Download Active listening - ACH Pediatric Residents

Pediatric Resident Academic Half Day
June 7, 2012
Ellie Vyver, MD, FRCPC
Division of Adolescent Medicine
Objectives
To examine substance abuse in the larger
context of social determinants of health
 To learn about adolescent susceptibility to the
effects of substances
 To have an understanding of risk and
protective factors as well as resiliency
 To be familiar with national, province and
local rates of substance use
 To develop an approach to the adolescent
using substances

The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011: Youth
and Young Adults – http://publichealth.gc.ca/CPHOreport
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
SUMMARY

Canadian youth are leading healthy lives

Subpopulations like aboriginal youth, street
involved youth, or sexual minorities are more
vulnerable to particular health or socio-economic
issues
Cost of Substance Abuse
Results of the Costs of Substance Abuse in
Canada 2002 study released in 2006
 Abuse of tobacco, alcohol and illegal drugs
cost Canadians about $40 billion ($18 billion
in 1992)
 Cost to Alberta was $4.4 billion ($1.6 billion
in 1992)

 Tobacco $1.8 billion for AB (Canada $17 billion)
 Alcohol $1.6 billion for AB (Canada $14.6 billion
 Illegal drugs $1 billion for AB (Canada $8.2
billion)
Cost of Substance Abuse

Costs by category for Alberta:
 Indirect costs (productivity losses): 63%
 Direct health care costs: 23%
 Direct law enforcement costs: 11%
 Other direct costs: 3%
Developmental Tasks of Adolescence






Development of self-esteem and a healthy identity
Emancipation from parents to autonomous
behaviors
Formation of a sexual identity
Meaningful social and peer relationships
Seeking vocational goals
Establishing moral and ethical values
Adolescent Brain Development
and Susceptibility

Period of significant brain development
 Increase in white matter volume
○ M>F
○ Reflects increased myelination
 Increase in gray matter volume in
preadolescence followed by decrease
○ Changes in frontal lobe involved in
development of executive functioning
 Emotional regulation
 Planning and organizing
 Response inhibition
Giedd et al., Brain development during childhood and adolescence: a longitudinal
MRI study. Nat Neurosci 1999;2:861
Gogtay N., Giedd JN., Lusk L., et al. Dynamic mapping of human cortical
development during childhood through early adulthood.
Proceedings of the National Academy of Science 2004;101(21):8172-8179
Dopamine
Synthesis in Preadolescent <
Adolescent < Adult
 Large increase in levels and activity
during adolescence
 Large role in reward circuitry of the brain
that fuels drug addiction

Hippocampus
Increases significantly in size during
adolescence
 Levels of dopamine in the hippocampus
show large increase
 Involved in new memory formation

Risk and Protective Factors

Terms used to identify aspects of
individuals or their environments that
make development of a given problem
more or less likely
Health Canada, 1999
Risk Factors

Defined as either life events or
experiences that are statistically
associated with an increase in
problematic behaviour such as
substance use
Protective Factors
Defined as the life events or
experiences that mitigate the effects of
risk factors and reduce the likelihood of
problematic behaviour
 Increase RESILIENCY

Resiliancy
The ability to overcome
adversity
Risk and Protective Factors

Can be categorized into five different
domains:
1. Individual
2. Family
3. Peers
4. Schools
5. Community
Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE: Monitoring the Future national
survey results on drug use, 1975–2006. Volume I: Secondary school students. Bethesda, MD:
National Institute on Drug Abuse; 699. (NIH Publication No. 07-6205)
Domain
Protective Factors
Risk Factors
Individual
High intelligence
Achievement oriented
Optimistic view of future
Good coping skills
Untreated mental
health/behavior problems
School problems
Genetic vulnerability
Early pubertal development
Rebelliousness
Perception that most peers use
Undiagnosed/untreated ADHD
Low religiosity
Perception drug use as low risk
After school employment
Prosocial values
Perception most peers don`t use
Treated ADHD
High religiosity
Perception drug use has risks
Family
Clear messages about no use
Parents model appropriate use
Strong attachment
Parental monitoring
Supportive parents
Unclear messages, expect use
Substance abuse
Alienated from family
Permissive or coercive parenting
Lots of conflict
Domain
Protective Factors
Risk Factors
Peers
Do not use
Prosocial values
Peers use
Peers alienated from
community
Schools
Offer opportunities for success
and involvement
Feel connected to school
Personnel seen as fair and caring
Poor quality
Adequate recreational activities
Strong community institutions
Media realistically portrays harms
Counter marketing
Lack or recreational activities
Community institutions lacking
Media portrays as normative
and promotes positive
expectancies
Lack of community norms
about use
Substance abuse common
Drugs easily available
Socioeconomic deprivation
Community
Feel alienated from school
Personnel seen as uncaring
TRENDS
Top 3 Substances

