Treating the Traumatized  Addicted Adolescent

Approximately 90 percent of individuals who develop chronic substance dependence disorders with associated severe mental, psychiatric and behavioral problems start using illicit substances while under the age of 18 (Dennis 2002). However, the largest and most alarming drug problem among adolescents are prescription drugs, particularly prescription opioids diverted from the mainstream medical system, thus further blurring the line between legal and illegal drugs. Prescription drug use among adolescents is a red flag for poly drug abuse, especially if onset is prior to the age of 15 (Brook, Brook, Gordan et al 1990).

Unintentional death involving prescription drugs in adolescence has increased 150 percent between 2001 and 2009. In fact, in 2008 the leading cause of death among adolescents is drug overdose, exceeding even highway fatalities (Cermak 2009). More than one-third of adolescents who began abusing drugs in the last year reported their first drug was a prescription drug. Under the age of 15, non-medical use of a prescription drug is a major indicator of illicit drug use replacing marijuana as the leading “gateway drug” into the illicit drug culture with diversion of prescription opioids, particularly OxyContin, being more available to youth than heroin in illicit drug ­markets.

In a study conducted by John Hopkins, reported deaths from prescription drug overdose rose 273 percent between 2006 and 2008. The spike in deaths can be associated to a dramatic increase in the use of powerful pain killers, such as oxycodone, OxyContin and percocet. Edward Krenzelok, Director of the Pittsburg Poison Control Center, cites that these opioid pain medications are “being tremendously over prescribed and people are not aware of the high risk associated with improper use.” Diversion of prescription opioids from the adult parents involving parent’s medicine cabinets is a major source of drugs for adolescents who abuse prescription medicine (GAO, 2009; Rawson, 2008; Rothman, 2008; Schuckit, 1987; Smith, 2009).

If addictive disease onset is before the age of 15, the severity and duration of disability associated with the addiction is prolonged. However, as described by the National Institute of Drug Abuse (NIDA), the earlier the intervention to disrupt the addiction cycle, the shorter the severity and duration. Earlier interventions and more intensive treatment requiring an inpatient phase with appropriate aftercare in a continuing care model is indicated, as outlined by Timmen Cermak, MD, of the California Society of Addiction Medicine (CSAM) in his “Blue Print for Adolescent Addiction Treatment” (Cermak, 2009) and Rick Rawson, PhD of UCLA Integrated Substance Abuse Programs in his “Continuing Care Model” (Rawson, 2008).

Children who have a family history of alcoholism face a four-times greater risk of alcoholism. Furthermore, some studies suggest that inherited biological traits and psychological characteristics link genetics and substance use with a pattern of poly-drug abuse.

In males the strongest correlation is with attention deficit/hyperactivity disorder as a predictor of early onset addiction, whereas with women, it is depression and eating disorders. Multi-variant analysis, however, makes it difficult to separate genetic factors from the disruptive, dysfunctional and traumatic child rearing environments of the active alcoholic family, irrespective of the socio-economic status of the dysfunctional family (Costello et al, 2002).

Risk factors NIDA outlines the major risk factors for early onset of addiction as:

• genetic predisposition to addiction in first order relatives;
• co-occurring disorders proceeding the onset of addiction;
• childhood psychological trauma; and
• disruptive addictive child rearing environments.

Genetic factors appear to play less of a role in early onset addiction than in adult models, with psychosocial trauma and disruptive child rearing environment playing a bigger role. With adolescent females, sexual abuse in a dysfunctional family environment has shown the strongest correlation with early onset addictive behavior.

In working with high risk traumatized adolescents, a very careful clinical approach is to treat both the trauma and the addiction in an integrative fashion. Traumatized adolescents with addiction disorders often have great difficulties learning recovery skills as their attention is focused on family conflicts aggravated by post-traumatic stress disorder (PTSD) (Guchereau, Jourkiv, Zametkin, 2009).

Treatment

Addiction treatment with female adolescents is less effective unless the psychosocial trauma is dealt with. Covington has outlined a Women’s Integrated Treatment (WIT) model that emphasized gender specific trauma-useful curriculum for the treatment plan (Covington, 2008; Zweben, 2003).

