10 Unique Issues in the Treatment of Adolescents

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you I'd like to welcome everybody today's presentation on tips 31 and 32 screening and assessment and Treatment of Adolescents. So tips, if you're not familiar, are treatment improvement protocols. They are documents, if you will, books that samhsa, the Substance Abuse and Mental Health Administration has put together that have help us translate research and stuff into practice. So tips 31 and 32 really focus on adolescents. And we're going to look at some of the unique things that we may be dealing with when we're dealing with adolescence. And one of the things that I want to point out that a lot of us forget is that adolescence does not stop when people graduate from high school. Adolescence actually goes up through, you know, 23, 24 years old. So, you know, you have early adolescence and late adolescence, but there is that period of adolescence. And when you think about the Ericksonian tasks that people need to accomplish during adolescence, they're very different than those during adulthood. They're still developing identity and all that kind of stuff. So we're going to talk about how, even if you work in an adult program, some of your younger clients may fit into this adolescent framework and need particular interventions. And especially if you're working with youth under the age of 18, some of this stuff will be most of this stuff will be applicable. So remember that adolescents are not just little adults. You know, just like you have a five year old, you're not going to reason with them like you would reason with your spouse. Adolescents are not little adults. We need to be aware of what developmental stage they're at. And that applies not only cognitively but also in their moral development. So we want to be aware of what is going on with this particular person, what's motivating them? Are they motivated by a need for independence? Are they motivated by a need for belongingness? Are they motivated by a need for mastery? You know, kind of what's going on because that's going to help guide our communication with them. And we also need to be aware of adolescent culture because it's very different than adult culture. You know, the culture they have in high school and among people of that age is different. They interact differently, they talk differently. Different things are important to them. They see solutions to problems differently than we do, partly because they don't have the wealth of experiences to draw from that. Those of us who are twice or three times their age do, but partly just because they are growing up in a different era. How someone who grew up with an iPad in their hand would think about solving a problem is going to be different than somebody who grew up before computers even existed. So, you know, we want to look at what that culture is espousing, what that culture represents. We want to look at, you know, if you're working with adolescents, it's really important in my mind to stay up to date on, you know, adolescent music and adolescent television shows and the things are out there and the issues that they're presenting. I know recently, like, the past year, maybe a little bit more, there have been more shows coming out that have been empowering LGBTQ youth and embracing them and talking about different individuation and making, you know, making it through adolescence, basically, and really started bringing that into the. Into the public venue. So it's easier for us who are not in that group to kind of look in and go, oh, okay, I see where they might be coming from here. So if you work with adolescents, you know, be aware, and not only the media, but also, you know, video games. A lot of adolescents are very involved with their video games, so it's important to understand what that means, what values those video games communicate, what values the communities that support those video games are standing for. There are a lot of forums and things that my son is in, and he interacts with people who play the same video game, and they have certain ways of looking at the world. And so for him to be involved in that, you know, I thought it was important for me to kind of get an idea about, you know, what do these people stand for? So encouraging parents to be aware of that. But as therapists, it's also important to be aware of the different video games that are popular and what they may be teaching youth cognitively. In early adolescence, adolescents are emphasizing their immediate reactions to behavior. There's. Remember, your brain does not fully develop the impulse control and everything and just fully finish developing until you're 24 or so. So when you're dealing with somebody who is a young adolescent, that impulse control not really there. So we want to help people see the immediate reactions to their behavior. We want to help them be able to take a break and, you know, take a breath and think about those later consequences. But it's up to us to help them learn how to forecast, so to speak. They will recognize the immediate reactions and consequences to their behavior. If somebody makes you mad in the hallway and you deck them, this is what's going to happen. But you know, what are the long term consequences of that behavior and what are other things that you could do when somebody makes you angry instead of decking them in the hallway? What would be a more appropriate response? So during early adolescence, we really want to help youth start getting a hold of being mindful so they can think before they act, and then they can analyze in their wise mind, so to speak, what the best choice of action is, both in the short term and the long term. And that's something that's going to develop over time. But we want to see youth gaining a greater sense of mastery and control over their own reactions. You know, you're going to have a feeling which is going to lead to an urge. But do you have to act on that urge? In later adolescence, there's a greater use of inductive and deductive reasoning. You know, if I do this, you know, these things will happen, or if I want this thing to happen over here, then I need to do X, Y and z. So, you know, in later adolescence there's much better problem solving skills, Partly because the youth have gone through so much more. They've started solving more complex problems and, you know, think about math. Take math for example. When kids are little, they're thinking about one plus two. They're working with tangibles in order to visualize what's going on, and they're doing things that are simpler. When they start getting into high school, then they start moving into algebra and more abstract concepts, and they're starting to be able to solve problems and create proofs for geometry. They're able to use this reasoning a little bit more. But that's because