ALCOHOL

CANNABIS

TOBACCO
ALCOHOL
National Alcohol Use Data
CAS 04
15-24
N=
CADUMS
08
15-24
CADUMS
09
15-24
CADUMS
10
15-24
2,085
1,443
955
3,989
Lifetime
Use
90.0
[85.4-93.2]
83.5
[79.7-86.8]
81.8
[77.6-85.4]
79.0
[76.8-81.1]
Past 12
month Use
82.9
[79.8-85.6]
78.4
[74.2-82.1]
75.5
[70.8-79.6]
71.5
[69.1-73.9]
Age of
initiation
(years)
15.6
[15.4-15.7]
15.6
[15.4-15.8]
15.9
[15.7-16.2]
15.9
[15.8-16.0]
Alcohol
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
Alberta Data for Alcohol Use
CANNABIS
National Cannabis Use Data
CAS 04
15-24
N=
CADUMS
08
15-24
CADUMS
09
15-24
CADUMS
10
15-24
2,085
1,443
955
3,989
37.0
[33.4-40.6]
32.7
[28.3-37.4]
26.3
[22.0-31.1]
25.1(*)
[22.8-27.3]
Cannabis lifetime
61.4
[57.7-65.0]
52.9
[48.1-57.6]
42.9
[37.9-48.0]
41.4(*)
[39.6-43.2]
Age of
initiation
(years)
15.6
[15.3-15.8]
15.5
[15.2-15.8]
15.6
[15.2-16.0]
15.7
[15.5-15.8]
Cannabis
use
Cannabis –
past year
How do Alberta Youth Compare?
The majority (83.7%) of students in Grades 7
to 12 report that they are not currently using
cannabis
 16.3% of students indicate that they have
used cannabis in the past 12 months
 Males (16.7%) and females (16.0%) are
equally likely to report using cannabis
 Older students are more likely to use
cannabis.
 Highest use in Calgary compared to rest of
province

TOBACCO
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
Alberta Youth and Tobacco

Overall, rates of smoking among students in
Grades 7 to 12 are low
 Most students (95.3%) are not current smokers.
 Older students are more likely to smoke
Among all students, 69.7% reported they had
never tried smoking tobacco.
 Equal proportions of males and females are nonsmokers (95.4% and 95.2% respectively)
 The percentage of all students who had ever
smoked a cigarette, even just a few puffs,
increased from 10.0% among students in Grade 7
to 47.8% in Grade 12
 Calgary has the lowest rate of current smokers
(5.2%)

Illicit Drugs
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2011:
Youth and Young Adults – http://publichealth.gc.ca/CPHOreport
Illicit Drug Use in 15-24 y.o.
Past-year use of at least one of cocaine
or crack, speed, hallucinogens, ectasy,
and heroin decreased from 11.3% in
2004 to 7.0% in 2010.
 The rate of past year use of any drug
excluding cannabis is almost nine times
higher than that of adults (7.9% vs.
0.8%)

Alberta Youth and Illicit Drugs
Majority of Alberta students (78.7%) have not
used illicit drugs (excluding cannabis)
 Illicit drugs most frequently used are MDMA
or ecstasy (3.7%) and hallucinogens (4.0%)
 Males (19.1%) and females (23.6%) have
similar rates of illicit drug use (excluding
cannabis)
 Increase in the proportion who use illicit drugs
(excluding cannabis) as grade increases.

