A Guide to Finding Adolescent Trauma-Sensitive Addiction Treatment

“There are wounds that never show on the body that are deeper and more hurtful than anything that bleeds.” Laurell Hamilton¹

It's hard enough just navigating the everyday turmoil of adolescence. It’s hardly surprising that for teens who experience trauma, alcohol and drugs can become necessary self-medication.

• If your son or daughter has survived a traumatic experience, be on the lookout for lingering trauma stress symptoms, know that these won’t necessarily go away on their own and that without healing, trauma stress symptoms can snowball into life-long problems.
• And if trauma co-occurs with substance abuse (and it often does, for many reasons) know that alcohol and drugs impair a person’s ability to get past trauma stress and that trauma stress complicate addiction recovery.

Fortunately, effective treatments exist and the quicker you address either trauma or trauma and substance abuse, the better the prognosis.

Read on to learn more about

1. What causes teen trauma stress and the warning signs of a problem to watch for.
2. Information on when to seek help.
3. Information on the importance of trauma-sensitive care (trauma-insensitive care can actually worsen the situation) – what defines it, where to find it and how to evaluate different programs.
4. What parents can do at home to help.

What Is Trauma?

Any situation in which a person fears for their life or safety or for the life and safety of a loved-one can lead to traumatic stress, for example: a car accident, a violent assault, the traumatic death of a loved one, a life-threatening illness, natural disasters, war, sexual or physical abuse and many others.

Trauma can be acute – such as a mugging, or chronic (several incidences occurring over a period of time). Some examples of chronic traumatic stress include childhood neglect, chronic sexual or physical abuse or ongoing domestic violence situations.

Some trauma-exposed teens experience few or no later consequences, while others may develop PTSD. Therefore, parents need to learn what to watch for and be prepared to intervene with help if necessary.

Warning Signs of Adolescent Traumatic Stress

Post traumatic stress disorder symptoms generally fall into three categories:

1. Re-experience – Flashbacks, nightmares, physical or emotional responses to reminders (triggers).
2. Avoidance – Avoiding anything and anyone that reminds of the event. This may also lead to feelings of disassociation.
3. Arousal – Feeling constantly on-guard, increased jumpiness and agitation, being easily startled and quick to anger, having difficulty concentrating.

After trauma exposure, be on the lookout for the following warning signs which may indicate traumatic stress:²

• Starting to take unhealthy risks
• Signs of depression
• Increased irritability or jumpiness
• Problems at school
• Getting upset or angry more quickly and easily than in the past
• He or she feels like they’re going crazy
• He or she feels different from everyone else
• Sudden antisocial behavior change – becoming more oppositional, ignoring social norms, risking the safety of self and others
• Becoming suddenly sexually active
• Talking about the traumatic event in exceptional detail
• Avoiding places or people that remind of the traumatic event
• Sleep disturbances
• Numbing symptoms - saying that they have no feelings at all about the traumatic occurrence
• Using unhealthy coping mechanisms, like alcohol or drug use, cutting or disordered eating

Traumatic stress symptoms usually start quickly after the traumatic event but in some cases, symptoms may not emerge for months after the fact. Symptoms that persist for more than 4 weeks without dissipating indicate a serious problem.³

The Importance of Dealing with Traumatic Stress

Whether or not traumatic stress leads to substance abuse, if your child isn’t coping well after trauma, it’s important to intervene. Unresolved trauma can cause emotional, cognitive and behavioral problems that can worsen over time.

Adolescents who struggle with trauma may experience delays and deficits in emotional and behavioral regulation, and this can lead to a range of consequences, such as:

• A diminished ability to consider the likely consequences (risks and dangers) of an action – this can lead to reckless and dangerous behaviors.
• Or the opposite reaction - becoming overly fearful and unwilling to face any risks – this can delay maturation and psychological growth.

Trauma can also derail academic and social performance.

• Teens struggling to cope with traumatic memories may have trouble focusing on schoolwork or attending to friends and forming normal beneficial relationships.

How Are Trauma and Substance Abuse Linked?

If you have one, you’re more likely to have the other - for example:

• Teens with a history of physical or sexual abuse are 3 times more likely to report past or present substance abuse than teens without any history of trauma.
• Some studies indicate that up to 59% of teens with PTSD will develop a substance abuse problem.
• A survey study of teens enrolled in addiction treatment programs found that 70% had a history of trauma.⁴ 

Teens coping with trauma may turn to drugs or alcohol for self medication or escape and teens who abuse alcohol or drugs tend to engage in activities that increase the risks of trauma exposure (sexual assault, car accident, etc.) In fact, for more than half of teens with trauma and substance abuse issues, substance abuse preceded trauma.

