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Evidence-Based Treatment
Treating adolescents as if they are “mini adults?”
A primary “task” of toddlers is to safely explore their environment and to develop an independent identity apart from their primary caregivers. While it is less recognized, this process repeats itself later in one’s life. This process is re-experienced during adolescence where as the child continues to explore and strive for autonomy. Adolescents, much like toddlers, want their caregivers to “go away”, yet need them to be available at the child’s discretion. At this stage children need independence in order to explore who they are, to develop a peer-based identity, and to develop the ability to problem solve on their own.
The lack of abstract thinking impedes the adolescent’s ability to recognize long-term consequences and short term dangers. As such, the child depends on the caregiver for this support and guidance . Factor in the adolescent’s need to try new and novel things and the potential for harm increases. The point is that they cannot develop functionally without the nurturing and protection of adults.
Adolescence is a time of vulnerability and upheaval. The juveniles are undergoing changes on every level of their being. Adolescence creates anxiety and stress for the children, as well as the entire family system. Caregivers are faced with the reality that the children are transitioning toward “leaving the nest”. In their role, caregivers may act as guides on the side, friends, task masters, or be unavailable. As such, the transition for the adolescent towards autonomy may be more difficult or may be “too” easy. These realities are played out within interpersonal relationships both within the family, as well as within outside systems. Beyond the overt and recognizable dynamics are the covert dynamics that are unspoken but unmistakably drive social dynamics and relational patterns. Those seeking to treat adolescents and their families must have insight into underlying drives and dynamics.
Adolescence is a time when caregivers experience powerlessness. A dissonance exists in that caregivers are both powerless and responsible. When caregivers realize that children are using substances, they most often feel frightened, angry, and confused; all at the same time. As adults they know that they must act but knowing what to do is difficult, and at times can be immobilizing. Oftentimes caregivers are not aware of the multitude of influences that affect their thoughts, feelings, attitudes, and actions. They are aware that something of grave danger is occurring to their children and their responses to it are influenced by a variety of factors; such as how they were raised. The multi-generational transmission of issues, attitudes, beliefs, becomes normative behaviors in the next generation.
Adolescents may become substance dependent over a period of months; yet the caregivers’ realization of the drug use may take years. An over-determined number of variables cloud their ability to accept the fact that the child has a problem (e.g., their own shame, guilt, fear, etc.). The reality of the use often exists outside the realm of conscious awareness; more as an unconscious idea (pre-contemplation). Sadly, awareness is most times thrust violently upon the caregivers via an unpleasant incident. Here an incident is defined as any situation that forces the reality of addiction to be faced. When the incident occurs the caregivers are forced into action; unfortunately the majority of caregivers are unprepared.
Despite having the reality thrust into their everyday world, caregivers commonly report continued attempts at avoidance; much like the stages of grief described by Elizabeth Kubler Ross. Ignoring the issue serves a short term goal to stabilize the family system and neutralize anxiety. The problem is that unaddressed issues do not disappear; rather they “grow” when a great deal of energy is spent addressing symptoms and avoiding root causes.
Caregivers of addicted teens that we have known have reported that one day the situation broke loose and everyone was left to face the “elephant in the living room”. Imagine the energy that it takes to ignore an elephant in your living room.
Knowing is not acting and acting is more difficult than it appears.
A reality is that caregivers of teens with substance use disorders (SUD) are caught between a rock and hard place because information on how to proceed is not readily available. Most caregivers and most counselors are not experts at addressing adolescent addiction. Consequently most adolescents do not receive treatment and great numbers become involved with the criminal justice system. Historically, adolescents and their families have been forced to interface with adult- focused treatment programs. Our experience is that the majority of parents become mired within the complexity of the bureaucratic systems that are supposed to exist to help them but do not. While the best-practice research has expanded considerably in the past ten years, it has yet to be widely disseminated into common practice protocols.
Reaching out for help and meeting mandates, rules and barriers can definitely b a confusing and maddening experience for the parents who is seeking help for h/her teen.
Teenagers who are sent to the wrong level of care are most likely to have the treatment make their problems worse.
Teens that enter adult- focused agencies often feel alienated rather than connected to their treatment.
The first step of effective treatment is referral to the appropriate level of care. This involves proper screening; especially when children are involved with the juvenile justice system. This is important to note as the justice system is set up with a punitive foundation; rather than one that is focused on identifying and treating addictive disorders. Identifying those who need treatment must take precedence over insurance and eligibility because it is often an issue of clinical appropriateness and not delinquency.
Caregivers are commonly forced to deal with multiple bureaucracies, such as family court, treatment, and insurance companies; each system has its own protocols and rules. Too often caregivers are left on their own to navigate these systems and the feeling of powerlessness is pervasive throughout these experiences.