they're developing that reasoning. Youth, young children aren't able to really think globally. They're not able to use inductive and deductive reasoning super well. You know, they tend to stay pretty focused on what is present and at hand. So in late adolescence, we see a lot more problem solving, we see a lot more cognitive flexibility just through experience and development. Family independence. During this period there, there are a lot of different developmental tasks. And I mean, think back to high school and college. You know, that was a period of turmoil for, you know, most of us. So thinking back, you know, what were you struggling with? You know, the challenges and developmental tasks and the things that youth face are very different than what an adult faces. You know, youth are still living under their parents roof, you know, through whoops, at least through early adolescence, and in many cases now through late adolescence, a lot of people are choosing to live at home when they go to college. So you know, there are going to be tensions and things that arise. So you have the beginning of rejection of parental guidelines. So if you work with adolescents, I want you to think about these things and throw out interventions that you use in order to help adolescents navigate these waters, so to speak. But as they begin to reject parental guidelines like drinking, smoking, being home by curfew, you know, certain rules, it's like, you know, I'm a grown up now, I shouldn't have to do this. And the parent comes back, well, as long as you live under my roof, yada yada. And there it becomes a fight about what needs to happen. So one of the things that can happen, especially if the youth is still living at home, you know, under the parents roof or whatever, they can try to negotiate what needs to be done. You know, if you still want the person to do chores, you know, if they move out, they're going to have to do chores. They may not do it to the same standard, but eventually they're going to have to do their own laundry or they're going to run out of underwear. So you want to start increasing the youth's independence while they're at home. Increasing the responsibility they take for their stuff could be one thing that the parent and the youth agree on, but also encouraging the youth to look at and talk about. What are your parents guidelines? Why do you think the parents set them? What are your feelings about curfew, smoking, drinking, premarital sex, whatever is coming up at this point. And start having the youth examine what are my ideas, you know, what are my thoughts on this and where do they come from? Is it because my best friend told me this or I think everybody at school's doing it? Or you know, what's the objective evidence? Ambivalence about wishes. You know, they may not even know what they want at this point. They're trying to figure out who they are and what they want. But when the world is your oyster, so to speak, you know, it feels like you're just this little tiny oyster kind of drowning in a sea. There are so many possibilities. So they may not know what they want. They may not know where they want to go to college or what they want to do. So helping them figure out what might you want to do. But also recognize that you don't have to know. Today when I went to college, I started with one major and I will tell you I did not graduate with that major. I changed majors two years into it. But that Was okay, I got into college and I realized that that wasn't a good fit for me, so I had to figure out what was a better fit, what was I being called to do? Helping them realize they don't have to make all those decisions right now. They don't have to know, you know, what's going to happen two years from now. They need to know. Maybe, you know, if you're dealing with a senior in high school, mine is. And so, okay, you have to figure out where you're going to go to college. You got to pick a college. You don't necessarily have to pick a major, but we got to start somewhere. And then you can always transfer. If you don't like that college, there are options. You're not doing anything set in stone, necessarily. And even if you're working with high school athletes that are going on scholarship, even if they go on scholarship, it doesn't mean they have to stay there henceforth and forevermore. They may not have a scholarship somewhere else if they transfer universities, but helping them understand that virtually nothing forever set in stone. Insistence on independence and privacy. You know, this is the age beginning, seems to be starting younger now. You know, 12, 13. I know my daughter has her ipod, and whenever anybody comes around, she's like, covering it up. She doesn't want people reading her texts. I'm like, girlfriend, if I wanted to read your text, I could, but I don't. And she just kind of looks at me and rolls her eyes and we're okay. But there's an insistence on this independence and privacy. But on the parents side, we're going, yeah, I want to allow you to spread your wings, but I also want to make sure you're safe. And so we struggle with finding, figuring out how much independence and privacy to let people have to let the youth have. And that's going to be a negotiation between the youth and the parents. And the youth is going to have to decide, what does independence look like for me, what do I want and how can I get it? Their level of independence. They may need to figure out how to get a job and move out of the house because they want that much independence. On the other hand, they may say, you know, I'm willing to be a little less independent if I can have the comfort of living at home. And they may not know how much independence they want. So that's something else we can talk about. What does independence look like and mean to you? What is it that you feel you're not getting right now that you hope you would get in this new situation. And sometimes you can have overt rebellion, limit testing, and withdrawal. You know, I don't have to do this. I'm 18. You can't make me do anything. A lot of parents have heard that, even from children that are still living in the house. So we need to start talking about, what are the rules? What can I make you do? And, you know, there is a fair amount of, let me see how much I can get away with now that I'm in college or, you know, now that I've moved out. But there's also overt rebellion and limit testing with other agencies, so to speak. You know, they're gonna push the limits a little bit. They may try speeding, they may try drinking, they may try this and that and dabble. They're figuring out who they are, but they're also pushing limits to see kind of what they can get away with. So it's important to keep that conversation going and understand what the periodic withdrawal might be about. Be alert to signs of substance use. Early in adolescence, most