Giving Parent Guidance and Using Behavioral Contracts

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Giving Parental Guidance and Using Behavioral Contracts

SHAWN KELLY: Hello. And welcome to this session entitled “Parent Involvement in the Treatment of Adolescent Substance Use Disorder.” My name is Dr. Shawn Kelly. I am a former fellow of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital. Thank you for attending. 

Today’s objectives will include our rationale for family involvement in the treatment of adolescent substance use and substance use disorder. We will discuss the conceptual framework around that involvement and treatment. We’ll discuss the stages of change. 

We will share our methods and tools we use in the program and some of the ASAP experience. We will review certain special cases as an opportunity to employ certain concepts or strategies for you, the learner. I have no relevant disclosures. 

I’d like to start with a definition of adolescence that includes the functional anatomy and the development of the brain of young people. This definition is very pictorial, as you can see. And what we describe is that adolescence is the period between full maturation of the nucleus accumbens and the prefrontal cortex. 

The nucleus accumbens and prefrontal is most often associated with the reward pathway. We talk about the gas pedal when we’re using an analogy. And the prefrontal cortex associated with reasoning, impulse control, perseverance, problem-solving can be thought of as the brakes. So this is the period when the gas is fully mature and the brakes are yet to mature fully. 

We have known for a long time that family involvement is an important factor in the initiation of substance use. In fact, from what we have studied, it appears to be the most important factor that can reduce the initiation of substance use of various substances at various time points for adolescents. 

It has become part of the mainstream of people who treat adolescents for substance use to involve the families. This is becoming a more widespread practice. And we’re seeing some literature being disseminated that reinforce this view. 

There is actually some improving body of evidence that says that even a relative low intensity and even group setting parent interventions can have a long-lasting and effective change in the amount of substance use that is occurring, or is about to occur, with various adolescents. 

We have known for a long time that there are some high-risk factors for substance use disorder. This list comes from the CDC. In blue are some of the special cases that might be relevant. Family history of substance use and parental substance use are very important points. Even the attitude in the house is an important risk factor. 

Association with delinquent or substance-using peers– and this is relevant because we hear a lot of the time that if we weren’t associating with these peers or those peers that things might be a lot better. And there is some truth to that fact and that assertion that we will hear frequently from parents. 

Mental health issues is a short bullet point that encompasses a lot of diagnoses, the most commonly being anxiety, followed by a major depressive disorder. 

And so we know that there are also factors that can predict a decrease in this use. From the research that we’ve seen before and from some other sources, we know that parent or family engagement is very important; the support or a supportive relationship in the impression of the adolescent. 

And the parents’ attitude– again, parents who are monitoring and looking in and very involved in their children’s lives. And a sense of connectedness and success in the academic setting is also very important and predictive. 

Just for a second to review of short bit of the data talking about what kind of rates of substance use we have in considering the recent changes that have occurred during the global pandemic. From the data that was released in 2021 that included the surveys up to the year 2020, we saw sort of a relative stabilizing of cannabis use. 

There is a bit more of a preference towards vaped cannabis that was occurring in adolescents across high school. And there was a brief decline noted in terms of daily cannabis use amongst 10th graders. These are sort of relevant things that show maybe a planing off, maybe a certain deflection downwards in the overall rates of cannabis use in that first year of the pandemic. 

From the same data, we see the weird and wonderful substances were on the uptick, thinking of cough medicines, amphetamines, and inhalants. These are sort of the drugstore/hardware store highs that we often see. And this is a bit of a troubling trend. And it sort of seems that people were using what they had access to at this point of the pandemic. 

This set of data actually looks at a slightly older age range, but includes some of the people that we do see at ASAP and some of the people that may be encountered in one’s practice. Looking at young adults, we saw that in 2021, there has sort of– since 2011, we have the highest rates of marijuana use. And hallucinogens have really come back, to a certain extent. And that is a– the data shows what has anecdotally been true for the last two years or so. 

So why do we do this, and to what end? We know that family skills training can decrease adolescent substance use. In ASAP, at the very most, we have four hours of contact with the patient and two hours with the parents per month. And that is at the very most. So any hope of sustained implementation of our evidence-based treatment recommendations is reliant upon parental empowerment and parental training. 

