What’s the big deal? Causes? How and when to seek help!
Some Adolescents experiment with use and or use occasionally. Some begin to use in such a way that as it starts to affect their healthy functioning they are able to stop or self-regulate on their own. Many will experience problems ranging from mild to severe.
Why are adolescent’s so vulnerable to substance abuse issues? The causes are many. This article will explore the major contributors and also serve as a guide for what to do next if you believe your child is experiencing a problem with drugs.
Stress is a major contributor. Adolescents don’t consciously use to medicate stress, at least at first. Use starts out as something that is fun for most. When frequency of use increases any stress experienced is medicated. This connection is at first unconscious.
Adolescence is a developmental period which prepares us for adulthood. There are many “tasks” which must be accomplished in adolescents. The adolescent must abandon the values and norms taught to them by family, throw them out so to speak, and develop ones which they can identify as their own (they wind up having a value system matching that of their parents by eighty something percent in the end). This is the reason for the classic generation gap. The adolescent rebels and tries on different values to see if they fit, ultimately forming a “self” based on these values. This process takes a lot of work. The onset of sexual urges, the expectation to function more autonomously in society, and the expectation to “succeed” causes much stress. This stress actually motivates the adolescent to problem solve thus helping him or her move thru the tasks of adolescent development. The more frequent the substance use becomes the more the stress is medicated, curtailing the motivation to complete the task.
Mental health issues and other life difficulties may exacerbate a drug problem for the adolescent. Often times a mood disorder develops in adolescents. If the child is smoking pot and increases the frequency and amount of their use this might mask the depressive symptoms. In fact, chronic cannabis abuse looks like depression in a lot of ways. Decreased motivation, isolation, sleep disturbance, (when THC is not used) and irritability are just some symptoms of depression which are also symptoms of chronic cannabis use.
To complicate matters more, guess what the symptoms of cannabis withdrawal are. That’s right, see above. This is why it can take two or three months to correctly assess an adolescent. To see the, “forest thru the tree’s” (pun intended, trees being a slang term for pot).
Other mood disorders such as bipolar disorder can also be medicated with cannabis and other substances. Psychotic disorders that usually appear symptomatically at around twenty years old may be triggered early by use of drugs especially dissociative and hallucinogens like PCP or LSD.
Loss, Trauma, and difficult life situations also may contribute to the development of a substance abuse problem. Economic distress, sexual or physical abuse, the death of a loved one or a friend and adoption are all risk factors that impact substance use problems.
New research that looks at the development of the adolescent brain indicates that the brain is not only growing during adolescence but also that connections and circuits are being established as the brain develops. Teens are more likely to engage in risky behaviors because the limbic system is going through a growth spurt and intensifying emotions while the pre frontal cortex, which then intercedes impulsive action, does not fully developed for ten more years or so. Therefore the old understanding of raging hormones combined with underdeveloped judgement is not really off base. (See “Scientific American” June 2015)
Adolescents also must take risks. Throwing away Mom and Dad’s values and getting some of your own involves risk. We expect the adolescent to be increasingly autonomous as they approach adulthood. This means they are beginners in a lot of life’s activities and hence not very good at them. Driving for instance; a 17 year old is a lousy driver until they gain experience. That’s why you can’t rent a car until you are twenty five. It’s a scary time for the adolescent and the family as moving out into the world involves risk.
Furthermore, drugs and alcohol may mask symptoms, medicate stress and aid in socialization by decreasing anxiety. Involvement in the culture of drugs and alcohol may meet social needs of the individual.
Recent legislation legalizing Medical Marijuana and its decriminalization in some states has led to a new mindset that “pot is okay.” As a society we are giving a very mixed message to our youth about pot.
Teens love to argue with parents about how pot is natural, legal and not addictive. Arguing back gets you nowhere and in fact only fuels the fire. I tend to join with the kid. I say, “Pot’s a great drug, it enhances the taste of food, and the experience of music and the arts, it’s great for depression and ADHD…” Then I talk about the down side, about addiction about the problems caused by self- medication. You get nowhere arguing because they just turn you off. It’s like telling a kid they are using because of peer pressure. You’re telling them they don’t have a brain and can’t think for themselves.