people have a best friend of the same sex. Late in adolescence, their peers often become very, very important. Their best friend is probably still a same sex best friend, but now they're a lot more interested in the opposite sex or, you know, eight, finding a partner. You know, if they're starting to figure out that they are gay, lesbian, bisexual, transgender, you know, they may start trying to figure out what that means to them at this point. And that can happen earlier rather than later. But we want to be aware that peers have a lot of influence, and the need to please peers, in many cases trumps the need to please, please parents. And so we might want to think about that and go, why, you know, your parents are there, they give you a roof. Da, da da da. Well, you know, when you think about it, it kind of makes sense because parents are safe. A lot of times, most people, most youth think that, you know, my parents, I can be a real bugger to them, but ultimately they love me, and they're not going to turn their back on me and let anything bad happen. So they know that we can get mad, we can get really mad, but we don't stop loving them. Their friends, on the other hand, they're a lot more fickle. You know, friends, especially at this age, may come and go with the changes of the winds. So the need to please their peers, the need to fit into a certain group that they want to identify with becomes extraordinarily important. They're trying to establish themselves, They're Trying to establish their identity and they need like others to surround them. So it makes sense that the peers are going to be more in the forefront because, you know, if they irritate their peers, they could be ostracized. School and vocation is another developmental task. They're starting to identify skills and interests. And you think of adolescence, you're like, well, you should have your skills and interests down by now. But adolescence starts pretty early. So think about, you know, when you're a freshman in high school, you're still kind of trying things out. You're still trying to figure out what you're good at, trying out for sports teams. A lot of your cognitive and physical development is just now starting. So youth are figuring out what they like and they may start, start a part time job later on in adolescence. Most adolescents these days don't start their part time job until at least 16, partly because employers are really reluctant to hire anybody under 16. But once they do start that part time job or that summer job, then they start having to juggle time. They start having to juggle demands. They may start having to tell their peers, no, I can't go out with you because I'm scheduled to work. So back to that need to please peers yet need to have money to put gas in the car sort of thing going on. There starts to be some of that adult conflict going on, or adulting conflict, if you will. So we can help them figure out how to manage, figure out how to prioritize what they're doing and you know, maybe figure out how to negotiate with their employer. If they're a good employee and they need a certain day off. Help them figure out how to ask for it. Not guaranteeing that they're going to get it, but so they start learning a good work ethic. They're starting to develop their self identity and self esteem and trying to figure out if they're normal. Most people when they're going through high school at some point they're like, am I just this complete oddball or am I normal? And so we can help them figure out what does normal mean? You know, normal, such a odd term, you know, what is it that makes you you? What is that makes you likable? What is, what is it that makes you unique? What is it that makes you a good person? So instead of focusing on that word normal, because I don't even know how to define it, let's look at what makes you you. And you know, where do you fit into this big puzzle of life? Conformity. They want to find a peer group to belong to. And their behavior tends to conform to meet peer group values. So the things that they're interested in, the things that they do, the sometimes the way they eat, the things they believe in, are often going to be heavily influenced by their peer group. And again, much to the dismay sometimes of their parents, because the parents they feel are generally always going to be there. Some continue to pursue group and peer acceptance even later, past, you know, early adolescence, into late adolescence and even early adulthood. But some are able to reject group pressure if it's not in their self interest. So if we can help youth develop a strong enough self esteem where they're not reliant on external validation to be okay, they're not reliant on being a part of this particular group or clique that's going to help them so much. If they're not reliant on particular peers, if they can say, I am all that in a bag of chips and if you don't like it, then I will go find somebody who does. Thank you very much. They're going to be head and shoulders above a lot of the other adolescents that they're in school with. So as professionals, when you're working with an early adolescent, you want to provide a firm, direct approach. I mean, there's still, you know, we're talking 13, 14, 15, maybe up to 17. They're still testing limits. They're trying to figure out who they are, but a lot of times they need some grounding. They need somebody to set limits and go, okay, that's as far as we're going to go on that one. Let's rein it back in a little bit. We want to convey limits in simple, concrete choices. If you choose to do this, if you choose to continue using, then I cannot continue to see you in treatment. If you choose to quit your job, then what are the consequences? So they can look at, I can keep my job and these are the consequences, or I can quit my job and these are the consequences and we can help them make a decision. So we're helping them again, use that concrete knowledge to forecast what's going to happen and then make a choice based on what they're hoping for. We need to try not to align with their parents, just to align with their parents. We need to try to be kind of objective. We need to be the mediator, seeing both sides of the fence, so to speak, and help the client explore the dialects. How can both of these be true? You know, my parent wants me to be independent, but I still have all these rules to follow. I'm grown up, but I still have, have to do chores when I'm at home. How do those things fit together? When their parents are proposing something that is causing conflict, you know, we want to help them see, why might the parent be proposing that? Why might the parent still be insistent on this? And, you know, what's your perspective? And is there a way that we can create a win, win situation out of this? In early adolescence, we really want to directly encourage youth to wait on