There’s a way that we want this to go. And the whole purpose of our parent guidance sessions are to narrow down all of the possibilities that deviate from the one that we want– to put girders along the side of the road, so that we can get to the destination we’re seeking and cut off some of the possibilities that are less favorable. 

The theory behind it is largely related to the theory of contingency management. Contingency management, in this context, is best described as external control of the environment and consequences for behaviors that is supposed to lead to more favorable behaviors and in a sustained way. 

We know, actually, that the contingency management strategy is the number one most effective intervention that we can do for things like substance– stimulant use disorder in the adult population. We know that for cannabis use in the adult population, contingency management is the best way to do it. And essentially, we are rewarding the behavior that we want. That is the most common definition of contingency management. I think it’s useful to use both sides, and we’ll discuss that as we go forward– positive and negative consequences. 

Just to review the ASAP approach, at the beginning of our sessions there is a part 1 interview, which is the data collection from the young person, where a member of the ASAP team, typically a medical provider, obtains a history and performs as much physical exams as possible through the medium that this interview is occurring. Part 2 is a parent interview. It’s totally separate. It’s run on a script, and we collect data from the parents as well. 

The team reviews the presented case and the recommendations thereof and makes certain tweaks to those recommendations. And at the family meeting, those recommendations are presented to the youth and their parents. 

At this point, the parents and youth are sort of separated in the treatment ongoing at ASAP. And one provider is assigned to the parents for parental guidance and sometimes some educational sessions. A different provider, or different providers, are assigned to the patient for ongoing motivational interviewing and relapse prevention-based therapies, medical follow-ups, perhaps psychopharmacological evaluations, et cetera, and education sessions as well. 

But there is a separation. And at this point, this is a very useful time to separate things, so that each member of the family feels that they have ownership over their therapeutic interactions within the ASAP program. 

OK. So just to briefly review, this is the stages of change from Prochaska and DiClemente that is frequently used in discussing readiness for change. And the important point is that meeting the patient where they’re at means meeting the parents where they are, too. And so the stages of change that we often discuss when we’re talking about readiness include precontemplation, contemplation, preparation, action, maintenance. Sometimes we can talk about relapse or termination as well. 

While this diagram shows a very smooth progression from one stage to the other, we know that in practice there is movement forward and backwards– sometimes even more movement forward and backwards within the same session or sentence for either patients or parents. But it’s important to know where people are at. 

Because if we start giving strategies for action or preparation for somebody who is in contemplation, sliding back into precontemplation, we may actually push them further away from the change that they need to make. And so this is very important, too. And it’s sometimes a challenging thing for the provider because we really want to start to intervene. We know that this is a meaningful intervention. 

However, if we approach parents who are not ready to make the change, it’s just like approaching a patient who’s not ready to make the change. We may push them away, and we may get further away from the endpoint that we are seeking. 

So ASAP is a program of carrots and sticks. This is something that one of my mentors, Dr. Mimi Schizer, likes to frequently say. And I think this is a wonderful analogy and a wonderful description for what we continue to do in ASAP. We want to have a somewhat enticing reward, and we want to have a behavior that we’d like to change. 

In terms of those carrots, what do they look like? For most adolescents– and oftentimes, this is a very useful list– there’s the 7 Cs of leverage. We can talk about cash or currency. I like to think of Amazon dollars or some other sort of electronic currency that can be used more safely than cash these days, which are chores; curfew; car access– that’s a big one; cell phone– that might be the juiciest carrot on the list; the companions we are able to see; and access to the computer. These are our various carrots. And what we need to do is select the carrots based on the interest of the adolescent. 

So oftentimes, in those initial interviews with the patient and parent, we’re talking about what kind of access to the car do these children have? Who is paying the phone bill? Do we have a bed time at home, et cetera. So we already have a pretty good sense of which carrots might be very useful to begin with. 

So we have carrots, and we need to hang them from sticks. The sticks are the behaviors that we would like to change. And then we like to put this framework into something written down in what we call a behavioral contract. Here are some useful concepts to make a good behavioral contract. 

We need to match the scale of the consequence and the behavior. So if there’s a small change that we would like, we don’t hang the juiciest carrot from that. And if there is a big change that we make, we need to have something that is rewarding as a positive or negative consequence from that behavior. 

Ideally, these are logical consequences that have a bit of a connection that can be seen by both parents and by the patient. Something like if there’s cannabis use in the car, one loses access to the car is a good example of that sort of thing. 

