The next few issues of "Stories From the Field" will focus on adolescent case studies. I had the opportunity to care for an adolescent population with substance use disorders for nearly 20 years. The facility that I work at had an adolescent unit. The vast majority of these adolescents were sent to treatment from the Division of Youth and Family Services (DYFS) in New Jersey. The length of stay was anywhere from 3 months to 1 year depending on the needs of the patient. This is a challenging patient population. I learned a lot from this patient population. It also has been one of the most rewarding aspects of my career in caring for patients with substance use disorders.
BACKGROUND INFORMATION
Kodjo, Auinger, and Ryan (2004) completed a cross-sectional analysis of the National Longitudinal Study of Adolescent Health (ADD Health) 1994-1995. This was a school-based, nationally representative survey of 6,504 seventh to 12th graders. This survey assessed drinking and drugging and their relationship to fighting. One thousand one hundred ten adolescents in the sample reported drinking, and 1,869 reported being under the influence of drugs while fighting. The authors concluded that a significant proportion of adolescents were engaged in physical fighting and had more likelihood to be injured or sustain injury while under the influence of alcohol and drugs compared with their counterparts. Selling drugs, gang fighting, and peer substance using were significantly associated with the outcome measures of the study. Univariate and bivariate analyses and logistic regressions utilizing SUDAAN were performed on the two outcome behaviors (alcohol use and fighting, drug use and fighting) for the overall sample (p < .05).
Aneshensel and Sucoff (1996) examined structural aspects of neighborhoods inclusive of socioeconomic stratification and racial/ethnic segregation and the effect on adolescents' emotional well-being and subjective perceptions of their neighborhood. A community sample of 877 adolescents from Los Angeles County, California, was utilized in the study. The researchers discovered that those adolescents in low-socioeconomic-status neighborhoods perceive greater ambient hazards such as crime, violence, drug use, and graffiti compared with those adolescents in high-socioeconomic-status neighborhoods. The mental health of adolescents was affected negatively when they perceived the neighborhood as dangerous. Symptoms of depression, oppositional defiance disorder, conduct disorders, and anxiety were more common in adolescents where the neighborhood was perceived as being more dangerous. Lack of social stability and cohesion emerged as contributors to adolescent mental health disorders. The researchers concluded that the socioeconomic and demographic environments that adolescents reside in must be considered when conducting research on mental health in this population.
Hill, Howell, Hawkins, and Battin-Pearson (1999) conducted a prospective examination of risk factors for gang membership. Longitudinal data were utilized to predict gang membership in adolescence from factors measured in childhood. Data were taken from the Seattle Social Development Project, an ethnically diverse, gender-balanced sample of 808 adolescents aged 10-18 years. Logistic regression was utilized to identify risk factors at ages 10-12 years that were predictive of joining a gang between the ages of 13 and 18 years. Factors that significantly predicted an adolescent joining a gang were inclusive of the neighborhood, family, school, peers, and individuals. It was noted that youth, who were exposed to multiple factors, were much more likely to join a gang.
As one can see from the previous two studies, neighborhoods, the family itself, school, peers, individual factors, and drinking and drugging contribute to an adolescent's negative behaviors inclusive of joining a gang and gang behavior. As adolescents are attempting to identify who they are during this period, the negative influences that the adolescent is exposed to on a daily basis can significantly impact outcomes. The following real cases for the next few issues provide excellent examples of how detrimental the effects and outcomes can be to the adolescent.
In this issue, the first case will be discussed.
