Substance Use and the Teenage Mind: A New Look at Treating Adolescents in Therapy

cultivating the energy of adolescence

Adolescence arrives with a surge of emotional energy. It can empower youth to expand their capabilities, make new friends, depend less on parents, and live more passionately. The influence of parents remains important in a child’s life, and is necessary to support teens in making good choices.

Adolescence is also a time when some teens look to experience alcohol or drugs (such as heroine, cocaine, marijuana, and prescription medicine, among other substances). All too often, tragic results follow.

As therapists, how can we help more teens and families avoid or repair the damage and danger of substance abuse? What can we know about adolescent development to better understand the needs, risk factors and vulnerabilities at this life stage, and respond effectively?

Adolescence Spans More Years Than Most People Realize

Adolescence starts at about age 11 in girls, 12½ in boys, and continues into a person’s mid-twenties. Neuroscience tells us that the brain changes dramatically during this time and does not fully develop until age 27.

Brain remodeling refers to the process of physical and neurological transformation. Excess neurons that formed during childhood die off naturally — a process of synaptic pruning. A performance-enhancing sheath (myelin) grows along the remaining active neurons — a change called myelination. The myelin sheath allows impulses to flow up to 3000 times faster along the brain’s circuits. The brain becomes more specialized, efficient and more integrated.

New Thoughts, Feelings and Vulnerabilities Emerge

We also know that new ways of thinking, feeling and behaving appear — sometimes dramatically — during this time. Four qualities emerge with adolescence: “Novelty seeking, social engagement, increased emotional intensity and creative exploration,” says Daniel Siegel in his book Brainstorm: The Power and Purpose of the Teenage Brain. These qualities inspire many young people to do amazing and wonderful things. However, without the benefit of healthy attachments, these drives can also misguide others toward dangerous, high-risk, even deadly behavior.

How vulnerable are adolescents to risky and dangerous substance use behaviors? The numbers are staggering. While they do not predict the risk for any one person, they reveal unmet needs for education and appropriate guidance for adolescents:

  • One in five youth between the ages of 12 and 17 in the US have an abusive/dependent or problematic use of illicit drugs or alcohol
  • Alcohol poisoning and related incidents cause 4,358 deaths each year for youth under age 21, and lead to emergency-room injuries for another 190,000 people in this age group each year (NIAA, Underage Drinking)
  • Over 27% of 8th, 10th and 12th graders in the US report past-year use of an illicit drug other than alcohol (NIDA DrugFacts, December 2014)
  • After marijuana, prescription and over the counter medications account for most illegal drug use by 12th graders in 2013
  • Underage drinking accounts for 11% of all alcohol consumed in the US, 90% of which is consumed in binge drinking (CDC Fact Sheets – Underage Drinking)
  • Youth who drink or use drugs are more likely to become victims of sexual or physical assault
  • The average onset of first use of drugs or alcohol for boys is 12, for girls it is 12½
  • For those who began consuming alcohol by age 15, 47% experienced alcohol dependence later in life, compared to 9% who began at age 21 or older (NCADD FAQ)

Adolescents make decisions, choose behavior, and experience consequences differently than adults do. It can be very perplexing for adults to look on and try to make sense of a young person’s journey.

The impact of substance use on adolescent development is complex. It challenges the stability of mental health during the teen years.   Here we look at the impact of substance abuse on adolescent development in three areas:

  • Brain and cognitive development
  • Emotional regulation and response to trauma
  • Peer and family relationships

Substance Use Impacts Teen Brain Development and Thinking

Adolescents are often smaller than adults and have a lower tolerance for alcohol and drugs. The brain is still growing and developing. The influence of drugs and alcohol on brain chemistry can affect normal development in ways that research is still uncovering.

Recent findings have revealed changes in the reward drive during adolescence. With the brain’s neuron remodeling comes an enhanced dopamine release during a stimulating experience. Adolescents often feel more powerfully alive during engaging activities. The baseline level of dopamine may also fall lower in teens, prompting an even stronger drive for another dopamine-enhanced reward. Feelings of vitality and excitement to break adult rules can motivate increasingly creative — or dangerous — plans of action. For example, underage youth figure out how to ‘get alcohol’ — not to explore the taste — but to ‘get drunk’.

Substance use may reward the thrill of danger with the enhanced pleasure response that would otherwise promote more positive, healthy experiences. As the effect of the alcohol or drug wears off, dopamine plummets, turning the reward-seeking drive toward repeated substance use. This behavior increases susceptibility to the development of a substance abuse disorder.

Teenage Logic Rules

Adolescent shifts in brain chemistry coincide with shifts in thinking. Teenage logic is skewed positive, explains Daniel Siegel. The “evaluation centers” of the brain tend to discount the cost of negative outcomes, and inflate the value of the upside.

For adolescents, the heightened dopamine release drive is compelling. The difficulty seeing the cost of future consequences and their own susceptibility to addiction shows in their decisions. Substance use may misdirect the natural exploratory impulse by rewarding dangerous choices, instead of thrills that lead to positive mental and emotional development. Knowledge of these shifts in brain chemistry and logic is important in psychoeducation, when helping a teen understand their thinking, their choices, and the results.