making decisions about having sex because they're just emotionally not ready for it in 99% of the cases. Now, most of them are going to roll their eyes at us if we say that and go, I am so you don't know what you're talking about. And you know, I can't tell them any different. So arguing that point is just going to lead to an impasse. But we can talk about potentially why they're wanting to make that decision and what other options are available and what are their friends doing? And get a better idea. Encourage them to explore and try to really figure out, is everybody else doing it? What are options are other people exploring? Encourage parental presence in the clinic, but try to do the session with the teen alone. So if the parents are there, that's great. You can call them in if you want to, you know, summarize the session, have a family session, whatever. But generally the teen is not going to open up in front of their parents. So you want to try to have the, the youth in a private session with you in late adolescence. These are our juniors and seniors in high school and, you know, freshmen and sophomores in college. Be an objective sounding board, but let the adolescent solve their own problems. They're starting to be young adults now, and so we want to encourage them to start using those advanced cognitive skills. We're not going to provide all the answers. We can help them sort through stuff, we can model for them how to sort through stuff, but we want them to solve the problems, negotiate choices with them. And again, this comes down to looking at not necessarily just this one decision, but let's play it all the way through. You know, you want to quit your job. Okay, what's the benefit to quitting your job? What's the benefit to keeping your job right now? Okay, that's your immediate benefit. But let's look five years down the road. You know, if you quit your job right now, then you're not going to be able to afford gas money. And what are some of the other consequences that are going to happen and have them play it all the way out to see if they really want to quit their job. And if not, encourage them to look at what are some other options. You know, you feel like you're working too much, you don't like the job you're at. What are some other options? Find a different job instead of just quitting work altogether, or talk to your boss or get a reassignment or, you know, there are a lot of different things that we might think of naturally. You know, of course I'm going to try to solve workplace disputes before I just up and quit a job or something. But an adolescent may not. So we want to let them know what the options are. We want to encourage them if there's a human resources department to use it and encourage them to explore their choice before they all the options for their choices instead of just seeing it as it has to be one or the other. When you're working with late adolescents, you know, sometimes you don't need to get so much history because you can start getting some pretty grandiose stories. They're trying to feel like they're all that in a bag of chips. So they may enhance things. They may have a little bit more drama just for the effect of it. Not that they're trying to be. Well, they are kind of trying to be manipulative. They're trying to make themselves feel good about themselves. So, you know, get a little bit of history. But, you know, you don't need to encourage them to embellish, confront gently about the consequences and their responsibilities. So, you know, if you've got a youth you're working with and they're in their freshman year of college and they've quit going to classes, what are the consequences of you not going to class? And what are your responsibilities to your parents who are paying your tuition? You know, if you drop out of college or flunk out of college, how's that going to play out? Let's play it all the way out. So confront them gently about is what you're doing right now helping you achieve the kind of life you want two, three, five years from now? Consider what gives them status in the eyes of their peers. If smoking and drinking gives them status, if they're a member of a Greek organization that tends to party a lot, you know, does that give them status? And, you know, if so, you're going to have to figure out how to work with that. You know, if they're typically having keggers every weekend at the frat house, how Is that impacting juniors work and grades and all that sort of stuff and encourage them to try to figure out a way to balance the two. Not necessarily give up the fraternity, but potentially looking at ways to cut back on, maybe weeknight parties, use peer group sessions as much as possible. A lot of youth are not real down on that, but I'm finding as I learn more about the different programs at college campuses, there are a lot of college campus support groups, college campus stress management groups, and they tend to be pretty well utilized. So don't just assume that adolescents aren't going to want to do that once they get to college. Tends to be a little bit of a shift in their attitudes towards seeking counseling and peer group help. Adapt systems to crises, walk ins impulsiveness and limit testing. So we want to make sure that we've got time. If an adolescent has a crisis and sometimes, you know, something will happen, they'll break up with their boyfriend and it feels like the world is going to end. So we do need to be sensitive to that if we're working with adolescents. Ensure confidentiality as much as possible and if you can, allow teens to seek care independently. Now, this is one of the unique issues about working with minors once they're 18 and older. You have that whole different set of rules that applies under HIPAA and CFR 42 and all those other things, but when they are under 18, you're still dealing with a minor. If there is an obligation to disclose. If the person is indicating suicidal or homicidal ideation, you know, if they're doing something that's potentially really harmful, then you have mandated reporting. There are other situations, depending on your state, where it's incumbent upon you or the a reasonable professional in your position would tell the parents that the person is engaging in, you know, autoerotic asphyxia or injecting heroin or, you know, whatever. You know, there are things that maybe the person is not suicidal or homicidal, but they're doing something that's potentially very dangerous to them. So you need to check with your legal team about exactly what you're required to report. Because every single case is going to be a little bit different. And each state has its own laws. So I don't want to advise you erroneously. One of the best ways to prevent problems in the therapeutic alliance if you have to do a mandatory report, is to start out counseling being very open about what you're required to