CASE STUDY
Molly was 17 years old when she entered treatment for heroin dependency. When performing her history and physical examination, it was no surprise to me that she had a problem with heroin. Molly had begun using heroin starting at the age of 12 years. When I questioned her as to what precipitated her abusing heroin, she went to her family history. She stated that her mother abused heroin in front of her by intravenous injection. Her father did the same. She said that she felt that this was a normal behavior as this is what she had been exposed to for most of her life. It was a normal part of family living. It was "more normal" for her to be "high" rather than be sober. One of the major triggering events that got Molly to even use more heroin was almost unbelievable. She stated that, one day, her father murdered her mother in front of her and then committed suicide in front of her. She stated that he shot his mother and then himself. I almost found this story not believable, but we talked for several minutes, and Molly shared every last detail. My heart ached for this adolescent. I had never before had an adolescent share such a story. At the time, I thought to myself that I certainly would have utilized drugs to try to mask the pain had I been in Molly's situation. It really is Molly's story that opened my eyes as to what some of our adolescent patients experience. I would say that all families are dysfunctional. My belief is that every human being is somewhat dysfunctional as there is no perfect human being. I would also always countermand that there is dysfunction and then there is "real dysfunction." Molly's situation fell into that "real dysfunction" category.
Molly had been under the care of DYFS since the death of her parents. Molly had gone from shelter to shelter to foster care and always relapsed on heroin. She used heroin intravenously. From my experience, adolescents were experimenters. When doing a history and physical examination, I would have a list, an arm's length long, of the various substances that they had tried. The most common substance that I found that the vast majority of adolescents used was marijuana. At that time, the heroin substance users in the adolescent population were few and far between. I could completely understand Molly's heroin dependency. She had a very poor environment that she was raised in. She had poor parental guidance and support. She lived in a terrible neighborhood. Furthermore, she had witnessed something that most of us as human beings will not experience and, hopefully, never will. There were no surprises here. Her history told the entire picture, and I was very thankful that she was honest with me and was able to share some of her deepest hidden secrets. It allowed our treatment facility to design an appropriate treatment plan for Molly. It also allowed us to work with DYFS as Molly would require long-term treatment and there was no guarantee that Molly would be a success story.
Besides Molly's addiction, clinicians need to be tuned to all other aspects of care and physical ailments that can accompany such patients.
I was not on duty or call on a Sunday, but I was the next day. My habit is to always call in the day or evening before my shift to assess what is on the medical staff patient list. I happened to call in one Sunday about a month or so after Molly had been admitted to the facility. The nurse advised me of what was on my list for the next day. She then advised me that Molly had drainage from her left axilla and asked if she could have a verbal order. The nurse stated that the drainage was greenish brown in color. I advised the nurse to discontinue any deodorant that the patient was using. I gave a verbal order for Duricef to start after a culture and sensitivity of the wound was obtained. Three days later, I received a telephone call that the culture and sensitivity report was positive for methicillin-resistant Staphylococcus aureus (MRSA). The Duricef was discontinued, the patient was placed on Bactrim DS one tablet by mouth twice daily, and an infectious disease consult was ordered. This was the first case of MRSA in our facility.
Molly had two reoccurrences of her MRSA while she was in our treatment facility. All these reoccurrences of MRSA were treated with eventual resolution.
Molly had psychiatric consultation throughout her stay. She attended the in-house education program on a daily basis. She progressed well in treatment and was one of those adolescents who really did not give the staff a lot of trouble. My belief is that everyone worked hard with her as they more than understood the circumstances that led to this adolescent's heroin dependency.
After 1 year of treatment, it was decided that Molly had maximized the benefits of the program. She was discharged to other family members. The discharge plan is always coordinated with the DYFS case manager. At times, some of the adolescents are placed in other types of care settings for continued treatment. They may also be placed in outpatient treatment settings. The goal is to reunite the adolescent with their family and to make them a productive citizen of society. Our facility believes strongly in the 12-step philosophy. This serves as the foundation of our treatment program. All clients are referred to daily or more frequent 12-step meetings for at least the first 90 days after in-patient treatment. From our perspective, Molly was a success story. She had completed treatment successfully.
A year after Molly's discharge, I was making rounds on a Sunday morning. One of the nurses was reading the morning newspaper. Some individuals like to read obituaries; I do not. The nurse reading the paper made everyone aware that Molly's obituary was in the newspaper. She died of an overdose of heroin.
Molly's case and her death made us all realize that substance use disorders are chronic illnesses. It also made us realize how difficult it can be to get someone to maintain sobriety when, during their foundational years, they were continually exposed to drug use and abuse by their parents.
REFERENCES