| Abstract|| |
Substance use disorders in children and adolescents are a significant cause of concern as they can have long term implications in practically every sphere. The etiological factors that contribute to substance use disorders are complex and the formulation must amalgamate and synthesize all the different factors including the predisposing, perpetuating, precipitating and protective factors in order to plan management. Interventions must stem from this comprehensive formulation and must be child-focused, multidisciplinary, multisystemic, with strong family participation and community involvement. The treating team must actively collaborate with the young person and help him/her understand the rationale for treatment in order for them to engage in it. Assessment and treatment of comorbidities are an important part of intervention package. Skill training for problem solving, emotional regulation, social skills, and communication are an essential part of the treatment for substance use disorders in adolescents. Relapse prevention strategies, including how to seek help when there is a lapse must be part and parcel of the interventions delivered to the young person. Substance use disorder interventions must be part of a larger plan that addresses other areas of concern in the young person's life. While there are few studies, and so a relatively weak and preliminary evidence base for pharmacotherapeutic interventions, early evidence shows that their combination with psychosocial interventions may have a synergistic effect on substance use reduction. Substance use disorders affect the entire family and the community at large and thus must be treated holistically, but by individualising the treatment to suit the needs of that particular child and family.
Keywords: Interventions, children, adolescents, substance use disorders
|How to cite this article:|
Jayarajan D, Jacob P. Psychosocial interventions among children and adolescents. Indian J Psychiatry 2018;60, Suppl S2:546-52
| Introduction|| |
Interventions for substance use disorders (SUD) in children and adolescents are often complex as the child/adolescent rarely seeks treatment or help on his/her own. More often than not they are brought by the family with requests from them for the most restrictive kind of treatment available. Due to this coercion, during the initial process of treatment seeking, there is a certain degree of hostility and mistrust, especially from the child/adolescent towards the treating team, right at the beginning of treatment. In order to counter the hostility associated with treatment against their will or without their expressed consent, the treating team must have an empathetic, understanding, respectful, and non-judgmental stance. Apart from this, another aspect that is difficult to navigate is the child's and parents' distinct goals and requirements for treatment. This again is complex, as while the child/adolescent is the primary client, the parent is the guardian and ultimately gives consent for various aspects of treatment. Herein lie issues of confidentiality and the limits of confidentiality that the child/adolescent must be told about at the beginning of treatment such that treatment can be as transparent a process as possible. Ensuring the transparency, confidentiality, and allowing for participatory decision making often times reassures the child/adolescent and they may be more willing to take part in the treatment process. Rapport and relationship building with the child/adolescent and their family is another important area that the clinician needs to keep in mind as the subsequent success of treatment depends on the strength of the therapeutic alliance.,
There is no doubt in anyone's mind that adolescents cannot receive the same treatment as adults. The benefit of including the family in the treatment process is also well established. Given that the risk factors for substance use disorders are varied and multi-factorial, any intervention can begin only with a good understanding of the problem behaviour, which includes the substance use history. History must be obtained from the child/adolescent at first in order to foster trust. Aspects that must be contained within the history include the way in which the problem developed over time, a good developmental history, family history, family interaction and communication patterns, any exposure to trauma, abuse, neglect and the history for the presence of disorders which might be comorbid with the substance use disorder. Risk for self-harm must also be assessed. As far as possible, history must be obtained in a conversational manner rather than one which is confrontational or straight away with the use of checklists and rating scales.
Another important area of enquiry that later contributes to the management plan is a functional analysis of the substance use behaviour, including the antecedents and the perceived consequences of use. Therefore, the context, expectancies, times, places and patterns of use, along with peer attitudes and the adolescent's social environment are important nuggets of information in order to inform the plan of management for the adolescent.
SUDs in adolescents often times results in an impairment in psychosocial and academic functioning and this is sometimes the reason why they come to clinical attention. The impairment seen can include academic difficulties, interpersonal problems, family conflict and dysfunction. Other features such as involvement with deviant peers, risk taking behaviour may also be seen. Comorbid psychiatric disorders may also be seen with this population and this is an important area of assessment and intervention.
