How do we help today's young people with substance misuse?

How do we help today's young people with substance misuse?

A young person shares his thoughts at DHI's Just Say It! event

By Phil Harris

If you were born in 1999, your life course would have traversed the most seismic shifts in the UK’s drug culture. Back then, familiar drugs were distributed through stable networks in renowned neighbourhoods. Few predicted the proliferation of new psychoactive substances -legal highs - that were developed faster than could be tested. Skunk, a rarity back then, is now a UK net export. Buying drugs on the ‘Dark Net’ has challenged old monopolies of established dealing. It has also meant that drug distribution follows rapidly changing neighbourhood-based patterns of use, rather than a stable national pattern of consumption. Cross county lines dealing has extended city-style dealing into rural corners.

Despite these changes, drug and alcohol use has been in decline in young people. Young people are now more screen time dependent that drug dependent. Ironically social media has reinvented an old social pressure related to intoxication that had been lost. When we drank in local pubs, unacceptable threshold of consumption was observed by family and neighbours. The move to anonymous city bars and clubs removed this informal social pressure on consumption. Now, Snapchat and Instagram have recreated these old social pressures, where image conscious youth now fear their least flattering moments of intoxication can be shared with the whole world forever. In ‘real’ worlds, wider enriching experiences such as travel, high performance sports, outdoor pursuits and novel challenges compete for time, money and interest. And cultural knowledge of the impact of substance use has diverted many young people away from experimentation.

These shifting currents have revealed an interesting washout effect. As casual drug use has declined it has revealed a more clearly identifiable pattern of problematic use. For example, increasing access to legal highs did not create ‘new’ treatment populations. Instead, the same high risk groups diversified. Likewise, decriminalisation of cannabis in the US has also identified that greater access to the drug was only problematic for those who already had high levels of use prior to legalisation. Young people do not have problems with drugs and alcohol; certain young people have problems with drugs and alcohol.

Research has shone a deeper light into patterns of problematic use. The evolution of drug and alcohol problems is multi-causal, with risk factors emanating from both the biological, psychological and environmental domains. These risk factors are accumulative - meaning that they snowball. So just by the accident of your birth, in-utero experience, genes, post-code and the established patterns of family use have already given the child a stacked hand. These risks are then activated by initiation factors like positive expectations of use, peer norms and impatience for adulthood that open up more risk. Continued involvement brings new confidence, new contacts and new drugs. Alienation and lack of opportunity allows use to fulfil the meaning gap in people’s lives. And as consequences of use increase, so does consumption as a form of stress compensation. Risk factors chain together link by link.

Furthermore, the underlying risks in young people’s lives cluster, creating highly predictable pathways of involvement. This includes an early onset group whose lives are characterised by transgenerational poverty, poor parental support and poor impulse control such as ADHD and Conduct disorders. A mid-onset initiation group occurs alongside a huge spike in mental health diagnosis: 50% cent of all mental health diagnosis in the UK is made on 14 year olds. 75% of diagnosis is made by the age 20 as young people experience a peak in internalised disorders such as depression, anxiety and self-harm. Our later onset groups are ‘peer involved’ young people who initiate use after the age of 14. These are largely stable-background youths who enter into peer driven use. And then finally there are ‘Fling’ users, these are students who are the highest drug and alcohol consumers but for short intense periods of time.

Research also shows that the onset of first use predicts the length of a users’ career. The Montreal Longitudinal and Experimental Study of over 1,000 males from impoverished neighbourhoods in Canada examined drug and alcohol use at age 17, 20 and 28. The results confirmed that the younger they started smoking cannabis, the more likely they had a drug problem later. Those who started before age 15 were at higher risk of problematic use, regardless of how often they consumed drugs at this age.

The Dunedin studies in New Zealand followed over 1,000 people born in 1972. This study found that just 20 per cent of the sample accounted for 81 per cent of criminal convictions, 66 per cent of welfare benefits, 78 per cent of prescription fills and 40 per cent of excess obese kilograms. They grew up in socioeconomically deprived environments, experienced maltreatment and exhibited low childhood self-control. This research has been augmented by Adverse Childhood Experiences (ACEs) studies in the US, which again have found high correlations between early deprivation and trauma with later health, mental health, domestic violence, suicide and substance misuse patterns in adulthood.

Social policy and the substance misuse field in general has been slow to understand and respond to the implications of this research. A recent large scale meta-analysis of 453 Randomised Control Trials involving 31,933 participants that spans 53 years found the effectiveness of youth interventions remained stagnant during this time. Specifically, treatment effectiveness increased non-significantly for Anxiety. Treatment effectiveness has decreased non-significantly for ADHD whilst the effectiveness of treatment for Depression and Conduct problems has worsened over the last 50 years.

So whilst the number of young people presenting for help has decreased, the complexity levels of those who do present has increased. Those in the field of youth work must recognise that we are now operating in a realm of need beyond social education and befriending but one of more acute mental health needs in a grossly underfunded sector. There is reticence in the field to identify young people’s needs specifically for fear of “labelling” young people. However, there is no evidence that diagnosis worsens young people’s conditions. Failure to better calibrate young people’s needs, and tailor their treatment accordingly, may be contributing to worsening outcomes for the most vulnerable young people.

The improvement of treatment outcomes for young people demands better understanding of their pathways and profiles. Interventions must begin to take better account of the specific drivers and profiles of use within each pathway. The inability to control impulsive behaviours is a different therapeutic challenge to Depression. Treatment intensity must also better reflect the underlying social functioning levels of young people that have become curtailed through substance involvement.

This should be combined with new approaches to interventions. For example, real time feedback processes to track and inform young people’s progress in treatment. Technology offers new a new world of opportunity in adapting and developing specific interventions matched to neural systems implicit in young people’s clinical profiles. This is not treatment as usual that is simply delivered online via the internet. Computer games like Go-Stop Tasks have improved impulse control in young people, Erickson’s Flanker Test improves concentration, Working Memory tests reduce cravings, Emotional Recognition Challenges improve depression and virtual reality holds promise to reduce anxiety. These games ‘work’ brain systems that improve their functioning and reduce presenting symptoms with practice. These approaches are often more attractive to screen-savvy youth. The introduction of such procedures has helped double to triple young people’s expected outcome in projects across Wales and Cornwall.

All too often young people are regarded by adults as a blank screen to project what they feel is wrong with the world or what they feel should be right in the world. At worse this has led to the politicisation of youth work whilst at its best we have simply drawn down adult models for the not yet adult. The history of effectiveness of young people’s services does not support either position. Instead we need to draw upon the increasing weight of research that illuminates what it is to be young and translate this into more developmentally informed approaches. This requires the profound acceptance of one central fact: we cannot make young people us but we can help young people become themselves.

This article was written for The Vision Project by Phil Harris. Phil has worked in community services field for over 25 years as a practitioner, trainer and manager.

If you found this article interesting, you might like to find out more about DHI's Young People's Services.

DHI has invited the author to write the above article. The views and opinions expressed in this article are those of the author and do not necessarily reflect the views, opinions, policies or otherwise of DHI.

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