report, the things that you're required to do. And, you know, if somebody tells you something that you feel the Parent needs to know. You can talk about that in session. If it's something that you're required to tell the parent, you can tell them. You know, this is something your parent has to know. And I'd really like you to be the one to tell them. We can bring them in here and we can have this discussion together. But empower them. Try not to make it feel like you went behind their back. So if they tell you something and it won't cause them harm to tell them right, then you understand I'm going to have to report this. You know, you can talk about it at that point. Sometimes it's not appropriate to tell them I'm going to have to report this. But most of the time it is, you know, most of the time it's better to empower the client and let them know what's going on and what's coming so they don't feel like they got sucker punched. Screening and assessment Selection of instruments for screening is guided by reliability and validity of the tool, its appropriateness in an adolescent population, types of settings in which the instrument was developed, and the intended purpose of the treatment. So when you're using an instrument, even if it's normed for adolescents, that is a pretty big age range. So was it normed on high school students or was it normed on college students? Lot of stuff is normed on college students. So it may not be completely applicable or as reliable or valid with high school students. So we want to look at who was it normed on? What is it exactly? Is it measuring? And make sure that it's targeting the population that you're working with. If you're working with 14 year olds, you're going to use different instruments than you're going to use with 24 year olds. Instruments typically are short in duration, especially screening instruments. They have high test retest reliability. And when you look at instruments, you really want to look for something that has like a 95% or 97% test retest reliability, which means if they take it Monday, they're going to get a score. And if they take it Thursday of that same week or the next week, they're probably going to get the exact same score or very close. That gives you more confidence that it's measuring what it's supposed to measure. If there's evidence of convergent validity, the instrument is strongly correlated with other instruments that measure similar constructs. So if you're trying to assess depression in an adolescent and you're trying to compare how well this instrument over here measures compared with the Beck Depression Inventory. Okay. You know, that's going to give you the Beck Depression Inventory. We have a lot of data on. And if both instruments say that the client is depressed, then it's pretty darn valid. Sometimes you look at predictive validity. How well do we think this person's going to do in school or how likely do we think it is that this person's going to relapse? So we administer this test and whatever the score is, says it's really, really likely or not very likely at all that this is going to happen. And it should have the ability to measure meaningful behavioral and attitudinal changes over time. So you want to be able to administer it and see improvements in the behavior. So there are a lot of different tools that are out there. There are sample screening forms. Depression, drug and alcohol use, bipolar, suicide risk, anxiety, and trauma screening tools. We're not going to go through all those. You can click on the links. They will take you to the SAMHSA website. Maybe. So here is on the SAMHSA center for Integrated Health Solutions. And you can look at all of the different instruments that are available to you to screen for those. Those different topics. When you're doing a family assessment, remember that not all adolescents think of family as blood relatives. You know, it could be the auntie who raised them. It could be, you know, they want. You want to encourage them to define family as, as they define it. So be open. If you're going to do family therapy, if you're going to enlist family support, ask them, who do you consider part of your family? The law and society may define family in ways that differ from the actual experiences of youth. So cultural and ethnic differences in family structures should also be respected. You know, for some cultures, the extended family is also part of the family. So you're going to have great grandma, grandma and mom all in the family session. So we don't want to disparage the elder generations if that's important to that youth's conception of family. The core problem may reside outside the adolescent. And the problem, the substance use, the depression is a symptom of family problems. So we want to recognize that the identified patient may just be the one that's kind of got the glaring issue at the moment. But what's causing that issue? What is prompting the depression or the substance use or the anger outbursts, things that might indicate a need for screening in adolescence. You know, if you're a school counselor, if you are an outreach worker, or, you know, a variety of different placements, if the person has problems during childhood or early adolescence, they start having school issues. They're involved with peers that have delinquent behaviors because we know that peer influence is super important. If they talk about daily use of one or more substances, including cigarettes. If there's exposure to adverse childhood experiences. So, and from the ACEs High survey, physical, sexual and verbal abuse or neglect, a family member with a mental health or addiction issue, a family member in prison, witnessing domestic violence or losing a parent to separation, divorce, or some other reason. So maybe the parent is deployed in Afghanistan or was killed in Afghanistan or whatever. So all of those are adverse childhood experiences that could increase the risk that this person may need mental health or substance abuse intervention services. If there's a sudden change in school performance, a marked change in physical or mental health. Remember, we've talked about how kids a lot of times somaticize. They'll start complaining about stomach aches and headaches and stuff and not necessarily talk about being depressed. So if there's a change in physical or mental health, we want to have them screened. If they start engaging in risky activities or running away or being truant from school, obviously that, especially if that hasn't been going on and suddenly starts, you want to get a screening as soon as possible. But if that's going on at all, you know, there's something going on at the, at the core, there is something that is prompting this truancy or running away. It could be a peer group, it could be a family issue. It could be depression or substance use. We won't know until we screen. But if the