Want to shut a kid down, say that to them.
The problem is society is giving youth a very mixed message about drugs, and especially about pot. Even middle to upper class towns now allow what used to be called “head shops” to do business in their town. I know they sell e cigs and vapes. Well, they also sell bongs and other types of apparatus used to smoke pot and dabs (a high potency form of pot made by cooking pot down to a waxy sticky substance).
Also, referrals to drug treatment from schools are down by more than fifty percent in the last five years.
There is a return to the trend of, not in my town and a fear that if treatment is mandated schools may have to pay for it. Our family courts have enacted the alternative to detention initiative. A knee jerk reaction to the failure to the war on drugs. This has resulted in an approximately fifty percent reduction in adjudicated youth in NJ over the past year. By going thru the family court system many adolescents were assessed, found to need treatment and received it. With the drastic reduction of kids that are sent into this system we are not identifying problems I the early stages.
As a direct result of the above changes in schools and the Family Courts most adolescent inpatient rehabs in NJ have closed and it is becoming more difficult to keep the doors open at our adolescent outpatient facilities. The sad irony; in patient detox admissions for opiate dependence in young adults have skyrocketed and outpatient ambulatory detox sites are also booming with twenty something clients.
Parents don’t usually cause a substance abuse problem, they’re not that powerful, unfortunately.
Recognizing signs of a substance abuse problem is difficult as adolescents isolate, push parents away, change mode of dress and sometimes are amiss with hygiene. All signs of substance use that could simply be “a phase” that has nothing to do with drugs. Trust your gut. When there is evidence of use don’t be certain it’s infrequent and “normal.” Error on the side of consulting a professional and seeking an assessment.
Some adolescence do however act out family issues with use and may medicate the pain and stress caused by family issues. These are called systemic causes. An example would be the child who keeps getting caught with drugs. When this happens the divorcing mother and father are brought together to deal with the problem. The function is the parents work together during this time and the adolescent experiences them in the same room and focused on them. Systemic causes are not always this simple and may be impossible to see from within the family system. This is why professionals in the field require training in family therapy.
ASSESSMENT: Guidelines to the assessment and treatment process
Why seek an assessment: Many young people experiment with drugs and alcohol, some use substances in a controlled way, some go through a phase of overuse and then are able to self-regulate, as I mentioned earlier. Some are truly going through a phase. Some develop a problem. Substance abuse can devastate the person and the family and often goes unchecked for a long period of time. Addiction is sometime hard to identify in the early stages. Also, self-medication can mask an underlying mood disorder or psychiatric condition which only worsens as the abuse continues. Early detection can save years of pain and frustration and may be a lifesaving event for some.
The Assessment process: An objective substance abuse assessment is the place to begin if you suspect or know your child is involved with drugs. (Remember alcohol is a drug)
I would like to address a number of issues, common concerns and questions that usually come up. First and foremost, and this may turn some of you off. It is most likely that the adolescent, upon being confronted with evidence of their chemical use, will lie. At the very least they tend to minimize their involvement. The most common retort goes like this, “Mom, Dad, I want to be honest with you, I’ve experimented with marijuana and that, well that’s not mine.”
No matter what has caused you to suspect a drug problem, the first thing to do is seek an assessment.
An assessment has never hurt anyone and is not a punishment. It is a mechanism by which trust can be gained back in the child. The more resistant the child becomes, the more the reason to be concerned.
Parents should ALWAYS be ready with a choice. What is the consequence if the child refuses to cooperate with the assessment? Do not assume you can convince your child to come, always have a limit. The limit may range from not being allowed to drive a car, withholding allowance, college tuition, to calling the police, involving the school, involve a local family service agency and even leaving the home (the child must be 18 or be emancipated). Whatever the consequence decided, the parent(s) must be willing to follow though and be aligned, if not your efforts will probably fail.