 8.9% in Grade 7
 27.4% in Grade 12

Calgary has one of the highest rates of illicit
drug use in the province
SALVIA
Salvia
Salvia divinorum
 Herb found in Southern Mexico; leaves are
very potent
 Atypical psychedelic
 "la pastora" / "the shepherdess", "the leaves
of the shepherdess", "diviner's mint“,
"diviner's sage“
 Smoked or leaves chewed
 Often tried once and not again as can cause
very dramatic and frightening hallucinations

“BATH SALTS”
Bath Salts
3,4-methylenedioxypyrovalerone (MDPV)
Stimulant
Effects comparable to amphetamines
Most often taken by insufflation but reports of
taken orally
 Liked for its euphoria and increased sense of
mental alertness, productivity, sociability,
creativity, and sexual arousal
 Associated with compulsive, repeated dosing:
“FIENDING”
 With fiending or high doses more likely to cause
hallucinations and psychotic behaviours




Erowid.org
A 15 year old female presents to the ER intoxicated.
Ambulance was called by her friends after she was found
passed out outside at a party. Her parents are not yet aware
that she is in the hospital.
What
are the medical issues to consider?
 What tests do you plan to order?
 Are there any questions you’d like to ask before
ordering these tests?
 Will you contact her parents?
oWhat will you tell them? How will you tell them?
o What assumptions might you make about her
family?
 What is the legislation in Canada about calling
parents?
Approach
Confidentiality
 HEEADSSS
 Screen for problematic use
 Disclose drug screening tests
 Give results without parents present
 Motivational interviewing

Consent to Treatment
Consent is a “process” by which patients
and/or their parent or guardian are provided
with a clear understanding of a proposed
procedure or treatment and the options
available. This is done in the context of the
medical needs of the patient. The process
results in a decision by the patient or
parent/guardian to otherwise what would be
assault.
Age of Consent?
For medical care
Not in Canada; except Quebec
The Legislation
Basic premise:
Any person of any age can request medical care.
HCP responsible for:

Providing information for informed consent

Determining that the young person is capable to consent
HEEADSSS
H – Home Environment
 E – Education and Employment
 E – Eating
 A – Activities
 D – Drugs
 S – Sexuality
 S – Suicide/depression
 S – Safety from injury and violence

Screening for Problematic Use

CRAFFT
 C – Have you ever driven a CAR or driven with





someone else while high or drunk?
R – Do you ever use drugs to RELAX, feel
better, or fit in?
A – Do you ever drink or get high ALONE?
F – Do you ever FORGET things while drinking
or using drugs?
F – Do your FAMILY or FRIENDS ever tell you
to cut down on drinking or drug use?
T – Has your alcohol or drug use ever gotten
you in TROUBLE?
Stages of Drug Use
Stage 0: No drug use
 Stage 1: Experimentation
 Stage 2: Regular use
 Stage 3: Abuse (as defined in DSM-IV)
 Stage 4: Dependence (as defined in
DSM-IV)

Stages of Change Model
(Prochaska and DiClemente)
From the client’s perspective
Maintenance Stage
Action Stage
“I am aware of what I need to do to
prevent relapse”
“I am doing what is needed
In order to change”
Preparation Stage
“I am looking at what I need
To do in order to change”
Contemplation Stage
“I may have something
I would like to change”
Pierre Leichner M.D.
Relapse Stage
“I need to review what I need for
change to occur”
Precontemplation Stage
“ I do not need to change. I don’t have a
Problem, they do”
Stages of Change Model
(Prochaska and DiClemente)
From the helper’s perspective
Action Stage
-Active listening
-Supporting change activities
-Encouraging rewards for action
-Supporting countering activities
Preparation Stage
-Active listening
-Elaboration of plans and goals
-Developing decisional balance
-Identifying supports
-Do not expect action
Maintenance Stage
-Active listening
-Provide recognition and support
-Be prepared for relapse
-Monitor and revise plan
Relapse Stage
-Active listening
-Reviewing progress
-Maintaining positive attitude
-Support learning from past events
Contemplation Stage
-Active listening
-Giving feedback / information
-Encouraging exploring issues
-Weighing pro’s and con’s for change
-Do not expect action
Pierre Leichner M.D.
Precontemplation Stage
-Active listening
-Looking for common ground
-Providing information and feedback
-Do not expect action
The Real Stages of Change Model
Action Stage
Maintenance Stage
Preparation Stage
Relapse
Stage
Contemplation Stage
Precontemplation Stage
Motivational Interviewing What is it?