adolescent is not acting as one would expect for his or her age and where he or she lives. You know, in America, we have mandatory schooling laws, so they're expected to go to school until certain age. Depending on your state, it can be as young as 14 or as old as 18. So there are certain things that we expect that are legally required of youth, and if they're not doing those, we want to take a look at why. So if the person is screened and they need to be sent on for assessment, we want to look at their family history. Is there a history of depression, anxiety, substance use, the family, Are the parents able to function? Are their parents able to parent effectively? Or are the parents just so overwhelmed with their own mental health or substance use issues that they're barely getting by? And a lot of times adolescents will act out, if you will, because they don't know any other way to solve the problem. You know, they start feeling like they are a fish out of water, if they're not getting support or if there's too much chaos at home. We want to look at the client's history. Has the child always had problems or is this a sudden change in behaviors? What are the presenting symptoms? What are current and past medications and any treatment effects? If they've been in treatment before, what worked, what didn't. Some people will be on ADHD medication for a while, then they'll decide to stop it, and then they may start having problems again. We want to look at, might there be some underlying ADHD stuff going on that still needs to be addressed, or if the medication worked, do you want to go back on it? There are a lot of different things, coping skills and strengths. How do you deal with life from day to day? Because it sounds like you got a lot going on. So have them talk about how they deal with the stress of school and, you know, whatever's going on at home. You know, when your parents are fighting, how do you deal with that? Where do you go? What do you do? You know, just kind of get an idea. Trauma Obviously we're going to take a look at that, looking at the adverse childhood experiences as well as any other traumas that may have occurred. And that can include things like the house burning down or, you know, getting destroyed in a hurricane or, you know, there are a lot of traumas that didn't make that particular survey that are extraordinarily impactful for youth. We want to figure out their self esteem. You know, are they feeling like they're pretty okay, or are they fearing abandonment, afraid of rejection, and just desperately clinging on to anybody who will give them positive validation, Going to give us some clues as to maybe what's going on. And we also want to assess for eating disorders in males and females because this is the age from 13 to 24 where most eating disorders start. Substance use history A lot of adolescents experiment with substances, so be open about it. Let's talk about it. How old were you when you first used the drug? How frequently do you use it? How much do you use? How long have you been using? Do you use substances together? Are you using cocaine and alcohol together? You know, let's just talk about it. Talk about the immediate and remote consequences of use. When you use, how does it make you feel? When you detox or when you come down off of it, how do you feel? And have there been any negative consequences from your use? Does anybody in your family use? You know, because that could indicate the family's attitude towards substance use. And what are Your family's attitudes towards substance use. And some families may have very positive attitudes towards alcohol, cigarettes and marijuana and very negative attitudes towards things like cocaine and methamphetamine. You know, so you want to kind of get an idea about the family's attitudes towards each individual drug, so to speak. Physical health. What is their current and past physical health? Adolescents are going through so much in the way of change and their hormones are all over the place. And we know that changes in estrogen and testosterone levels change the level of availability of serotonin. So we want to look at kind of what's going on with the youth. And you know, there some physiological cause, you know, it could be just developmental, but is there some physiological cause that might be contributing to the mood symptoms or the behaviors? Again, any medications they're taking. Don't forget to ask adolescents, not just college people, about pre workout supplements, especially athletes and you know, anybody who, anybody who works out. We do want to ask if they're using workout supplements because there are. And energy drinks because there's a lot of stuff, like I said yesterday in energy drinks besides just caffeine. And they're not sure how some of those things like taurine and guarana actually impact the growing adolescent brain. And there's a fair amount of research online if you want to look stuff up, talk about family health history, any history of diabetes or, you know, hypothyroid or anything. And housing, do you have safe, clean housing? What's your school experience like? Performance? You feel like you're doing okay? Attendance? Are you getting there? Most days. Do you like it? What do you like about it? You know, there are some things that you're just not going to like. But you know, overall, is it tolerable? And do you have difficulty with any type of learning? You know, do you have dyslexia? This is when we might want to look at ADHD as well. If they have difficulty organizing and following through with tasks. So we can help provide interventions to youth who may be struggling in school because they have some sort of learning disability. So this is a perfect time to ask. A lot of times if youth have learning disabilities and they start to perform, perform poorly, then their attitude towards school and their self esteem will also go down. Depression will increase, as does anxiety. So school is important because it is, you know, it's basically the job that adolescents have right now socially. We want to ask them how their peer relationships are going. Talk about peer violence, talk about interpersonal violence, dating violence. Let them know, you know, it's not okay. And let them know what's reasonable to expect in peer relationships. Look for changes in peer groups. Assess their interpersonal skills. Are they able to communicate effectively? A lot of youth today are actually struggling to communicate in a face to face sort of situation because they spend so much time texting. So they have a lot of social anxiety in situations where there are multiple other people. What's their neighborhood environment like? Are they involved with a gang? What sort of pro social activities do they do? You know, what do you do in your free time? Do you volunteer at the church? Do you help out at the boys and girls club? Do