If you cannot decide on a consequence or align on one with your partner, seek out a therapist who has experience in this area, let yourselves be advised and guided and try to form a consensus. This is very important.
Is the assessment confidential? Yes, no professional will release any information without a signed and written consent. This includes the child’s consent if he or she is over 14 years old, at least in the state of NJ. You are in control. You should feel comfortable accessing your insurance as employers cannot use medical information against you or your child, it is illegal. Consult an attorney for any clarification you may need. If you are not comfortable with information being released to your insurance carrier, I have agreed to keep a simple file, destroy it in seven years and conducted drug urine screening under an alias or using a patient code. Again the professional must make you feel comfortable and safe.
How do I find the right place/person to conduct the assessment? Seek a referral from your health care insurance company, the child’s school (Call the SAC, student assistance counselor, formerly the substance abuse counselor) a therapist you know, your local police departments juvenile officer or word of mouth. You could also seek out a local self-help group, (Families Anonymous, Alanon, Parents Support Group and the like) these groups are very helpful and the folks you meet will probably have some good referrals for you. You can look in the yellow pages and find local treatment centers. I say local, beware the nationwide 800 numbers and placement services you may find on line, I suggest you start with someone local.
Talk to these people ask questions; get a sense for the facility or person. Trust your instincts and go with whom you are comfortable with. Is the person licensed, is the facility licensed? I suggest an LCADC (licensed certified alcohol and drug counselor) LCSW (licensed clinical social worker) or an LPC (licensed professional counselor) or licensed Psychologist, as basic requirements for those conducting assessments, especially if they are not part of a licensed facility. The LCADC is the specific license for alcohol and drug treatment. Professionals with the other licenses can be quite knowledgeable and experts in the field. Do your research. If you are looking at an outpatient facility talk to them about the level and types of care they have available. Ask if referrals are made outside the facility if needed. You are looking for someone to be objective with your child’s best interests in mind. Some might steer you toward a private therapist, but they too may be guilty of needing to fill their slots and the like. Do your research, ask for references, and ask if you are comfortable.
The assessment entails an interview of the child and the family. Often written questionnaires are utilized to amass background information and demographics. A use history is obtained. Sometimes inconsistencies in the child’s report are pointed out in an effort to gain a more honest report. To what extent this technique is used is a matter of technique, style and also a function of the severity of use suspected. ASAM criteria (ameru) DSM IV (diagnostic stat) and some older forms of testing are applied.
Sometimes a SASSY (Sy-uby) which is a projective type of questionnaire, which rates level of severity and personality issues, is utilized. It is a useful tool but not necessary for an initial assessment.
Within reason, the clinician should take into account, “ where the client is at” What level of motivation is there, is the child mandated, does the family want help, is the client system accepting of the diagnosis. We can certainly apply a diagnosis of chemical dependency; this does not mean that people will accept this. Often times the child needs to fail repeatedly before there is a level of motivation for change. The level of treatment recommended should take this into account. Starting with the least restrictive treatment modality is usually preferable.
Is this a mental health issue? If we fix the mood disorder will the substance problem go away? I’m often asked, is this a psychiatric problem or a drug problem? My response is this is a kid problem. Often, treatment serves as an ongoing assessment. Sometimes the child is self-medicating a mood disorder, or other psychiatric condition. Sometimes the use may be in response to family discord or actually serve a function in the family. Often the child is simply addicted to chemicals and use, which may have started out as self-medicating, is now a full-blown addiction. Determining what exactly is going on is a process that takes place over the course of treatment. A mental health screening and history are conducted during the initial assessment. For most children a psychiatric evaluation should also be conducted. The evaluation may take place immediately or sometimes four to six weeks into treatment. Some clinicians say wait until the person is abstinent for a number of weeks before seeing the sychiatrist. With drugs out of the system the psychiatrist is able to get a much better picture of what is going on. Conversely, if the child is too depressed to stop using perhaps we should address this immediately. So, when is a tricky question? Rely on your treatment teams’ judgment.
Types of Treatment: I will list them bellow from least structure to most structured and comment on each level of treatment.