Evolved from experience in the treatment of problem
drinkers

First described by William Miller in 1983 in an article
published in Behavioral Psychotherapy

Elaborated by Miller and Stephen Rollnick:
Motivational Interviewing: Preparing People for
Change (2nd edition) (Miller/Rollnick) (April 2002) (First
edition in 1991)

Meta-Analysis of Research on Motivational
Interviewing Treatment Effectiveness (Marmite, 2005)
reviewed 72 studies on MI and showed efficacy
Annabelle Blanchet M.D.
MIT - How to do it?

Directive, client-centered counseling style for
eliciting behavior change by helping patients to
explore and resolve ambivalence

Central purpose is the examination and resolution of
ambivalence, and the counselor is intentionally
directive in pursuing this goal.
Annabelle Blanchet M.D.
MIT – General Principles (DARES)

Develop Discrepancy

Avoid Arguments

Roll with Resistance

Express Empathy

Support Self-efficacy
Annabelle Blanchet M.D.
Develop Discrepancy
 The patient rather than the listener should present
the arguments for change
 Change is motivated by a perceived discrepancy
between present behavior and important
personal goals or values
Annabelle Blanchet M.D.
Roll with Resistance & Avoid Arguments
 Avoid arguing for change
 Resistance is not directly opposed
 New perspectives are invited but not imposed
 The patient is a primary resource in finding answers and
solutions
 Resistance is a signal to respond differently
Annabelle Blanchet M.
Express Empathy
 Acceptance
 Skillful
facilitates change
reflective listening is fundamental
 Ambivalence
is normal
Annabelle Blanchet M.D.
Support Self-efficacy
 A person's belief in the possibility of change is an
important motivator
 The patient, not the counselor, is responsible for
choosing and carrying out change
 The counselor's own belief in the person's ability to
change becomes a self-fulfilling prophecy
Annabelle Blanchet M.D.
MIT & Youth

High ambivalence

Developmentally - questioning authority

Cohersive approach likely unsuccessful

The invulnerable teen

The maturing brain and lack of experiences
Annabelle Blanchet M
Treatment - What works?
Limited evidence related to efficacy of
treatment approaches for adolescents
 Concurrent mental health problems
need to be included as part of treatment
 Challenges:

 Retention/attrition: drop out rate as high as
50-67%
 Access
 Relevance
Treatment
Youth substance use programs should not
use the same treatment approaches that are
used for adults
 Treatment should encompass elements of
family, school, peers, and community
 Consistent theme in the literature regarding
the importance of addressing family issues
 Treatment plan that is flexible and responsive
to the unique needs of the individual youth

Treatment
Research dose not indicate which
treatment modalities are most effective
 Options include:

 Individual outpatient counselling
 Family-centered practice
 Experiential learning
 Wilderness-based
 Detoxification and stabilization
 Residential
Treatment
Harm Reduction
Vs
Abstinence-based
Harm Reduction
Focus shifted away from eliminating use
 Aims to reduce related risks by
modifying the behaviour (which may
include eliminating use)
 Accepts that youth may choose to use
substances
 Acknowledges the potential health and
psychosocial risks

Addiction Services for Youth
PChAD Act
The Protection of Children Abusing Drugs Act
 Act came into effect in Alberta July 1, 2006.
 Purpose is to give parents and guardians an
option to help their children (under age 18
years) whose substance use has caused

 Significant physical, psychological or social harm
to themselves OR physical harm to others
AND
 Refusing voluntary addiction treatment services
What have we learned?
Canadian youth are generally living healthy
lives and transitional well into adulthood
 Many social determinants influence health
 Subpopulations like aboriginal youth, street
involved youth, or sexual minorities are
more vulnerable
 Alcohol, cannabis, and tobacco are the
most commonly used substances and use
of them has been decreasing over time
 Key approaches are motivational
interviewing and harm reduction