you babysit your little sister, Go to the library? What is it that you do? And who are their mental health mentors and social supports? Who are the adults that you look up to? And you know, are they available? If they're saying I don't have any and you know, I come home from school and I play video games, I don't have any other pro social involvement. That's something we might want to look at sort of expanding. What's their sexual history as far as their activity, their orientation and any history of STDs or pregnancies? Have they been involved in juvenile justice? What are the developmental milestones? You know, looking for those Ericksonian stages, looking for empathy, looking for their ability to take multiple perspectives and all the Piaget and cognitive stuff as well. You know, just kind of get an idea. You know, how old were you? If you know, when you started talking and you know, have you had problems in school and you know, just look for some of those family history and their home environment, any involvement with DCF and any other strengths that they have. You know, tell me what makes you super awesome. So as I mentioned, adolescents have unique issues. They have differing stages of cognitive development. So, you know, if you work with a 13 year old, they're not all the same. You know, some 13 year olds are more mature. Some, you know, 13 year old girls may be more articulate than some 13 year old boys. Not always, but they're going to mature at different levels. They're going to mature at different rates, cognitively, interpersonally and physically. Hormone fluctuations, again, we have young women that are beginning puberty at 9 and 10 years old now. So you don't want to assume. We also have some people that still aren't beginning puberty until 14 or 15. That's a little on the later side, but we want to just assume know that there are hormone fluctuations going on and talk with the youth about how to identify those and deal with them. So when you're having a really high testosterone day or a really high estrogen day and you're feeling cranky and irritable and whatever, what can you do? How can you handle that? They have underdeveloped impulse control because that prefrontal cortex isn't fully developed until about age 25. They often can't change their recovery environment. Especially if you're dealing with a younger adolescent. They can't say, you know, I'm 14 years old, but I'm tired of this crap, mom and dad, I'm moving out. I worked with one young woman who broke my heart, stuck with me, sticks with me to today. She was 14. And where I came from, evidently 14 years old was how old you had to be before you could get your own apartment. And so she intentionally got pregnant so she could get her own apartment and get on Medicaid and move out of her parents house. So just kind of taking that under advisement, so to speak, that a lot of youth are stuck in whatever dysfunctional environment that they happen to reside in right now. So we need to figure out how to help them survive. That many times parents aren't willing to jump on. They see that identified patient, they're like, here, you fix him. It's not us, it's him. You fix him. And convincing them that it might be more of a family problem may not happen. So in the meantime, we need to help junior how to figure out how are you going to survive this? You know, you can move out when you're 16 or 18 or whatever if you need to. But right now, how can you survive and make this more tolerable? They may respond differently and or cannot be prescribed many psychotropics. I mean we have a lot of those black box warnings that this will cause suicidal ideation in adolescence. So you want to be aware of what the side effects are. And you know, the psychiatrist obviously is. But it also means that their options are limited for pharmacological interventions. Kind of along that a lot of youth are very adept at searching the web for ways to self medicate and feel better. So we do need to be aware that they are more likely to experiment with self medication with over the counter concoctions. Being aware and talking openly about that is going to be really important. They go through individuation and identity development. So they're in turmoil, they're trying to figure out who am I. You know, we're sitting in our chair and we're pretty confident on who we are, but they're not sure who they are. They may know who they don't want to be. You know, I don't want to be like my dad or I don't want to be like my mom. But they may not know who they do want to be. So it's up to us to help them try to figure out what does you look like. They may be unmotivated for change. They're just like, you know, whatever, especially if they're in that toxic environment and they don't see any way out and they feel trapped. So instead of looking at change, you know, let's change your behavior. Let's look at how can I help you survive? Let's change the, change the narrative a little bit. And that may help them get a little bit more involved. Some prefer virtual interaction. You know, video is fine, but they get uncomfortable in face to face settings or they just, they're that much more comfortable talking online. We do have to remember that with adolescents especially there is what I call 24 hour bullying. Instagram, Facebook, Pinterest, you know, you name it. I'm sure there's lots of other resources out there where youth post pictures and make comments and can flame each other and just be really horribly nasty to one another. And a lot of youth self esteem is wrapped up in how many likes they get and how many shares they get. So it's important to remember that even when they're at home from school, they're not safe. They're not safe anymore like we used to be. And there's confidentiality and need for parental consent. And this article here summarizes some of the parental consent laws. It's not a 2018 article, so you still want to check with your legal team about what types of treatment you have to have parental consent for before you can provide it. A lot of states will allow you to do substance abuse intervention without parental consent if the youth presents, but not mental health. So you know, you want to know what your state requirements are. Addictions and mood issues often stem from different causes than for adults. So we want to pay attention to what's going on with you. You know, it could be developmental, it could be, you know, their peer group treatment must address their cognitive stuff. What are the thoughts? Maintaining their behavior and mood. So tell me what you're thinking emotionally. What are their moods? Maintaining their thoughts. If they're in a funk all the time, they're probably going to be looking at the world through pretty dark colored glasses. So we want to address those issues. How can we infuse some happy so to speak. And we talk about doing things that the