If, and this is a big “if”, and when an appropriate treatment program is found, engagement; not alienation, should be the primary goal of the adolescents’ treatment provider. The latest research clearly demonstrates the need to involve the family. At minimum, counselors need to clearly explain the screening, initial determination, and level of care determination processes. It would be helpful if this was done in laymen terms. Once done, it would be in the best interest of the family if the counselor determined that the family understood everything that they may have just been “flooded” with. If the role of the treatment provider and family is not clearly understood by the family, and all involved do not understand their roles in the process, how can treatment be successful?
Family education must be considered as an essential aspect of adolescent addictions treatment. Consider how overwhelming it must be to be pushed into the alien world of addictions treatment without a map. Think about this, when families interface with the medical world the physician explains what s/he thinks is wrong, the protocol to address the concern, treatment options, and how everyone will know that treatment was successful. In the addictions world parents are either alienated from the process or they are told what to do; not why they are doing it.
Parents are often blamed and told what they did wrong which exacerbates feelings of guilt, confusion, and frustration. Placing the focus on the parents may serve to take the focus away from the clinician’s lack of adolescent treatment ability.
Adolescents are a special needs population that has historically been treated as mini adults. What works for adults will not work for adolescents.
The majority of people who use substances begin when they are adolescents. The long term consequences of use are extensive and undoubtedly negative. As adolescents are vulnerable they need parents to guide them and parents need addictions treatment professionals who have been specifically trained to treat this unique population
( 3 Votes )
According to the 12 Core Functions, Core Function #I is screening; with the concrete purpose of determining if the client is appropriate and eligible for admission to a particular program. This process is carried out in the respective 5 Global Criteria:
1). Evaluate psychological, social, and physiological signs and symptoms of alcohol and other drug use and abuse.
2). Determine the client’s appropriateness for admission or referral.
3). Determine the client’s eligibility for admission or referral.
4). Identify any coexisting conditions (medical, psychiatric, physical, etc.) that indicate need for additional professional and/or services.
5). Adhere to applicable laws, regulations, and agency policies governing alcohol and other drug services.
For a comprehensive assessment to be completed, a counselor must be able to distinguish the difference between “appropriate” and eligible”. In line with inter agency collaboration in the state of New York , in a letter dated July 2008, there is now a policy known as the “No wrong door policy”. Simply this means that if a patient is not appropriate and/or eligible for your agency’s level of care, the patient can no longer be “turfed” or “dumped”; rather there must be a referral on the part of the clinician to the appropriate level of care. Therefore, it is ineffectual to complete a comprehensive assessment, if the agency does not meet the needs of the individual.
The national standards; which have been set forth in Substance Abuse Mental Health Services Administration’s ( SAMHSA’s) Technical Assistance Publication (TAP) 21 “Addiction Counseling Competencies The Knowledge, Skills, and Attitudes of Professional Practice” lists the first Practice Dimension as Clinical Evaluation; which includes the 2 elements of screening and assessment. To clarify, TAP 21 is broken down into two sections. Section 1 focuses on the Transdisciplinary Foundations (TFs); which” describe the knowledge and attitudes needed by all disciplines…that deal directly with individuals with substance use disorders” (SAMHSA, 2005, p. 3). Section 2, focuses on the 8 Practice Dimensions (PD); which now add skills to the knowledge and attitudes. The PDs are the “professional practice needs, or practice dimensions, of addiction counselors". Between the two sections, there are 123 competencies; 23 fall under the 4 TFs and the next 100 contain the Knowledge, Skills and Attitudes (KSA’s) of the 8 PDs.
PD 1 defines screening as “ the process by which the counselor, client, and available significant others review the current situation , symptoms, and other available information to determine the most appropriate initial course of action, given the client’s needs and characteristics and available resources within the community” (p. 39). Competency 32 under PD1 states: “Based on the initial action plan, take specific steps to initiate an admission or referral and ensure follow through” (p.44).
Assessment follows screening as an “on going process through which the counselor collaborates with the client and others to gather and interpret information necessary for planning treatment and evaluating client progress” (p. 46).
In the SAMHSA Treatment Improvement Protocol (TIP) 42 “Substance Abuse Treatment for Persons with Co-Occurring Disorders”, screening is defined as: “a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder, and in this context the possibility of a co-occurring substance use or mental disorder” (p.66). Refer to core Function 1, Global Criteria 4-The screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted” (p.66). Further, “screening processes always should define a protocol for determining which clients screen positive and for ensuring that those clients receive a thorough assessment” (p. 66).
Simply, screening is “the first cut”. Either the individual is both eligible and appropriate for your agency or not. It answers the question: “Is there a substance use concern that warrants a further assessment?”
Proper placement of an adolescent into an "appropriate level of care" requires much more than "screening." Treatment placement is part of developing a treatment plan and requires a comprehensive assessment not just screening.