Urine screening only:
This may be appropriate if there is little concern there is a substance problem. The knowledge that random urines are to be taken may give the child motivation not to use and reason to give when refusing drugs and alcohol. Any child with a problem may very well “beat “any drug test. I always recommend that testing be conducted at a treatment center. Most treatment professionals in the field are pretty savvy regarding how patients may adulterate their urines. Also, most treatment centers observe the urine. I must stress there are many ways by which to adulterate a urine, by tampering, replacing, and detoxifying or flushing ones system with water in order to dilute the result. The child may “get over” on the urine even at the best facilities.
Most importantly, if you are going to utilize urine testing you must have a consequence, a plan for what happens when the child tests positive. Do not make the mistake assuming the child will not use because they are being tested. There should always be a consequence and a re-assessment with a professional should me sought.
Individual therapy with random urines:
Much preferable to drug screening by itself, but still limited. Individuals are appropriate in two circumstances. One, the child is motivated to address the use and the underlying or co-occurring issues and the child is not chemically dependent. Two, the child and/or family are very resistant to a higher level of care. In these latter cases I call individual therapy, entrapment. We predict the child will not be able to remain abstinent and then the prediction comes true. This can be a very effective strategy.
Unfortunately, there is limited therapeutic work going on as the child has probably lied about past use and current use. With so many secrets therapy just doesn’t work. What is important is that the therapist does have a chance to build rapport, trust and respect. One must allow ones predictions to come true without alienating the child or family.
Under this section I will include that the parent(s) may seek counseling to formulate a plan and become aligned as mentioned earlier. Also, family therapy may be appropriate and utilized with each of the two circumstances mentioned above.
Education and evaluation Programs:
The child and a family member attend an educational series of varied length. At our treatment center we call this Triple E, (Education, Extended Evaluation) a six-week educational series is attended one evening per week for six weeks and random urine screens are obtained.
Topics include: Addiction, Abuse, codependency, and adolescent development.
These programs serve to educate the parent as well. This process also introduces the family to the treatment center and creates a connection to the facility. If the child uses chemicals during the extended evaluation a recommendation to a higher level of care is made. The family, often times are more receptive to such a recommendation because they have been through this process.
This modality takes different forms. All the forms include some combination of group therapy and education. Urine screens are usually obtained. At our facility we call this program Early Intervention.
(EIP) The child attends a group one day; the family attends a family evening on another day during the week. Family evening is comprised of a combination of education, parents’ therapy group and a multiple family group. In multiple family group all of the children, their parents, and sometimes other family members attend.
This level of care usually treats substance abuse, not chemical dependency. Involvement is based on the premise that the patient is not addicted to substances and this means that he/she can control there use if so motivated. This type of treatment focuses on the underlying causes of abuse, family functioning, decision making, empowerment and parenting. Patients complete treatment with an increased self-awareness and are able to discontinue and/or control use not necessitating re-involvement in treatment.
These programs may also serve as an extended evaluation, if the child can remain abstinent and the family evidences improvement the program is deemed a success. If the child struggles with continued use, then a higher level of care may be indicated. Often times, as mentioned earlier, the child is not forthcoming regarding their level of involvement with chemicals. They minimize and attempt, sometimes with herculean effort to continue their use without this being detected. Ultimately these efforts fail and the evidence of the child’s inability to control their use is highlighted. This dynamic can be crucial to mobilizing and aligning the child and/or the parents, toward seeking an appropriate level of care. In another situation, the parents may be guarded about placing their child in a higher level of care which treats, “those other bad kids that I don’t want my kid with.” In this situation, this level of care may serve to educate the family as to the need for a higher level of treatment. The above scenarios are also considered a success, in that the child and family are ultimately engaged in the appropriate level of care.
Intensive Outpatient Programs were designed as an alternative to traditional in patient rehab. The individual is able to continue work, school and most activities while in primary care for addiction. There is also a cost advantage that compels health care insurance companies to rely heavily on IOP’s. If a person fails at this level of care then IN pt rehab is recommended. Often time’s failure at his level of care provides the insight and motivation necessary for a successful rehab stay. If the individual is not motivated they may simply, “do time” in rehab. The inner game plan being, I’ll be a good little patient in here so I can get out quickly and use in peace.