person enjoys. You know, what is it that really you like to do? Physical, educate about the impact of moods and thoughts on energy, pain and physical health, and the impact of sleep, nutrition and health behaviors on moods. So it's important for them to understand they got to take care of their body socially. You want to look at the impact of moods and thoughts on their relationships. You know, if you're in a funk all the time, how is it impacting your relationship with your parents, with your girlfriend, with your best friend? How is it impacting your health? And how are your relationships impacting your health? Because sometimes relationships may be encouraging them to do things that are not necessarily in their best health interest. And then we can look at moral development, helping them figure out how to make the right or best choice for, for them and why. And it's not always clear. So we want to teach that whole ethical decision making model. And yes, mindfulness exercises are great to help people realize what's triggering their moods and what they need. I'm a big proponent of vulnerability prevention, daily mindfulness as well as teaching adolescents distress tolerance skills kind of from the get go so they can try to get hold of this roller coaster that seems to be going on in their, in their brain. We want to take into account gender, ethnicity, disability status, stage of readiness for change. There's that pool again. And cultural background. Identify and treat delays in normal cognitive and social emotional development associated with substance abuse, neglect, or significant mood disorders during adolescence. When people are really, really depressed in adolescence, they may withdraw. They may, you know, close in on themselves so they don't individuate as much. They don't develop the social skills you would expect for somebody who is, you know, in later adolescence. There may be a lot of social, emotional, developmental stuff that gets stunted because the depression was so oppressive or the anxiety was so overcoming. Involve the adolescent's family as they define it because of its possible role in the origins of the problem and its ability to change the youth's environment. Now, this isn't always possible and sometimes the youth will go, no, I don't want them involved at all. So, you know, you gotta roll with what punches you get dealt. But if you can get family members or even some family members involved so you know that they've got an ally or three, it is helpful in order to make sure that they feel like they've got a lifeline out there. Be sensitive to motivational barriers and strive to form mutually agreeable goals. I'm not Here to tell you not to have sex or, you know, not to do this or that because you're going to do what you want to do. What I want to do is figure out how to help you be happy and healthy and, you know, get your parents off your back or whatever the case is. The youth is there, they have an end goal in mind and usually it's to get out of treatment, but sometimes it's to solve the chaos in the family or something. So I want to know what is your goal for being here and how can we achieve that? Remember that the adolescents fund of experiences is much smaller than ours. So things that seem like a crisis to them may seem less consequential to us. So we want to be sensitive and not go, oh, you know, it'll feel better in a couple days. No, it may not. It may still hurt like hell. So remember how dramatic and how overwhelming just about everything seemed when you were a teenager. When you develop your treatment plan, identify biopsychosocial problems, not just psychological issues, because we know that there are contributing factors. Biopsychosocially identify attainable goals for those issues. Enhance strengths and resources to meet those goals. So refer them out. Give them books to read. Youth like books. Give them websites. They love websites. You know, something that will help them enhance their knowledge and be able to strengthen their skills. Specify objectives. They're realistic and measurable for each goal. So you know, I'd like to see you attending school 19 out of the 22 days this month, you know, and that's a pretty low goal there. And describe interventions needed to achieve objectives. So what do you need to do in order to make sure you get to school on time 19 out of the 22 days. Common treatment plan issues that you might focus on. Wellness behaviors, cognitive distortions, coping skills and distress tolerance, Anger management, communication skills, how to be assertive and create a win win situation. Silencing the internal critic. A lot of adolescent, well, a lot of adults, but a lot of adolescents also have that internal critic, that just that voice inside their head that heckles them constantly. So helping them silence that self esteem development, identity development, goal setting and motivational enhancement. Okay, so you want to go to Vanderbilt when you graduate. How can we do that? What needs to happen? So help them figure out how to set and attain goals. Relationship skills, stress management, time management, vocational counseling. And this may not be your thing, but helping them figure out where do I go to figure out what kind of career might be good for me? And most places have workforce development centers that youth can go to to take interest inventories and explore vocational options. Grief and loss is another issue that comes up a lot, and it can be surviving breakups, dealing with a backstabbing best friend. You know, there are a lot of different types of grief and trauma that youth can experience and body image issues. So treating adolescents requires special skills and training. You know, you don't just want to go in and assume that they're going to be little adults. Most adolescents begin to cope or receive external begin to use substances to cope or receive external validation. So they're trying to numb the pain or, or they're trying to fit in with a peer group. Okay, so we recognize the function of the use. How else can we help you cope? How else can we help you fit in? Adolescents development is often thwarted at the point of problem initiation. So if they have a major depressive disorder or generalized anxiety or substance use, a lot of times development slows way down at that point because the adolescent is just barely struggling to stay afloat. A strengths based motivational approach works well with older adolescents and adolescents can be helped to develop into healthy adults. So even if somebody has had a really tough childhood and adolescence, it doesn't mean that all is lost. They really can develop into healthy, happy, strong, productive human beings. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com providing 24.7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. 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