Adolescents and Brain Development
For the past five years I’ve overseen an adolescent substance abuse treatment center in southern Turkey, near the Syrian border. The boys are between the ages of 13-20, with solvents and inhalants as their primary drug of abuse. Working with teenage boys is a challenge—and I thought raising my own two teenage daughters was interesting! Since the 1990s, there has been an explosion of information on brain development. For centuries, science thought that brain development was complete by adolescence. Emerging science has taught us that brain maturation may not be complete until about age 25. The immature brain has less brake on its “go system.” Regions of brain serving primary functions (motor/sensory systems) mature the earliest. Temporal/parietal association cortices (language/spatial attention) mature next. Higher order functions, such as prefrontal/lateral temporal cortices that modulate basic attention, mature last.
Brain development triggers puberty, increases efficiency in energy utilization and gives rise to cognitive development and neuro-biological functioning. For the adolescent brain, there is often a preference for physical/sensory activities, higher levels of excitability, activities with peers that trigger high intensity/arousal, and novelty. At a less optimal level, adolescent brain development may have difficulty balancing emotions and logic in decision-making, and considering negative consequences for their actions. This leads to a greater tendency to risk-taking behavior and impulsiveness. Thus, the immature brain equals lower brain power, and an absence of judgment. Drugs can further hijack these activities as well as dopamine activity.
Effective Treatment Approaches
Because of the impact of drugs on the adolescent brain, over the past five years, in the development of the Turkey treatment center, I have learned that treatment needs to address a number of key issues:
1. We need to discuss with youth the science of neurobiology and addiction, as well as the implications of using as a teen.
2. Provide a milieu that is teen-friendly, marked by structure, rules, recreation, sensory activities, peer community, and novelty.
3. We need to teach skills that are not optimized yet by the teen brain, such as, impulse control, “second thought” processes, social decision-making, how to deal with risky situations, and how to take healthy risks.
4. Since over 50% of the youth who relapse did not expect substances to be in use in the situation where they relapsed, did not think about using beforehand, and use was done in the presence of new friends, treatment needs to prepare teens for these situations.
5. 12 Step programs work well with teens because they provide an abstinence model that allows the teen’s brain to deal with the toxicity of drugs. 12 Step programs further promote “novelty,” new approaches to life. They offer structure (the Steps), a spiritual component (reasons to live), and fellowship, friendship, and sponsorship, i.e., role modeling.
6. Research has shown that Cognitive Behavioral Therapy and Motivational Interviewing (MI) approaches are particularly helpful with adolescents because they offer immediate, relevant, and specific problem solving, and solutions that are realistic and concrete.
7. MI is especially helpful because it de-emphasizes labels, emphasizes personal choice and responsibility, focuses on eliciting the client’s own concerns and solutions, and provides goals that are negotiable and client-centered.
8. The recipe for a healthy teen brain include a good balanced diet, vitamins, exercise, sufficient sleep, social connections, positive thinking, help to others, and new ways of learning.
In 2008, an adolescent substance abuse rehabilitation program was begun in the suburbs of Gaziantep, thirty minutes from the Syrian border, and two hours from Iraq. It was named the Oya Bahadir Yuksel Rehabilitation Center. Esra Cavusoglu from Istanbul Turkey is the primary person who is overseeing this project and the Turkey model. Under her leadership, the project will become a model of Turkey and perhaps Europe. I have had the privilege of playing a significant role in the development and operations of the Center.
A significant percentage of the Gaziantep population is Turks with Kurdish heritage who fled their homes to escape the ongoing terrorist attacks along the Turkish- Syrian-Iraq-Iran borders. The population served at the Center is boys, ages 15-19, who have, for the most part, been living on the streets of Gaziantep for several years. Many have been separated from their abusive families for years.
Multiple problems associated with cannabis use are the norm, including alcohol use, longtime histories of victimization, acts of physical violence and other illegal activity, and multiple social, emotional and medical problems. Many of the boys live off of whatever they can steal from homes, unsuspecting tourists, and their families.
When there is evidence of substance dependence in Gaziantep Turkey among adolescent boys, many report health problems, acute mental distress, attention deficit hyperactivity disorders, and conduct disorders. For boys who have run away from home and are living on the Gaziantep streets, solvents are the drug most often used, along with cannabis. Solvents (glue, thinner and even petroleum) are low cost. Most boys use solvents, cannabis, alcohol, Ecstasy, “roche” (nicknamed because of the “roche” name on the pill benzodiazepine), and if they can afford it, any form of alcohol.