Emotional Regulation and Response to Trauma Is Shaped by Substance Use

Adolescents may turn to alcohol and other drugs to manage the intensity of emotions and mood. They want to try and keep emotions within a window of tolerance – an individual range where affective, somatic, and cognitive arousal feels manageable.

Numbing becomes the primary strategy to regulate emotions for some teens. When drinking or using helps them dissociate from their inner world, they don’t pursue other healthier ways of functioning, or learn the mindfulness and self-care skills they need to cope in healthier ways.

Substance use may keep affect within the window of tolerance for a time, but it doesn’t work for long. The distress of unresolved trauma always comes back. Author John Green may have said it best: “That’s the thing about pain. It demands to be felt.”

It is likely that substance use may start and continue as a coping strategy for teens dealing with traumatic stress. How prevalent is a history of trauma among adolescents? The statistics of childhood trauma paint an astounding picture of unresolved pain:

  • One in four children and adolescents in the US experiences at least one potentially traumatic event before the age of 16
  • Four out of 10 adolescents have witnessed violence
  • 17% have been physically assaulted
  • 8% have experienced sexual assault
  • More than 13% of 17 year olds (1 in 8) have experienced posttraumatic stress disorder in their lives
  • More than half of African-American, Hispanic, and Native American adolescents have witnessed violence in their lifetimes

Substance use helps those with a history of trauma forget unpleasant experiences, avoid negative emotions, do away with worries, or feel numb or indifferent to daily challenges or reminders of past trauma. For someone with unresolved trauma, using “Does not keep me happy – it keeps me from being so sad I want to die.”

Early onset of substance use, especially before age 13, may indicate that childhood trauma is a factor in ongoing using behavior.

Assessment questions (discussed below) can help determine how a trauma history may need to be addressed in treatment.

Peer and Family Relationships

Peer pressure describes the compelling need for peer acceptance — to be wanted and valued in a group of friends. The pull to fit in with one’s peers is essential to learning how to form healthy bonds for survival. But this drive can also sway decisions in favor of substance abuse when:

  • Teens believe “everyone else” is doing it and want to blend in
  • Using is a way of spending time with friends, of being accepted, of becoming popular, of enhancing social and other activities
  • They have not learned to navigate fears that if they refuse, they might alienate potential friends
  • Teens want to pursue a curiosity with peers

Progression from experimentation to social misuse to addiction can stunt emotional growth and derail the formation of healthy attachments and supportive relationships that make us feel meaningful and good.

Witnessing a parent or relative’s substance use is a well-established risk factor, and a reason some teens give for starting alcohol or drug use. Of note, only 7% of teens report that they began to use to cope with emotional difficulties. But for many, guilt, shame and low self-esteem increase because of using behavior. While they may not have started using with the intent to numb overwhelming emotions, this is the eventual outcome.

Work in therapy involves acknowledging the teen’s real need for peer acceptance. A trauma-informed approach enables the teen to recognize and process trauma and resolve painful emotions. A healthy sense of interdependence comes as teens can embrace both their needs for peer acceptance and their still vital reliance on parents, family and mentors.

One of the biggest treatment challenges is to engage positive family support, especially if parents expect therapy to “fix” the substance use problem without their involvement. Collaborative treatment means working with the family system instead of fighting it. An important benefit is the strengthening of bonds that adolescents need, which helps them learn to cultivate valuable, positive relationships.

Implications for Assessment and Treatment

The goal of assessment and treatment is to help teens and their families get the support they need for a strong recovery. However, the path to recovery may be complicated. Uncovering factors related to the behavioral issues takes careful assessment.

Therapists have a number of robust approaches and techniques to assess and treat substance abuse in adolescence. For example, one assessment tool, the CRAFFT screening tool, is intended for use with adolescents. It is a series of 6 questions appropriate for people under age 21, to aid in screening for high-risk alcohol or substance abuse.

A trauma-informed approach to therapy is a necessity to establish a much-needed place of safety and connection with a trustworthy adult ally. Therapy also needs to help build strengths in the family system and social connections to provide resources for teens outside of counseling time. A number of treatments may need to be integrated, depending on the needs of each case. For example, a therapy plan needs to include trauma-informed care, understanding and learning emotional regulation, a systems approach, and trauma processing.

The process of finding approaches and interventions that work best takes time, patience, education, flexibility, and rapport and safety building, so only general ideas can be outlined here.

Therapists can receive a more in-depth understanding in a training program I am presenting with my colleague, Denise Tordella, MA, LPC: Making the Connection: An Integrated Approach for the Treatment of Adolescent Substance Abuse and Trauma (at the Institute for Advanced Psychotherapy, Training and Education in Pikesville MD on Thursday October 15, 2015; details here).

Adolescence presents unique challenges and opportunities to mental health. We can help teens and families find their strengths as they grow, so adolescents can enter adulthood with the health, vitality and abilities cultivated in their teen years.

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