Guchereau classified that PTSD among adolescents is significantly under diagnosed with a majority of the studies emerging from the juvenile justice system. This has led to the belief that psychosocial trauma and addictive disorder occurs primarily in criminalized adolescents from lower socioeconomic populations which dominate the juvenile justice system. As youth move up the socioeconomic scale, they interface more with the medical system rather than the criminal justice system, and the medical system is much more likely to underreport psychosocial trauma.

This has led to the mistaken belief that there is less psychosocial trauma in middle and upper class adolescents with substance use disorder. In fact, clinical experience has shown that there is a high degree of trauma with early onset addiction, but that it is more hidden and less likely to be criminalized. Upper socioeconomic alcoholic parents with dysfunctional family environments involving physical and sexual abuse retain a veneer of respectability hidden from law enforcement, which often focuses on lower socioeconomic populations (Guchereau, 2009; Merikanges, Rounsaville & Prusoff, 1992).

Studies of the criminal justice system have found that an individual who is poor and non-white is far more likely to be arrested and receive a felony conviction than a white, middle class offender for the same drug offense (Human Rights Watch, 2002; 2009).

Adolescents need a different treatment model for drug addiction than adults, one that focuses on habilitation emphasizing the teaching of psychosocial skills. Adults, on the other hand, require a rehabilitation model that focuses on returning to preexisting recovery skills.

Early onset addiction with co-occurring symptoms requires more clinical skills to deal with trauma in the past because of the denial, shame and guilt that exists in both the patient and the family (Dennis, 2008).

Gender-specific treatment approaches

Clinical experience at Newport Academy has found a very high incidence of psychosocial trauma in young women with early onset addiction. Recent work in the trauma field has focused on traumatized youth to initiate their drug use in order to self-medicate or calm their inner turmoil. This population of adolescents with trauma, that predicted the onset of substance abuse, has a higher incidence of co-occurring disorders, particularly depression and eating disorders in young women.

Studies estimate that one in four adolescents will experience at least one traumatic event in their lifetime before the age of 16. Additionally, there is a high correlation between trauma and the risk for substance abuse later in life. Teens who experience trauma and substance abuse have much higher incidence of academic, psychological and social impairments (Costello, et al, 2002).

To improve clinical outcomes with this population, a gender-specific residential treatment model (as outlined by Newport Academy) provides these adolescents—who otherwise would be very reluctant to disclose such trauma—a safe and nurturing environment to discuss their ­experiences.

Such gender-specific treatment ­models afford adolescents an environment in which to build strong peer support, which is essential in the treatment process. Peer interaction can help facilitate discussions on sensitive issues, such as those of sexuality, assertiveness training, body image issues, the development of strong same-sex role models and the formation of healthy boundaries.

In particular, the specific needs of adolescent girls should be addressed with residential programs identifying and allowing for the differences and needs of adolescent boys and girls.

At Newport Academy, the majority of female residents admitted to the program have experienced trauma—most notably sexual abuse, date rape and sexual coercion. This trauma is not defined by socioeconomic status, and girls in treatment often experience a cluster of symptoms, including: an inability to connect emo­tionally with other residents or staff members; intrusive thoughts and a re-experiencing of the traumatic event; depression; intense distress; body image issues; self mutilation; guilt; shame; and poor self-esteem.

It is critical that any residential environment provide a safe and nurturing setting for adolescent girls to explore these sensitive issues without the obvious distractions that a mixed-gender environment would provide. Research has shown that females in a mixed gender residential program tend to hold back in group settings and have a reluctance to share issues related to sexuality, abuse or rape. Addiction treatment programs can greatly increase their effectiveness through programs that provide gender-specific programming where adolescents are provided a place of healing and where their own experiences can be openly shared and ­valued (Miller, 2003).

Gender-specific adolescent training approaches for adolescent substance abuse and co-occurring disorders at Newport Academy involve creating a safe therapeutic arena where confrontational approaches are not tolerated. The key elements of the clinical program include: appropriate assessment; involving the family throughout the adolescent’s treatment with an Intensive Family Program designed specifically for the identified adolescent and family at week four; developmentally appropriate groups reflecting the differences between males and females; experiential groups to keep teens engaged and to foster a climate of trust; an integrated treatment approach that addresses all the various aspects of the adolescent’s development and needs; and a highly qualified staff trained in substance dependency, co-occurring mental health disorders and adolescent development. In short, effective treatment for adolescents with substance abuse and co-occurring trauma requires interventions that address the unique challenges of both disorders in a gender-specific residential environment.

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