Programs generally meet three to our times a week for three to four hours, usually in the evening. The program is comprised of psycho-educational sessions, group and sometimes a family group.
It is at this level of care that traditional self-help, twelve step involvement is utilized. One of the primary goals of treatment is acceptance of powerlessness over the disease of chemical dependency and surrendering to accepting the suggestions of the twelve step program. Some are quite resistant to such a philosophy with the references to God and spirituality. Often times this is the last bastion of denial that must be overcome. Space and scope does not allow in-depth exploration of this topic. I must point out this should not be a road block. If it is being presented as one, it is the patient’s resistance fueling the power struggle, in order to take the focus off of real issues.
Going to rehab is often a necessary step toward the adolescent achievement of sobriety.
Length of stay may be a few days to months. Typically a two to four week stay is advisable utilizing healthcare insurance. The old standard is 28 Days, as that was the number of days included in health care insurance in the 1970’s. Hence, treatment programs were designed around that time frame. Now days managed care has nibbled away at that number. A person must meet “medical necessity criteria” in order to utilize there inpatient insurance benefit. Rehab is actually broken down into three categories: detox, acute or hospital care and residential. Be very clear; if your insurance plan says you have 30 days of in patient, this does not necessarily mean your teenager will be able to stay in patient for 30 days. A needs assessment is conducted by the insurance company, when certain criteria are not met; a recommendation is made to an outpatient level of care such as an IOP.
Longer is better, especially for adolescents and young adults. If you have the financial recourses available it may be worthwhile to invest in this level of care. Timing is very important, make sure you are consulting with a professional and including all parties involved. It is easy to make insurance companies the villain in these cases. Still, it may make sense to allow the child to fail on an outpatient bases before placing them inpatient. The adolescent may very well be more receptive to Rehab if they have failed at the chance provided to them to stay sober while living in their community. They have failed, so there is a better chance of them gaining an awareness of the need for help. With a premature in patient placement the adolescent may very well say, this is crazy, everyone is over reacting, I can’t take this seriously. Generally if you are going to jump into in patient early on, be prepared to send them to a longer term placement, at least 3 – 4 months.
We see a higher level of success with kids who fail at various levels of outpatient, then go to an in-patient facility, and then attend IOP as an aftercare component.
Remember this is a chronic and insidious disease. We have seen adolescents who have been placed in multiple facilities only to return to use soon after each discharge. Then there are natural consequences such as legal ones and the, now young adult is compelled to attend treatment, only to return to use.
Detox and Medically Assisted Treatment
Adolescents may require inpatient detox if they are physically dependent on opiates and or benzodiazepines (Valium – Xanax – Klonopin) Ambulatory detox utilizing medically assisted treatment may be considered. The use of Suboxone (a drug which alleviates opiate withdrawal symptoms and curtails urge) has met with mixed reviews, especially its long term use and use with the adolescent population. Naltrexone and Vivitrol may also be considered. These are drugs which block the pleasurable effects of alcohol and opiates. Naltrexone is in pill form while Naltrexone is a monthly injection. Antabuse, a drug that makes a person sick if they drink alcohol is used at times but mostly indicted for the highly motivated individual.
Wilderness programs/ therapeutic boarding schools
An in depth discussion of this level of treatment is outside the scope of this article. However, a few words to the wise. If you are considering placement in such programs, hire an experienced educational consultant. Allow them to guide you in your decision. These folks may seem expensive. This modality of treatment is expensive also, so consult the experts, it’s worth it.
This type of placement usually consists of an initial course in a wilderness program, sometimes lasting several months. Then the child is placed in a therapeutic boarding school for an average of one to two years. The child is usually matched to a school that meets their emotional, behavioral and educational needs.
This is a long term commitment. Caution is suggested before the child is withdrawn prematurely against recommendations. I have seen this end in disaster. I have also seen children placed in such setting for four to five years, and have mixed feelings about such long treatment stays.
