Trauma And Post-Traumatic Stress Disorder And Adolescent Substance Use Disorder

By Fred J. Dyer, Ph.D., CADC

There is a growing recognition of the extent of exposure to psychological trauma among substance using adolescents and its potential to compromise the effectiveness of treatment for substance use disorders. This has prompted clinicians and programs to seek new interventions and to adapt existing treatments in order to address the impact of traumatic stress on the lives and recovery of adolescents.

It is important for clinicians and substance abuse counselors to understand that traumas can be a result of any event that can cause extreme emotional distress, including direct threats to bodily integrity, such as physical and sexual assaults, as well as witnessing violence or death, abandonment, betrayal, emotional abuse, and child neglect. Substance-using adolescents exhibit higher rates of trauma exposure compared to rates among their non-using counterparts. Further, substance-abusing youths frequently report high rates of exposure to multiple types of trauma, including child physical and sexual abuse, witnessing community or domestic violence, parental drug use or mental illness, and abandonment. Studies based on clinical samples of adolescents in treatment for alcohol and other substance use disorders report similarly high prevalence of trauma exposure.

Complex trauma refers to the experience of multiple chronic and prolonged developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse or community violence) that generally occurs in childhood.

Any discussion about trauma, PTSD, and substance use, particularly concerning adolescents, should include their exposure to violence and violent acts, along with the following behavioral and affective presentations:

• Child maltreatment leads to survival strategies that are often antisocial and/or self-destructive.
• The experience of early trauma leads youth to become hypersensitive to arousal in the face of threat and to respond to such threats by disconnecting emotionally or acting out aggressively.
• Traumatized kids require a calming and soothing environment to increase the level at which they are functioning.
• Traumatized youth are likely to evidence an absence of future orientation.
• Youth exposed to violence at home and in their communities are likely to develop juvenile vigilantism, in which they do not trust an adult’s capacity and motivation to ensure safety and as a result believe they must take matters into their own hands.
• Youth who have participated in the violent drug economy or chronic theft are likely to have distorted materialistic values.
• Traumatized youth who have experienced abandonment are likely to feel that life is meaningless.
• Issues of shame are paramount among violent youth.
• Youth violence is a youth’s (boy’s) attempt to achieve justice as he perceives it.
• Violent boys often seem to feel that they cannot afford empathy.

Relative to functioning and impairment, several factors affect youths’ risk for developing PTSD and the severity of symptoms, including the proximity, duration, and intensity of the trauma as well as the reactions of parents and caregivers to the traumatic event. Harm that is deliberately inflicted or interpersonal in nature tends to be more damaging and more likely to result in PTSD than other types of trauma. Exposure to traumas in early childhood when children are less cognitively developed and more physically dependent on adult caretakers tends to be associated with dissociative symptoms.

Most cases of PTSD develop shortly after the traumatic event. In the hours or days after the event, most people have at least some symptoms of PTSD. In at least half of all trauma survivors, complete recovery occurs within three months, even in the absence of treatment.

Symptoms lasting 1-3 months may be diagnosed as acute PTSD. If symptoms persist longer than three months, then PTSD is likely to be chronic. Symptoms may wax and wane over time, often in response to life stressors. PTSD may go into partial remission and reemerge later on, sometimes years later. Symptom reemergence may occur in response to reminders of the original trauma or be triggered by additional life stressors.

In a minority (4-6%) of people the disorder does not develop until months or even years or decades afterwards. Delayed-onset PTSD is defined by a delay interval of at least six months. Research suggests that there may be two forms of delayed-onset PTSD, one in which the person has little or no psychopathology after the trauma and another that would be more properly called “slowly developing” PTSD, consisting of post-trauma symptoms that gradually increase in severity. Stressors occurring after the trauma may contribute to the development of both forms of delayed onset PTSD.

There are three motivations for adolescent substance use: (1) a drug experience motive; (2) peer motive; and (3) coping motive— the youth will use alcohol and drugs as a way to cope with and manage the symptoms brought about by the traumatic event.

Factors associated with good prognosis following exposure to trauma include engagement in treatment, early and ongoing social supports, avoidance of re-traumatization, positive pre-morbid function, and an absence of other psychiatric disorders or substance abuse.

There are three motivations for adolescent substance use: (1) a drug experience motive; (2) peer motive; and (3) coping motive— the youth will use alcohol and drugs as a way to cope with and manage the symptoms brought about by the traumatic event.

There is significant evidence that cognitive behavioral treatment approaches are more efficacious in decreasing trauma-related symptomatology in adolescents. There is also substantial evidence that cognitive interventions are efficacious in decreasing child and adolescent depressive and anxiety symptoms. The following cognitive behavioral treatment approaches can effectively be used in addressing adolescent PTSD, trauma, and substance use:
• Psycho-education about trauma and its relationships to stress reactions, coping, and problem behaviors, such as substance use.
• Emotional management skills building that help cope with psychological and physiological symptoms related to trauma cues.
• Problem-solving skills that help survivors break down problems, identify options for responding to them, and try them out in safe settings.
• Cognitive restructuring that addresses distorted beliefs and cognitive schemas about the self and others and teaches survivors to use self-talk that enhances their ability to manage stress and PTSD symptoms.

These skills are also fundamental components of sustained recovery from addiction among adolescents. In addition, some cognitive behavioral treatments combine limited exposure to traumatic memories and feelings in tolerable doses, so that they can be mastered and integrated into a coherent life-self narrative.

Finally, cognitive behavioral treatment approaches are best utilized through an integrative treatment modality.

Fred Dyer, PhD., CADC, is an internationally recognized speaker, trainer, author and consultant who services juvenile justice/detention/residential programs, child welfare/foster care agencies, child and adolescent residential facilities, mental health facilities and adolescent substance abuse prevention programs in the areas of implementation and utilization of evidence-based, gender responsive, culturally competent, and developmentally and age appropriate practices. He can be reached at
References available upon request.