Given the secretive nature of substance use disorders, it is important to obtain information from collateral sources, including the adolescent, parents, other caregivers (such as grandparents), teachers, child protection agencies (if the child lives in such an institution) and previous treatment records, if any. This information must be obtained sensitively keeping in mind issues of confidentiality.
Goals of treatment must be discussed with the child/adolescent and family. These goals can be formulated after also taking into account the adolescent's understanding of their substance use behaviour and its potential for harm, as well as their readiness for change. Based on the above-mentioned parameters, immediate, short and long-term goals must be formulated, deliberated and agreed upon by all parties. Thereafter, the clinician needs to outline treatment options including pharmacological, psychological and psychosocial and discuss with the adolescent and the family, the options that would be most suitable. The need for drug testing as part of the treatment plan needs to be discussed again upfront with the adolescent, as otherwise it is looked upon as a lack of trust from the treating team and that can affect the therapeutic alliance. Treatment for SUDs usually involves complete abstinence from the substance and while this can be the long-term goal, the treating team must keep in mind that it is often a long, arduous journey. Harm reduction is often the first step in this journey and this must be discussed with the adolescent and their family. During the period when the adolescent's motivation is still wavering, or the adolescent does not have the requisite skill set necessary for achieving or maintaining abstinence, harm reduction is a necessary interim goal. Treatment is usually delivered by a multi-disciplinary team and the location and types of treatment will be decided clinically and of course with inputs from the adolescent and family.
For the rest of the paper, the term substance use disorders will be used for all substances. This article provides a broad framework of psychosocial treatment options for all substances. Non-substance related behavioural addictions will not be dealt with in this article. For the ease of reading, the term “adolescent” will be used for both older children and adolescents.
In order to understand how to use psychosocial and pharmacological strategies we will discuss a case vignette. A brief discussion of the evidence based treatment strategies available for substance use disorders in adolescents will be presented thereafter.
Psychosocial approaches to treatment of SUDs in adolescents must begin with a comprehensive understanding of the problem. A formulation provides an opportunity to the treating team to incorporate and integrate various risk factors that have predisposed, precipitated, perpetuated and finally continue to maintain the adolescent's substance use problem. Protective factors are also looked for actively. The case vignette discussed below will focus especially on how to synthesize the information obtained during assessment in order to create a formulation that will incorporate various aspects that must be tackled with interventions.
“V” is a 17-year-old boy, first born of three siblings, from a lower socio-economic strata with alcohol and cannabis use for 2 years. He dropped out of college and did various odd jobs in order to maintain his substance use behaviour. Mother reported that he was always a difficult child with hyperactivity in school, complaints from teachers and classmates that he was aggressive toward them, and with difficulty in academics. His development was age appropriate, according to the mother. However, she said that she had significant mental health problems during “V's” early childhood as she had three small children and an abusive husband. At home, he was never given any responsibility but was over-indulged by the parents as he was their only boy child. He was aggressive with the mother and sisters as well when they did not give him money or prevented him from going out with his friends. Would often go out with his friends and come back late in the night, or not at all. Learnt to drive a bike without a license and would often go out with his friends on their bikes. Father had Alcohol Use Disorder (severe) and mother had Alcohol Use Disorder (moderate). Parents had significant marital discord and would often use the children to settle their disputes. Father and mother were verbally abusive toward each other and there was domestic violence at home, even witnessed by the children. Both parents were permissive and inconsistent in their parenting style with poor monitoring. Mother often disciplined the children by using very punitive means. Both parents when inebriated were neglectful of the children and their whereabouts. Due to their substance use issues, they had lost jobs and often there were significant financial problems at home. “V” has been in the company of a deviant peer group for the past two years and was brought to clinical attention when he was caught stealing phones and was sent to the Observation Home. On further enquiry, it was seen that the children in the peer group also had substance use issues as well as adverse home environments. On interviewing “V”, he did report feeling sad and upset, especially when he came home as his home environment was not a happy one. He said he wanted a happy family. He wanted to do well academically but found academics hard. He preferred to stay out with his friends. He felt his friends cared about him and shared his troubles. He also said he worried about his sisters and their safety. He also felt that cannabis was not as bad as alcohol. “V” blamed his mother for all his troubles as he felt she did not keep a good home. The family did not have any other social support.