Teens with substance use disorders are also more likely to develop PTSD after trauma than teens without substance use disorders. The compromised emotional, social and cognitive functioning that co-occurs with adolescent substance use disorders likely also reduces a teen’s ability to cope with trauma exposure.

When to Seek Help

For substance abuse:

• Though you’d never want to consider residential care until you’ve fully explored progressive levels of stay-at-home interventions, you’d definitely want to consider some form of treatment should (persistent) drug or alcohol use become problematic.

For trauma:

• Though a person might experience severe trauma stress in the first days after an incident, stress symptoms usually dissipate and you start to feel better within a few days or weeks.
  
• Seek help when an adolescent experiences lingering trauma symptoms that worsen or don’t diminish in intensity over time, when symptoms are severe enough to interfere with normal functioning or when symptoms are highly distressing.⁵

So whenever you’re dealing with a situation where severe persistent trauma symptoms co-occur with drug or alcohol abuse you should strongly consider professional help.

1. A person may be self-medicating severe symptoms with drugs or alcohol, and since untreated stress symptoms may not go away on their own, this can easily lead to serious addiction issues.
2. Alternatively, when substance abuse precedes trauma, the drug or alcohol use can diminish a person’s ability to bounce back from trauma and so the substance use worsens the situation.

In the next sections:

• How trauma affects treatment needs
• Finding a trauma-sensitive treatment provider
• Elements of effective care for teens with trauma and substance abuse issues
• Beyond professional help – what parents can do at home to help

How Does Trauma History Affect Treatment Needs?

A trauma history complicates the addiction recovery process.

• Integrated treatment is important - When trauma and substance abuse get treated separately, post-treatment relapse is more likely.
• In general – a history of abuse worsens treatment outcomes.
• Teens dealing with trauma and substance abuse are less likely/able to heed warnings about the consequences of actions, change peer groups and find other ways to have fun or manage stress or negative emotions.
• Teens struggling with PTSD and substance abuse have more difficulty maintaining recovery since trauma reminders increase drug and alcohol cravings - Emotional and environmental triggers can spark traumatic stress symptoms and drug or alcohol cravings.

The Importance of Integrated Treatment

While a drug abusing teen without a trauma history might experience cravings when confronted with people, places or things that trigger memories of using, a teen with a trauma history would also experience cravings when exposed to anything that triggers reminders of past trauma. Unless a person can learn to manage these emotional trauma reminders, relapse is likely. For this reason, substance abuse treatment needs to also address trauma symptoms.

Take Home Message

1. Teens with traumatic stress benefit from integrated treatment that addresses the linkages between substance use and traumatic stress.
   
2. Because a trauma history complicates treatment outcomes, it’s important to intervene early, to stay involved with treatment throughout the continuing care phase and to be ready to re-engage with treatment should relapse occur.
   
3. Since trauma complicates treatment, a teen with trauma and substance abuse issues will likely need more intensive treatment than a teen facing only one of these significant challenges.⁶

Finding an Integrated Program – What to Look For

The importance of trauma-informed care.

The last thing you want to do is make the problem worse, and unfortunately, treatment practices that aren’t sensitive to the needs of trauma-affected youth can do just that:

• Imagine how forced transport to a treatment facility or military style confrontation tactics at a boot camp could worsen feelings of mistrust and helplessness.
  

When looking for a treatment provider, one of the first things you want to look for is ‘Trauma-Informed Care’. Programs offering trauma-informed care are different from conventional treatment programs in 2 important ways:

1. They don’t worsen the trauma

Since certain treatment practices may trigger trauma symptoms or even re-traumatize, trauma-sensitive programs strive to promote a safe and welcoming atmosphere at all times and deliver interventions that provide hope and empowerment to youth. All staff members are trained to be trauma-aware.

2. They offer trauma-specific interventions

These interventions address the trauma and help young people learn to self regulate behaviors and emotions.

An effective trauma-sensitive treatment program will make emotional and physical safety an absolute top priority, be aware and sensitive to client boundaries and work to promote client trust.⁷

Elements of Effective Trauma-Sensitive Treatment

OK – so you need to find a provider or program that will treat trauma symptoms and substance abuse/addiction at the same time and you should definitely prioritize finding a trauma-sensitive program – but beyond this, what else should you look for when searching for an effective program for your son or daughter?

