Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
thetic marijuana (known as spice or K2 ). Organic marijuana use, however, particularly on a daily basis among older youth, tends to remain stable (Johnston, O’Malley, Bachman et al., 2016; Johnston, O’Malley, Miech et al., 2016; Miech et al., 2017). Despite the prevailing stereotype of substance use by minority youth, studies indicate that, when comparing White, Black, and Hispanic youth, White youth tend to have the highest rates of substance use and Black youth the lowest; rates of use among Hispanic youth usually fall in between (Johnston, O’Malley, Miech et al., 2016). When comparing adolescents’ substance use by gender, the rates of nonmedical use of psychotherapeutic drugs (pain relievers, tranquilizers, and stimulants) is higher among females aged 12 to 17. However, among females aged 12 to 17, the rate of current nonmedical use of psychotherapeutic drugs, including pain relievers, decreased from a high of 4.4% in 2002 to 2.4% in 2013 (Johnston, O’Malley, Bachman et al., 2015; SAMHSA, 2020b). The heavy use of alcohol among young people is often viewed as a “gateway” to other drugs. More significantly, young people are experimenting with drugs, alcohol, and tobacco at earlier ages, and studies show that the younger an individual is when use begins, the more likely the person is to have substance use problems later in life. Adults aged 21 or older who had first used alcohol at age 14 or younger are more than seven times as likely to be classified with alcohol dependence or abuse than adults who had their first drink at age 21 or older (SAM- HSA, 2020). Such findings reinforce the need for prevention programs whose aim is to postpone the age of initiation into substance use (Straussner, 2013). Nearly all adults who meet medical criteria for a SUD have started “experimenting” with alcohol or drugs at some point during their teenage years. Adolescent substance use occurs within the social context of family, school, and community. In the United States, 40% of adolescents engage in substance use, making such behavior a relatively normative experience (Johnston, O’Malley, Miech et al., 2016). In a child’s brain, neural connections proliferate, largely as a result of the extrava- gant branching of the dendrites (receiving sections of the cell body of neurons). Beginning with puberty and ending in the early 20s, the branching dendrites (which look a bit like trees) throughout the brain are pruned, thus decreasing the number of superfluous connections. This incomplete pruning process results in what is seen as the immaturity of the adolescent brain. This process takes place last in the prefrontal cortex— that part of the brain most concerned with judgment and the weighing of risks versus benefits of various actions (Wagner et al., 2015). It is not until this process is complete that individu- als can reason with a mature brain. Prior to the completion of this process, it is difficult for people to recognize the potential negative consequences of some acts and so restrain the impulse to act in ways that, though gratifying, may be harmful. Added to this situation, the use of substances, especially alcohol, in adolescence may affect the reward circuit in the brain, causing an individual to prefer high-risk activities such as substance
use that promise large but uncertain rewards (Nasrallah et al., 2011). Finally, animal models suggest that alcohol use in adolescence may reduce cell volume and neurogenesis in the hippocampus of the brain (Wagner et al., 2015). The hippo- campus is necessary for the storage and retrieval of memories. If the hippocampal function is compromised, individuals will have difficulty learning from experience. People in this situa- tion will make the same mistakes repeatedly and be surprised at the unpleasant outcome. Treatment for children and adolescents requires a holistic approach. The complex needs of adolescents and their families, level of motivation, spectrum of problems, and availability of resources must be considered. Often, children require addi- tional components, including the involvement of their parents. One important treatment approach for young people is trauma- focused CBT (TF-CBT). This treatment is a specialized trauma approach appropriate for young people aged 3 to 18 who have experienced a wide range of traumatic events. TF-CBT, which utilizes both individual sessions with youth and joint sessions with their parents over a period of 12 to 16 sessions, includes modules focused on psychoeducation, relaxation and affect modulation, cognitive processing, the development of trauma narratives, safety planning, in vivo practice, and parental skills development (Racco & Vis, 2015). Cary and McMillen (2012) report that the most helpful TF-CBT techniques for youth and their families are psychoeducation about trauma-related symptoms, modulation skills for physiological and emotional distress, and creation of a trauma narrative. The following scenario concerns a 15-year-old boy mandated through the court to treatment: Tom is a 15-year-old male. He is the only child of a single mother. He is currently in high school but spends much of his class time in an alternative program because of truancy and aggressive attitudes that disrupt regular classes. He has a juvenile record that includes two arrests: one for shoplifting and one for public intoxication. He is currently on juvenile probation for the public intoxication charge. This information is available to the therapist because the visit is taking place as the result of a court order. Therapist : Tom, as you know, I am seeing you today because the judge ordered you to come. I know what the police and the court say happened last week, but I would really like to know what you think happened last week. Tom : Nothing happened. Everybody is making a big deal out of nothing. I didn’t do anything. Therapist : I understand that you might not want to talk about it. But something did happen last Friday night that ended up putting you in a lot of trouble. I’m not your probation officer. I just want to understand things from your perspective. So, can we just back up and talk about everything that happened last Friday night? Tom : OK, what do you want to know? Therapist : Well, first, did you start off at home last Friday evening? Tom : Yeah, I was at home watching TV. It was really boring.
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