We will now discuss this case formulation under the following headings: predisposing factors, perpetuating factors, precipitating factors and protective factors. This case formulation has been adapted from The Handbook of Child and Adolescent Clinical Psychology: A Contextual Approach by Alan Carr.
Predisposing Factors (both personal and contextual)
- Difficult temperament
- History suggestive of ADHD
- History of Conduct Disorder
- History suggestive of Specific Learning Disability
- Risk taking and novelty seeking high
- External locus of control
- Positive beliefs about substances of abuse
- Attachment related issues
- Inconsistent parental discipline
- Permissive and neglectful parenting which was often times punitive
- Parental alcohol use disorder
- Parental psychological problems
- Marital discord
- Domestic violence
- Family disorganisation and disengagement
- Social disadvantage
Perpetuating Factors (both personal and contextual)
- Physiological dependence
- Academic problems
- Involvement in the Juvenile Justice System
- Negative mood states due to issues in the family, academic problems, financial difficulties, involvement with the law
- Risk taking and novelty seeking
- Positive beliefs about substances of abuse
- Dysfunctional coping skills
- Modelling of substance use behaviours by parents
- Low parental self-esteem and poor coping skills
- Poor parenting skills
- Poor family organisation and disengagement, poor communication patterns in the family, lack of hierarchy, poor supervision
- Low assertiveness skills
- Part of a substance using and deviant peer group
- Availability of substances of abuse
- Poor social support
- Peer pressure
- Inability to do well in academics
- Worsening home environment
- Financial difficulties
- Negative mood states
- Conflict with the law
- Good physical health
- Willing to engage with the treating team
From this formulation, it is clear that there are multiple risk factors in operation. In fact, Hawkins et al., postulated that the greater the number of risk factors, the greater the risk of substance use disorders. It therefore flows from the formulation that the treatment must also be multi-pronged, multi-disciplinary taking into account the multitude of risk factors that has resulted in the current clinical condition. The intervention strategies must be based on a bio-psycho-socio-legal perspective in order to wholly address all the factors that has brought the adolescent to clinical attention.,
The first step is to develop a good working alliance with as many family members as possible in order for them to help the adolescent change his behaviour and also to offer them help for their own difficulties. Here the substance use disorder is framed as a family problem rather than where one individual is targeted. One effective way to do this is to have a number of family meetings in order for every member of the family to see their role in maintaining the problem and also their essential role in changing these problems maintaining patterns of behaviour. Through these meetings, goals and plans can be identified for each family member and can be monitored by the therapist. Family based interventions are then carried out in a systematic manner, keeping in mind all their difficulties. Individual therapy for the adolescent can initially focus on motivation enhancement and then move on to Cognitive Behavioural Therapy (CBT) strategies so that the adolescent can resolve their ambivalence to making a change and then understand ways in which those changes can be made. CBT is especially useful in making the adolescent understand his substance use problems in context (both internal and external) especially the contexts in which it arises and the maintaining factors for the same. Pharmacotherapy for the substance use disorder as well as the comorbidities can then be instituted with the adolescent understanding the rationale for pharmacological management. Assertiveness training, problem solving skills and social skills training are also taught to the adolescent in order to avoid peer pressure to engage in substance use behaviour again. Apart from this, given the adolescent's learning difficulties, other opportunities available to the adolescent such as community college and vocational training must be discussed with the adolescent and family. The parents must be offered individual help for their psychological and substance use problems. Once new routines for the adolescent and family have been established relapse prevention strategies must be discussed, both with the adolescent and the family. Liaison with the training centres, and if need be the juvenile justice system needs to be part of the plan as well.