Well, according to The National Child Traumatic Stress Network (NTCSN), when looking for an adolescent trauma + substance use disorder treatment program/provider, here’s what to look for:⁸

• The provider offers more intensive treatment options for youth and families dealing with trauma and substance abuse (so while youth in an outpatient substance treatment program might attend 2 sessions per week, youth with trauma issues might attend 3 and have an additional weekly family session on top of that, for example.)
• The provider strives to build a collaborative, open and trusting relationship.
• The provider emphasizes managing both substance abuse and trauma symptoms right from the start of treatment.
• Relapse prevention skills for both trauma symptoms and substance use are taught early in the program.
  
• The program includes skills training on stress management (relaxation training, re-framing, etc.) and on dealing with negative emotions (identifying emotions, communicating effectively, working to improve negative emotions.)
• Therapy staff use cognitive behavioral techniques to teach ways to correct and overcome negative thinking patterns.
• The program offers social skills training, if needed.
• The provider links teens and family members to community resources, such as mutual self-help groups.
• The program offers an educational component, to teach youth and family members about trauma and substance use disorders, and to encourage reasonable expectations.
• Parents are encouraged to get involved in the treatment process, hopefully to increase parenting, conflict resolution and communication skills. Parental involvement is very important. When parents get actively involved in treatment and are willing to work with treatment providers the odds of a positive outcome go up.

Finding a Trauma + Addiction Treatment Program

One tool you can use to discover your local trauma-sensitive programs is SAMHSA’s Mental Health Treatment Locator Tool.

Instructions:

1. Use the locator tool to find a list of all mental health providers in your area
2. Once you have this list, click on the ‘Change Service Selections’ button.
3. In the advanced search menu, click on the button linked to the correct age group, the button next to ‘Individuals with PTSD’ and the button next to ‘Individuals co-occurring mental and substance abuse disorders.’
4. Click submit and you’ll receive a list of trauma-sensitive teen addiction treatment providers in your area.

Choosing a Trauma-Sensitive Treatment Program

Finding a program that uses evidence-based interventions.

When interviewing prospective providers or staff members at prospective programs you should ask about trauma interventions.

1. Interventions with research proving their effectiveness are called evidence-based programs, and SAMHSA keeps a registry of these programs that you can access.
   
2. Ask any provider under consideration which evidence-based trauma programs they use.
   
3. Then visit the evidence-based program registry to learn more and to evaluate for yourself the appropriateness of the intervention for your situation.

Here is a link to the evidence-based registry and to 24 evidence-based trauma interventions for youth from ages 13 – 25. 

Programs that make use of evidence-based interventions are likely more effective than programs that do not.

What Can Parents Do at Home?

Teens dealing with trauma are at increased risk of substance use and abuse, criminal activities, anxiety and other psychological disorders and social and legal problems.⁹

The two things that help most to mitigate these increased risks are:

1. Early professional intervention
2. Parental support

So when trauma symptoms persist for weeks and cause significant distress, it’s important that you seek professional help, and since the longer symptoms endure the greater the developmental damage (like a snowballing effect) it’s important to act without delay.

But though professional treatment is essential, trauma-sensitive parenting practices can also help your teen cope with traumatic stress. Given this, consider the following parenting practices:¹⁰ 

• Help your teen deal with guilt – survivor guilt is a common phenomenon after trauma. Talk to your child about feelings of guilt and work on identifying what he or she is and is not responsible for. This can help your child to let-go of inappropriate guilt and shame.
  
• Try to understand what triggers reminders and trauma symptoms and know that triggers can lead to a loss of behavioral or emotional control. Be patient and supportive.
• Help your teen get past embarrassment that might block open communication. Make sure your teen knows that their post-trauma emotional reactions are normal and nothing to be ashamed of. Try to get them talking about their feelings.
• A traumatic event can cause a major shift in your teen’s world view and this can lead to a lot of anger and disruptive impulses. Talk about this and try to help your son or daughter find constructive ways to express their emotions. Finding a constructive outlet reduces feelings of helplessness and reduces the potential consequences associated with engaging in antisocial acts as an alternative outlet.

Parents can also aid in recovery by:

• Encouraging normal sleeping and eating habits and patterns.
• Encouraging a reconnection with supportive friends and loved-ones in the community.
• Encouraging participation in any personally relevant spirituality or faith community.
• Encouraging participation in community support groups.¹¹