers who have legal custody ad practical ifluece over treatmet-related decisios. It is also importat to idetify others who are most likely to be ivolved i a adolescet s care day to day, icludig close frieds ad metors who might support the adolescet s successful egagemet i treatmet. Be particularly sesitive to situatios i which a adolescet does ot live with a biological paret Buildig Alliaces As with ay treatmet, it is importat that youth ad caregivers feel that their cliicia is a ally. This icludes havig a set of commo goals. The etire family must believe that their work with the cliicia ad participatio i treatmet will lead to improvemet i issues that are importat to them. Establish rapport, set clear boudaries, ad allow for autoomy. May adolescets do ot respod to a itervetio that they perceive as beig imposed upo them, whether by a cliicia, parets, or other authority figures. Regardless of the specific treatmet approach, it is essetial to get to kow the adolescet i the begiig of treatmet ad develop a solid workig relatioship. It is also essetial to outlie a framework for the therapeutic relatioship that establishes clear boudaries but also allows the adolescet to make autoomous decisios Fid out what the adolescet wats to talk about. Although adolescets may be reluctat to disclose details about their risky behavior, there are ways to ecourage meaigful coversatios that will lead to ope discussio about what is goig o i their lives. These strategies iclude: P P P Showig geuie iterest i ad respect for his or her uique iterests, cocers, ad worldview Demostratig uderstadig of his or her culture Offerig guidace that addresses the adolescet s life problems as he or she perceives them 72 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Iformig youth about ormal behavior Teeagers beefit from cotrastig their behavior with that of the average perso their age. A 13-year-old who believes that everyoe gets druk sometimes may be surprised to lear, for example, that the majority of 8th-graders have ever bee druk. 8 It is crucial to provide tees with iformatio that clarifies the differece betwee recreatioal use ad problematic use (icludig abuse or depedece). Usig appropriate assessmet tools Admiisterig assessmet istrumets that are t face-to-face teds to ecourage greater disclosure. Adolescets ted to provide more iformatio o topics such as substace abuse ad suicidal ideatio whe they are t talkig to a cliicia. For example, cliicias ca use the Adolescet Questioaire (Adquest), a 80-item self-report measure that icludes questios about health, sexuality, safety, substace abuse, ad frieds, desiged to ope up may areas of iterest ad egage the adolescet i coversatios ivolvig these topics. 9 (See Treatmet for Youth with Traumatic Stress ad Substace Abuse Problems for more o this ad other assessmet resources.) Discussig the limits of cofidetiality To build trust with a adolescet, discuss the limits of cofidetiality at the start of treatmet ad pla with the adolescet specifically how iformatio will be commuicated to parets ad other authority figures. Stick to your agreemet! There is o surer way to lose the trust of a adolescet tha by sharig iformatio without the adolescet s awareess. Reassure the adolescet that if you must disclose iformatio (e.g., if someoe s life is i dager), you will make every effort to tell him/her before you do it. Employig Motivatioal Iterviewig Motivatioal iterviewig (MI) has bee show to be effective at reducig alcohol ad substace use i adolescets with a iitial low motivatio to chage. 10 Although it is ot possible to address the full scope of MI i this abbreviated format, some of the mai priciples iclude: Takig a empathetic, ojudgmetal stace ad listeig reflectively. This ivolves attemptig to uderstad teeagers perspectives ad helpig them feel uderstood, so that they ca be more ope ad hoest with others Idetifyig how the adolescets curret behavior may affect their goals. This ivolves workig with adolescets to idetify persoally meaigful goals, ad helpig them to evaluate whether what they are doig ow will iterfere with where they wat to be i the future The Natioal Child Traumatic Stress Network www.nctsn.org 73
Rollig with resistace. Rather tha arguig with tees whe they hit a roadblock, help them develop their ow solutios to the problems that they have idetified Supportig self-efficacy for chage. The belief that chage is possible is a importat motivator for successful chage. Help adolescets to be hopeful ad cofidet about their ability to impact their ow future i a positive way Leavig the door ope Whe adolescets wat to termiate treatmet, make sure they kow that they ca come back at ay time. Experieced treatmet providers kow that ofte it takes awhile for a adolescet to start comig i regularly. Ehacig Commuity Awareess Commuity members ofte iteract with tees, but they ofte do ot have the traiig to idetify ad uderstad youth at risk. To improve commuity awareess, substace abuse professioals ad metal health providers should make every effort to provide commuity groups with iformatio about the symptoms associated with substace abuse ad traumatic stress, as well as iformatio about factors that ca icrease or mitigate the risk of these disorders. Armig the commuity with this kowledge will be useful i idetifyig ad treatig youth i eed, as well as i prevetig future difficulties. It is also critical to provide commuity member with liks to help. This icludes iformatio regardig hotlies to call whe a perso suspects that a child or adolescet is beig abused, cotacts for guidace durig a crisis, ad referrals for meetig additioal youth ad family eeds. 74 Uderstadig the Liks Betwee Adolescet Trauma ad Substace Abuse Jue 2008
Refereces 1. Kight, J. R., Shrier, L. A., Braveder, T. D., Farrell, M., Vader Bilt, J., ad Shaffer, H. J. (1999). A ew brief scree for adolescet substace abuse. Arch Pediatr Adolesc Med, 153(6), 591 6. 2. Kight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., ad Chag, G. (2002). Validity of the CRAFFT substace abuse screeig test amog adolescet cliic patiets. Arch Pediatr Adolesc Med, 156(6), 607 14. 3. Jull, A. (2003). The CRAFFT test was accurate for screeig for substace abuse amog adolescet cliic patiets. Evid Based Nurs, 6(1), 23. 4. Lerma, P., ad Pottick, K. (1995). The parets perspective: Deliquecy, aggressio, ad metal health. New York, NY: Gordo ad Breach Sciece Publishers. 5. Forst, M., ad Crim, D. (1994). A substace use profile of deliquet ad homeless youths. Joural of Drug Educatio, 24, 219 231. 6. Slesick, N., Meyers, R. J., Meade, M., ad Segelke, D. H. (2000). Bleak ad hopeless o more. Egagemet of reluctat substace-abusig ruaway youth ad their families. J Subst Abuse Treat, 19(3), 215 22. 7. Dakof, G., Tejeda, M., ad Liddle, H. (2001). Predictors of egagemet i adolescet drug abuse treatmet. Joural of the America Academy of Child ad Adolescet Psychiatry, 40, 274 281. 8. Johsto, L. D., O Malley, P. M., Bachma, J. G., ad Schuleberg, J. E. (2007). Moitorig the Future: Natioal results o adolescet drug use: Overview of key fidigs, 2006. Bethesda, MD: Natioal Istitute o Drug Abuse. Retrieved April 16, 2008 from http://www.moitorigthefuture. org/pubs/moographs/overview2006.pdf. 9. Peake, K., Epstei, I., ad Medeiros, D., Eds. (2005). Cliical ad research uses of a adolescet metal health itake questioaire: What kids eed to talk about. Bighamto, NY: The Haworth Press, Ic. 10. Miller, W., ad Rollick, S. (2002). Motivatioal iterviewig: Preparig people for chage. 2d ed. New York, NY: Guilford Press. The Natioal Child Traumatic Stress Network www.nctsn.org 75