| Evidence Based Treatment Strategies for Substance Use Disorders in Adolescents|| |
Pharmacotherapeutic approaches, or medication assisted treatments, combined with psychosocial interventions form the central component of treatment for SUDs in adults. While psychosocial interventions remain the first line of treatment for adolescent substance users, adolescents with more severe SUDs may benefit from pharmacotherapeutic interventions too. For most of these interventions, evidence is limited both worldwide and in the Indian scenario. Studies from young adults cannot be extrapolated to adolescents because of developmental differences which affect their biological, and subjective, responses to substances of abuse, as well their responses to prescribed medications. In addition to treatment response, various biological, temperamental and social factors may impact the adolescent's willingness to participate in treatment as well as their adherence to any treatment regimen. Given the effects of substance use on adolescent development, abstinence is an important end-goal. However, based on the motivation of the adolescent to quit as well as other contextual factors, harm reduction could be an important interim goal. To examine the evidence for pharmacotherapeutic options for each substance,
Alcohol- For withdrawal, no controlled studies exist for pharmacotherapeutic options for AWS, and so treatment principles from adult guidelines can guide management. Benzodiazepines are the first line of treatment for severe AWS in adolescents and in-patient treatment should be considered., For maintenance treatment, there is preliminary evidence for naltrexone,, disulfiram,, topiramate, and ondansetron are tolerated safe to use in this age group. However, more RCTs are required; and by the Oxford Centre for Evidence Based Medicine, the level of evidence is level 2 or lower.
Tobacco- Trials of the nicotine patch or bupropion SR may be considered in adolescents who fail to respond to psychosocial treatments, and must be given in combination with a psychosocial intervention. More RCTs are required to assess for long-term efficacy. Varenicline has preliminary evidence and needs further trials before it can be recommended.,
Opioids- The evidence for buprenorphine use in adolescents suggests it is effective in detoxification. In addition, it may be used for maintenance therapy in the buprenorphine-naloxone formulation for those aged ages 16 years and older, those who have more severe opioid addiction, those who use intravenous drugs, those who have comorbid psychiatric disorders, and those who fail detoxification plus behavioural counselling. Methadone may be considered in cases of treatment failures, but more evidence needs to be obtained for both methadone and naltrexone before it can be recommended. The evidence can be taken as level 3 or lower.
Cannabis- The evidence – level 3 evidence – for N-Acetylcysteine (NAC - 1200 mg twice daily) indicates that it is safely tolerated and increases the chances for a negative urine drug screen compared to placebo. A trial found topiramate to be poorly tolerated (level 2 evidence).(21)
Inhalants- While case reports have reported the use of baclofen for inhalant use in adolescents, no recommendations can be made for the same.
Stimulants- Currently, no recommendations can be made.
Hammond recommends the following criteria when deciding about the need for pharmacotherapy as well as choosing a medication,
“When to consider pharmacotherapy for SUDs in adolescents
- Moderate to severe SUD Comorbid/co-occurring psychiatric disorders
- Youth has failed psychosocial interventions (e.g. 2 prior detoxification attempts for adolescent SUDs to consider methadone)
- Youth is engaged in psychosocial interventions but is not improving (no change in drug use, no functional improvement)
- High risk for morbidity and mortality (intravenous drug use, drunk or drugged driving, unprotected sexual intercourse, accidents)
- Family or parents/guardians are engaged in treatment planning and willing to monitor medication
- What factors should be considered in choosing a medication
- Patient's past experience with SUD maintenance medications
- Patient and family's opinions and beliefs
- Family and parent/guardian involvement in treatment plan (for monitoring)
- Level of motivation for abstinence
- Health status (medical and psychiatric history, and allergies)
- Contraindications for medications
- Safety profile of medication and drug-to-drug interactions between medication and drugs of abuse
- History of medication compliance.”
