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Identification and treatment strategies for youth with gambling problems

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Delaware, 2007. International Centre for Youth Gambling ... VLT, sports betting, cards. Serious financial difficulties. Failure in school and/or at work ... – PowerPoint PPT presentation

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Title: Identification and treatment strategies for youth with gambling problems


1
Identification and treatment strategies for youth
with gambling problems
  • Jeffrey L. Derevensky, Ph.D.
  • McGill University

International Centre for Youth Gambling Problems
and High-Risk Behaviors www.youthgambling.com Del
aware, 2007
2
Our current state of knowledge
  • Gambling is more popular amongst males than
    females
  • Adolescent pathological gamblers are greater
    risk-takers
  • Gambling has become a family activity
  • Adolescents with gambling problems have poor
    general coping skills
  • Adolescent problem gamblers report beginning
    gambling at earlier ages, approximately 10 years
    of age
  • Rapid movement from social gambler to problem
    gambler

3
  • Adolescent problem gamblers have lower self-
    esteem compared with other adolescents
  • Adolescent problem gamblers have higher rates of
    depression
  • Adolescent problem gamblers dissociate more
    frequently when gambling
  • Adolescents with gambling problems, ages 14-17,
    are at heightened risk for suicide ideation and
    suicide attempts
  • Old friends are often replaced by gambling
    associates
  • Remain at increased risk for the development of
    an addiction or multiple addictions
  • Score higher on excitability, extroversion,
    impulsive and anxiety lower on conformity and
    self-discipline measures

4
  • More major life events and early childhood
    traumas
  • Gambling venues are relatively easily accessible
    Old friends are often replaced by gambling
    associates
  • Increased delinquency and crime, disruption of
    familial relationships and decreased academic
    performance
  • More self-reported learning and behavioral
    problems

5
Similarities between youth and adult problem
gamblers
  • Pervasiveness of the problem
  • Similar reasons for reporting gambling
  • Lying, stealing, cheating
  • Illusion of control (Irrational cognitions and
    thinking)
  • Preoccupation with thoughts of gambling
  • High suicide ideation and attempts
  • Chasing behavior
  • Gambling as a means of escape/dissociation
  • Depression/Anxiety
  • Missing of work and/or school
  • Loss of friends and changes in social support

6
  • Videotape

7
Profile of the adolescent problem gambler
  • Predominantly male
  • Significant anxiety
  • Familial problems and poor peer relationships
  • Preoccupation with gambling- reported inability
    to stop despite repeated efforts
  • VLT, sports betting, cards
  • Serious financial difficulties
  • Failure in school and/or at work
  • Lying to family and friends

8
Profile - continued
  • Friends usually have similar gambling problems
  • Stealing from family, friends, stores, bank
    fraud, etc.
  • Depression or feeling dead inside
  • Gambling to escape and to feel better
  • General lack of effective coping abilities and
    problem solving skills
  • Confused and conflicted about whether they really
    want to stop gambling
  • Need for arousal or strong sensations

9
Why do I gamble?
  • Gambling was there for me when no one else was.
    Gambling made me know I was special and even
    powerful. The days flew byI was in a different
    world. Nothing else was important to me (male,
    age 14).
  • Of course I stole money from my family. Its
    nothing personal, I needed the money (male, age
    18).
  • If you really think of it, it was easy to come up
    with reasons why I should keep playing. If I was
    winning..well that was reason enough. If I was
    losing, well that is OK because Id be winning
    soon. But its more about the chase than the
    actual dollars. The chase allows you to forget
    about everything else (male, age 14).

10
  • Everything that was good about gambling is now
    bad. It is my whole life and Im tired. Im tired
    of lying and stealingfor something I cant seem
    to control, but dont want to do. What has
    happened to me? I need help (male, age 14).
  • My problems are like a tree. The root is my
    gambling with one branch being a thief, another a
    liar, another being out of school and work. If
    you cut a branch off you havent gotten to the
    root of my problemgambling (male, age 19).

11
Coping as a mediating factor
  • Off-kilt physiological resting state Maladaptive
    coping
  • Psychological nature
  • characterized by unhealthy feelings, either
    due to trauma, loss, or poor
    upbringing.
  • Addictive behavior

12
Identification and Classification
13
Nomenclature Hodge-Podge (Winters, 2001)
Problem Severity Continuum
Compulsive gambling
At-Risk gambling
Problem gambling
Social gambling
No gambling
Pathological gambling
Habitual gambling
14
Is Youth Problem Gambling A Primary Disorder?
Alcohol Dependence
ADHD
Conduct Disorder
Problem Gambling
Other Disorder
Depression
Drug Dependence
15
Clinical Description of Pathological Gambling
  • Continuous involvement in and preoccupation with
    gambling (and an inability to stop) despite
    resulting adverse consequences

16
Diagnostic Statistical Manual-IV Adapted for
Juveniles (DSM-IV-J)
  • DSM-IV-J (Fisher, 1992) DSM-IV-MR-J (Fisher,
    2000) developed for children and adolescents.
  • Consists of 12 items, 9 categories and responses
    are given in "yes" or "no" format- new scale has
    multiple responses.
  • Modeled very closely on the adult version (DSM-IV
    criteria for pathological gambling), with several
    significant adaptations.
  • Other scales include the SOGRS-RA, GA-20.