Our Treatment Approach
There are several evidence-based practices (EBPs) with good indicators for success. There are four that the Turkey Model has incorporated (12 Steps, Behavioral, Family-Based, and Therapeutic Community):
• 12 Step approach. As is the case with most rehabilitation programs, the main feature of our approach is step work; a series of treatment and lifestyle goals that are works in groups and individually. The first 3 steps are covered in the acute and intensive phase of treatment, while steps 4-5 are addressed in extended care. Other components of our approach includes group counseling (the primary mode of treatment delivery), individual counseling, lectures and psycho education, family programming (see below), written assignments (including step work), recreational activities, participation in Level 3 planning, and attendance at Narcotics Anonymous (N.A.) meetings and Al-Anon meetings for family members
• Cognitive Behavioral Therapy (CBT). Behavioral approaches focus on the underlying cognitive processes, beliefs, and environmental cues associated with the teen’s use of substances and teaching them coping skills to help them remain drug-free. The goal of our behavioral approach is to teach the adolescent to “unlearn” their use of substances and to learn alternative, prosocial ways to cope with their lives. Coping with the craving for substances is a critical phase in our treatment. In particular, given behavior is mediated
by thoughts and beliefs, so the focus is on altering thinking as a way to change behavior.
We emphasize aggression replacement training, reasoning, change thinking, interpersonal social problem solving, multi-systemic therapy, multidimensional family counseling, adolescent community reinforcement, and assertive continuing care. Other behavioral approaches focus on the development of coping skills, introduced and modeled by staff. Such skills training include substance refusal skills, resisting peer pressure to use substances, communication skills (non-verbal communication, assertiveness training, negotiation and conflict resolution skills, anger management skills), problem-solving skills, relaxation training, social network development, and leisure-time management. New behaviors are tried out in low-risk situations (during group counseling role play sessions, individually with their counselor) and eventually applied in more difficult, “real life” situations. Homework assignments are used to try out new behaviors or for collecting problem situations to discuss during counseling.
Behavioral contracting is used to address behaviors to be changed. Weekly or daily incremental goals are mutually agreed upon. As each goal is reached, the adolescent is highly praised and reinforced through privileging. Behaviors are explicitly defined on the contract with criteria and time limitations noted.
• Family-based approaches. Despite the history of abuse within the home, the family plays a critical role in the development and maintenance of substance abuse problems. In Turkey, the family is a collection of sub-systems (e.g. parents, grandparents, step-parents, siblings, relatives, neighbors, and community), each with a variety of roles. Our family program is multidimensional and progressive, depending on the stage of development, familial relationships, severity of the illness and impaired relationships. Our approach
includes observing the family’s interactional patterns, identifying problems in interactions, family education about the disease of addiction and how the family is involved, and steps the family can take to address the adolescent’s issues.
• A Positive Peer Culture, as found in a modified therapeutic community. Our philosophy seeks to address all aspects of the adolescent, body, mind, and spirit, integrating these elements through a positive peer culture. Since Turkey is 99% Muslim, theological education has been an essential part of our rehabilitation program for many of the boys.
It is imperative that the adolescent learn how to integrate healthy behaviors into his maladaptive drug-based lifestyle. The therapeutic community is a surrogate family for the adolescent, providing a therapeutic and supportive environment for the person to mature and grow. Many of the boys have known each other on the streets. In some cases, they protected each other in dangerous situations or fought with each other.
Our program is highly structured, with days scheduled from early morning through the evening and weekends. Idle time is the worst enemy for the adolescent’s recovery. Days are filled with school classes and tutoring, peer groups, group counseling, individual therapy, recreation, vocational and skills training and occupational training. Management of the community rests, in part; on the resident/adolescent himself and all are assigned tasks and jobs.
Through progress and productivity, they rise through the hierarchy to positions of coordination and leadership. Rewards are an integral part of the program. Given the nature of an adolescent treatment program, there are unique issues that arise in clinical supervision:
• Duty to warn situations. What do to in a culture that has unclear “duty to warn” regulations? How to respond when the teen asks that their “secret” not be shared with anyone else, especially their parents?
• Providing culturally-responsive supervision. Given the cultural differences between American and Turkish models of treatment, how do we design a management, treatment, and supervision system that reflects cultural variables?
• Dealing with supervisee counter transference toward addicted teens, especially for those who manifest significant family pathology and potentially dangerous home situations.
• Facing counselor boundaries and limitations when working with a difficult patient population. When is a relapse just a slip? How many readmissions should the Center offer an adolescent?
In sum, I have learned a great deal about working with adolescents with long histories of drug abuse, physical and sexual abuse, in an environment where training and clinical supervision has rarely been provided.
David J. Powell, Ph.D. is Assistant Clinical Professor, Yale University School of Medicine and President of the International Center for Health Concerns, Inc. He has been a mental health and substance abuse professional since 1965 and is widely regarded as the leading expert on clinical supervision in the substance abuse field.