They need to be enforceable. This is very important. And this goes back to the stage of change that the parents are in. We can write up many a behavioral contract and lay down the law, so to speak. 

And if we aren’t able to enforce when the contract is violated or fulfilled– perhaps we can’t come through with the reward that we have promised– the contract loses its power. And we actually lose some credibility with our adolescents, both the parents and the providers here. We need to be able to monitor this. So we need to be looking. We need to be checking, that sort of thing. 

Level expectations– that’s level, the verb. We want to try to make this– any sort of expectations for the behavior need to be outlined in the contract. We don’t want to have any unspoken or imagined expectations, be it on either side. That’s something that’s very important. 

And the other thing is that we have one carrot for one stick. If the cell phone is a particularly potent motivator, we can’t tether all the behaviors we want to cell phone access. Because if we have three behaviors that we want, and we come through with two and not one, does that lead to the reward or not? And it becomes very complicated. So we need to find multiple carrots. 

This is an old example of a behavioral contract that was written up and used as a vague template. They can be as formal as this. I like to have them written down. I find it to be a useful go-to, and we can sort of return to the document when there is any dispute over how to enforce. Because sometimes at the time of enforcement, it is really nice to have a policy written out that is– we can make reference to for both people. 

And so what we see here is across the top, we have the series of expectations and the series of sticks. And then coming down the side, we have the carrot. And so this example, what we see is drug tests. That is the behavior that we want. And so what the behavior is outlined here– all drug tests are negative for three consecutive months. 

I think that this older contract, in my practice, would be modified slightly. And my preference is often not to– right away, anyways– hang our reward on the negative or absence of substance from the urine tests. What I want is participation in the urine tests more often. And sometimes, that’s where we begin. 

And so if we have participation in the drug test– you submit your urine test when asked, or on the schedule that we have created, or whatever parameters we need to write in for this individual in this family– then if we meet that expectation, there is a reward. You may have access to your friends after school– whatever it may be. And if you don’t submit a test, then we are stuck at home until you do submit a test– something like that. So it’s logical. The scale is right. It’s enforceable, hopefully. And that’s what we do. So this is a good example. 

And so sometimes we can– it’s important to have both. When we meet the expectations it’s not– sometimes there is a reward there. And it’s not just if you don’t meet the expectations we’re taking something away or you’re losing out. So I think this is a very nice framework for doing these contracts, and I think it’s very useful. 

So when we’re talking to parents about how to talk to their children at this time, it’s very difficult for a lot of parents. And we hear this often. She lies constantly, or he lies, or they lie constantly. And I think that this is a nice thing to say to parents, and it’s a nice thing for parents to hear. It’s a nice thing for providers to hear. Because we’re not always getting the full story or the truth. 

Adolescents do lie a lot. But this is not due to inherent dishonesty, but due to a strong preference to meet a perceived expectation rather than disclose a hard truth. When I said leveling expectations earlier, this is one of the roles I see for urine testing. 

When we do urine testing, it helps us sort of set the table. And now we are dealing with facts, and we are not dealing with imagined expectations or real expectations from either side, spoken or unspoken. We are dealing with the truth. And it’s a much more inviting game and sort of interaction when we have all of those unspoken things just swept off– swept out of the way. It just allows us to interact in a much more useful and much more productive way. 

So I like this image. Family is enjoying a lovely breakfast, and the youth is being– shutting his ears. This is a good metaphor for what happens in some houses. And the youth in question who is using substances, at every interaction that they’re having with their parent or parents, there is a discussion about use. 

Oh, you’re not going to go out tonight and use. These people– you’re not going to see this person. Or yesterday you came home high. And sometimes we have youth who try to be at home less, or parents who are shutting the door in their office. And what we have is sometimes this avoidance of the conflict that is constantly happening at home. 

So I think it’s really important, and we can make a major shift in the tone of the interactions at home, by scheduling a time and a place for review. This might mean that on Tuesdays at 7:00 after dinner, we talk for 15 minutes about what’s been going on with the contract and with substance use this week. We won’t talk about it outside of that time unless there’s an emergency. 

And if parents can stick to that and keep their concerns for a scheduled time– perhaps it needs to be multiple times a week. But if we can do that, then we see less avoidance, and we see a nicer tone during the times that we know we’re not going to have to have a discussion about substance use. So I think this is a very useful tool. Sort of– sometimes we are misguided in our approach, and it’s nice to roll it back a little bit. 