Consult the Pros is my advice when considering this level of care.
Cost and Insurance
Unfortunately expense must be taken into consideration. It’s great if you have unlimited resources.
There are many great private pay facilities in this country and the ability to access them can save lives Still, I have seen families spend inordinate amounts of money on interventionists, high end rehabs, boutique therapies and the like, only to enable their child. How do I mean, I call these kids care addicts.
They do ok for a while then, as they are expected to start to take on real life responsibilities like work and school and forming social relationships on their own, they relapse. This elongates the out-patient phase of treatment and often results in placement back in a Rehab. This feeds into their arrested development and sends them on a cycle of care and relapse, care and relapse. I have also seen families literally,” dispose” of a child by enrolling them in long term treatment. Often these families choose such a placement rather than look at themselves and engage in family treatment to address the problem.
Sometimes parental abuse and addiction are the issues being avoided. So sometimes having all the resources in the world can actually be harmful.
If you have healthcare insurance you need to make yourself aware of your coverage and limitations. Is residential care covered? What is your deductible, per incident, per family member, per family? How many treatment days are available, per calendar year, per lifetime? Is the benefit managed? What levels of treatment require pre authorization? Is the treatment facility you are looking at in network? What is your out of network benefit and how does it differ from your in network benefit?
On the other end of the spectrum is the family with little or no recourses. No Insurance or Medicaid. Let me make this clear; there is a great difference in the care available in private pay, commercial insurance reimbursed facilities vs. publicly funded facilities. This is a fact of life. This is not to say that quality care and successful outcomes do not occur in publicly funded programs. Still staff to patient ratios are different as are the physical presentation of the facilities. I have seen many adolescents and young adults, “get it “in such facilities after multiple stays at some of the premier rehabs in the country.
So, what one needs to do is objectively assess ones resources and use them wisely. Consult with professionals.
Often I hear the parent say, I have no money and we are out of insurance, I will take a second mortgage to pay for a rehab stay if it will save my child. I usually do not advise this. I make sure the parents understand that one rehab stay is not always successful. I stress seeking out an accessible alternative.
There are many very good treatment facilities that work under grants and other funding sources. It may be a frustrating process to access such facilities but keep advocating and be persistent. Such facilities want motivated families and patients. After all they are deciding who gets to use precious resources.
Being persistent in the face of such bureaucracy can pay off.
Your use of healthcare benefits cannot effect your employment. The employer has no right to know how you utilize your insurance benefit. This is illegal. In small companies people fear that employers may become aware of your claims. If you fear your employer may hold the fact of your child needing drug treatment against you, get a lawyer, and advocate for yourself.
People who seek to enter the military, police, CIA, FBI, Secret Service or seek high level clearance, you will be asked to sign a waiver or release that would allow access to your records. In these cases confidentiality is not being broken, the individual is consenting to the release. I have had experience with families that have aspired to have their children seek a career in the FBI or some similar agency.
These families have refused to utilize health care insurance for this reason, so there is no paper trail of treatment. Still the individual swears to be honest. Extensive research is conducted, including interviewing friend’s relatives and educators. If you were in treatment as an adolescent, it may very well surface anyway. My best advice is get the help and worry about the rest later.
I can’t stress strongly enough how important it is to seek help if you even think your child may have a problem. An assessment has never hurt anyone and may save your child’s life. An assessment may also identify other issues and problems not related to drugs. I have made many recommendations to therapy, family therapy and psychiatric care and made no substance abuse treatment recommendations, after conducting a chemical dependency assessment.
Do not let the child talk you out of seeking treatment. They may lie, barter, plead fragility or go into a rage. The fact is the more the resistance and drama, the more the need for intervention.
If you can’t seem to set a limit that works with your adolescent or have become split with your spouse seek out a professional and consult with them. Always be aligned with your spouse regarding plans, limits and consequences.
By Nelson L. Hadler, MSW, LCSW, LCADC, CCS at Summit Behavioral Health