The next section will deal with the psychosocial treatments available for adolescents with substance use disorder
Psychosocial approaches with an evidence base
The psychological and psychosocial intervention strategies detailed below are in accordance with the Adolescent Substance Use Disorder Treatment Guidelines given by the National Institute of Drug Abuse (NIDA).,
Motivational Enhancement Therapy
This is a client-centered approach that can help adolescents resolve the ambivalence associated with treatment. Adolescents may realise that they need help but may not be willing to make the lifestyle changes necessary in order to seek help and remain abstinent. Motivational Enhancement Therapy (MET) may help them in bolstering their resolve in seeking help and in making a plan for change. It has been shown to improve engagement in treatment and in reducing substance induced risky behaviour. Often MET is the first step to treatment and if engaged by the treating team appropriately, the adolescent is willing to overcome their initial resistance to treatment.,
Cognitive Behavioural Therapy
Cognitive Behavioural Therapy, both individual and group (CBT-I and CBT-G) have been shown to be effective for adolescent substance use disorders. Based on the adolescent's history of substance use, functional analysis can be used to understand patterns of use, dysfunctional coping mechanisms or attitudes towards substances which can then be used to design the intervention. Cognitive behavioural therapy can then be used to bolster the therapeutic alliance, teach the adolescent more effective ways of coping, using more effective problem-solving techniques to achieve and maintain abstinence as well as to deal with relapses.
Family Based Interventions
Family based interventions are essential for the successful treatment of adolescent substance use disorders. Parental and sibling substance use disorders must be looked for, assessed and help must be offered as an important step toward treating the adolescent with a substance use disorder. Family pathology such as poor parent-child relationship, low bonding to the family, family conflict, poor parental monitoring and ineffective use of discipline are often linked to adolescent substance use disorders. Therefore, these vulnerabilities need to be addressed using evidence-supported interventions such as Brief Strategic Family Therapy (BSFT), Functional Family Therapy (FFT), Multisystemic Therapy (MST), and Multidimensional Family Therapy (MDFT).
Evaluation and treatment for comorbidities
Several psychiatric disorders are comorbid with substance use disorders and our current understanding includes treatment of these comorbid disorders along with the treatment for the substance use disorder.,, Treatment of each individual condition is beyond the scope of this article. An in-depth assessment of any adolescent who presents with substance use is an important first step. Conversely, any child with mental health issues must be evaluated for substance use disorders.,
Other important areas of intervention
Academic difficulties are often times seen in adolescents with substance use disorders and school failure is seen as a risk factor for substance abuse problems. The causes may vary from learning disorders, ADHD to neurocognitive deficits associated with protracted alcohol use., In the case of young people using substances such as cannabis, the effect on educational attainment is more evident for a variety of reasons An academic evaluation and a collaborative plan made with the adolescent on how he/she will continue to engage with the schooling system along with skill development is an important part of management.
Another important area of assessment is whether the adolescent has undergone any adverse experiences such as maltreatment, neglect, abuse as this is often the case., An in-depth assessment as well as psychosocial and if necessary pharmacological treatment for the same is necessary in order to fully manage the substance use disorder., Children in conflict with the law must be assessed for substance use disorders, psychiatric comorbidity as well as exposure to trauma. Their treatment can be made mandatory by liaising with the Juvenile Justice Boards.
Summary and Future Directions
Treatment of substance use disorders in children and adolescents is often complex and multifaceted. More research is needed in the area of pharmacotherapeutic and psychosocial approaches that are useful in the child and adolescent population. However, the basic tenets for assessment and treatment for both adults and children remain the same in terms of maintaining a non-judgmental and empathetic attitude by all members of the treating team. Treatment is multidisciplinary, using a combination of pharmacological and psychosocial interventions after a comprehensive assessment. Needless to say, that the treatment must be individualised to suit the particular needs, vulnerabilities and strengths of that particular child and family. Treating the child and family as a whole, keeping in mind that substance use disorders are epiphenomena is important to remember and practice. Biopsychosocial and sometimes legal management is the cornerstone of treatment for substance use disorders in adolescents.
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Conflicts of interest
There are no conflicts of interest.
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Associate Professor, Department of Child and Adolescent Psychiatry, NIMHANS, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None