These special circumstances are exceptionally difficult and require sometimes patience, sometimes novel approaches, sometimes involvement of other health professionals. But when we have parents who use, this is very difficult. It’s very difficult to change a child’s behavior when one of their most important models is– he is living in a different way than we are suggesting. 

Sometimes the education level of parents can make it difficult. Or even beyond education level, preconceptions and attitudes are very important. When there is a more complicated relationship between the parents and child, be it sort of– adoption is one, and divorced parents is another. 

And what it is, is a slightly more complicated dynamic where there is certain pressures, and there are certain levers that the adolescent may be able to use, or the parents may be able to use, to sort of complicate matters. What’s really important is, in the case of divorce or separation, is having a united front and an agreed upon plan whenever we can. 

OK. So here are some important elements of parental responsibility. First and foremost, clear messaging on use of substances. One of the ones that we frequently use in ASAP has always been, I don’t want you to use anything. It’s not good for your developing brain. 

I’ll say that again. I don’t want you to use anything. It’s not good for your developing brain. That is an abstinence message, and that’s what we can put as our goal and we. And that can be the idea that echoes in the voice of the ASAP provider, or in the voice of the adolescent’s parents when the situation arises. 

We need to have enforcement of the behavioral contract. And so if it is urine testing or the other consequences, positive or negative, we need to have these things set at a level that work. 

We want to have a balance between surveillance and independence because we can’t have parents acting as the prefrontal cortex of their young people and constantly looking. And we need the young people to have some sense of independence. This is a developmental need at that time. And setting the tone is really important, too. 

Just to review and to think of what we might be able to do with cases, and if you’re doing this with people, you may want to pause. Otherwise, just think to yourself, what principles from before might be applicable in this situation. 

So you are meeting the parents of a 14-year-old young person. He was diagnosed with moderate cannabis use disorder, moderate nicotine use disorder, alcohol use, and dextromethorphan use. Additionally, he has diagnoses of generalized anxiety disorder and a question regarding depression versus bipolar, too. 

We have highly educated and cooperating parents. They’ve done several iterations of behavioral contracts that we have helped make. And we’ve had really limited follow-through there. So the enforceability issue has come up. And today we were asked to tell this 14-year-old that he needs to go to inpatient therapy. 

This is an important consequence of failure of the initial approach, and sort of– we may have lost some of the potency of the carrot and stick model when the carrots have been given– or the stick has been shortened, and the carrot has been reached anyway. So that’s an important case. 

Case number two– a 17-year-old with mild alcohol, moderate nicotine, and severe cannabis use disorder also has a diagnosis of depression and has had previous multiple inpatient treatments for four months total. We receive a distressed email from Dad #1. We are in a crisis. And 17, our patient, has been increasing as cannabis use again in and around the home in the presence of his younger sibling. 

There is a separation occurring between the parents. And Dad #2 is staying in the house on alternate weeks, and the two are no longer romantically involved. Dad #2, however, smokes cannabis daily in the evenings before retiring to sleep. This is a significant case where we need to have a unified front, and we need to find a way to make messaging make sense to this young person. 

Case number three– a young adult here with moderate alcohol use disorder, severe nicotine use disorder, developmental delay, ADHD, and major depressive disorder. We had some success with nicotine early on. But now the substance use has escalated, and we are now smoking crack on the weekends. Mom and dad had been very faithful to the behavioral contracts I’ve written. What can we do? 

When we’ve been faithful to the behavioral contracts as written, perhaps and the enforcement has been good, perhaps what we need to do is change what we are enforcing, and we can sort of change our behaviors around these things, and make the consequences harsher or sweeter, depending on the end that we’re talking about. Or maybe this person is beyond the reach of a system of behavioral contracts. I think that that’s also an important consideration– knowing when these tools may not be as useful as others. 

So the conclusions. We know that parent guidance is an effective strategy for decreasing adolescent substance use before and after initiation. Expectations for behavior must be clear and tethered to enforceable positive and negative consequences. 

We are asking parents to change their behaviors. As such, we must respect readiness and meet them where they are at. Scheduling a time for review can help change the tone of parent-child interactions from confrontational to collaborative. 

So thank you very much for attending the session. Bye for now.