17
Problem gamblers.
18
DSM-IV-J gambling screen (Fisher, 1992)
Do you often find yourself thinking about
gambling activities at odd times of the day
and/or planning the next time you will play?
(81.6) Do you lie to your family or friends or
hide how much you gamble? (78.9) After
spending money on gambling activities do you play
again another day to try and win your money back?
(More than half the time?) (73.7) In the
past year have you spent your school dinner
money, or money for bus fares, on gambling
activities? (68.4)
19
In the past year have you taken money from
someone you live with, without their knowing, to
gamble? (57.9) Do you ever gamble as a way of
escaping problems? (50.0) Do you find you need
to spend more and more money on gambling
activities? (36.8) In the past year, have you
stolen money from outside the family, or
shoplifted, to gamble? (28.9) Do you become
restless, tense, fed up, or bad tempered when
trying to cut down or stop gambling? (26.3)
20

In the past year, have you gone to someone for
help with a serious money worry caused by
participation in gambling? (21.1) Have you
fallen out with members of your family, or close
friends, because of your gambling behavior?
(10.5) In the past year, have you missed
school to participate in gambling experiences? (5
times or more) (7.9) ?4 or more to meet the
criteria for PPG Percentages of endorsements
from study of adolescents by Derevensky Gupta
(2000).
21
Do all gamblers present with the same profile?
22
The Pathways Model
23
Pathways Model proposes that...
  • All problem gamblers are not alike.
  • There are three (or more) distinct pathways to
    problem gambling.
  • Gamblers in each pathway differ by the presence
    or absence of psycho-social and biological
    factors and behavioral manifestations.
  • Gamblers in different pathways require different
    treatment strategies.

24
Pathways Model (Blaszczynski Nower, 2002)
  • Behaviourally conditioned
  • Reinforcement cognitive distortions ? bad
    decisions
  • Emotionally vulnerable
  • Relieve/modulate pre-morbid aversive affective
    states become behaviourally conditioned
  • Biologically-based impulsive
  • Impulsivity, multiple maladaptive behaviours
    behaviourally conditioned

25
  • Treatment approaches.

26
Psychosocial Treatments
  • Behavior Therapy
  • Individual stimulus control (e.g., Echeburua et
    al., 1996) PGs are taught ways to avoid high
    risk situations for gambling.
  • Cue exposure and response prevention (e.g., Brent
    Nicki, 1997) PGs are exposed to
    gambling-related cues, then prevented from acting
    on gambling urges.
  • Systematic desensitization (e.g., McConaghy et
    al., 1991) After induction of relaxation, PGs
    imagine scenes in which they are exposed to
    increasing approximations to their preferred
    gambling venue.

27
Psychosocial Treatments
  • Cognitive Behavior Therapy
  • Restructuring of gambling-specific cognitive
    distortions (e.g., Ladouceur Walker, 1996)
  • The concept of randomness
  • Understanding erroneous beliefs (the illusion of
    control, the gamblers fallacy)
  • Awareness of inaccurate perceptions
  • Cognitive correction of erroneous perceptions

28
Psychosocial Treatments
  • Cognitive Behavior Therapy (2)
  • Restructuring of gambling-specific cognitive
    distortions, problem-solving training, social
    skills training, relapse prevention training
    (e.g., Sylvain, Ladouceur, Boisvert, 1997)
  • Relapse prevention training (e.g., Hodgins
    el-Guebaly, 2000)

29
Psychosocial Treatments
  • Cognitive-Behavioral Treatments to induce
    Controlled Gambling Ladouceur and his colleagues
    have also undertaken a series of
    cognitive-behavioral treatment studies in recent
    years that have led them to conclude that using
    abstinence as the unique proposed treatment goal
    may not be a panacea for all pathological
    gamblers.

30
Psychosocial Treatments
  • Motivational Enhancement (e.g., Hodgins, Currie,
    el-Guebaly, 2001) Designed to provide PGs
    feedback on likely consequences of their
    pathological gambling, in an effort to increase
    their motivation to reduce or eliminate their
    pathological gambling behavior.

31
Pharmacological Treatments
  • SSRIs (to reduce comorbid depression and OCD and
    decrease urges to gamble) Especially
    fluvoxamine, but also including clomipramine,
    paroxetine, citalopram, and fluoxetine
  • Lithium carbonate A mood stabilizer that can
    help PGs with a bipolar spectrum diagnosis
  • Opioid antagonist Naltrexone (to reduce
    urge-related symptoms and decrease problematic
    behaviors).

32
Therapeutic Approaches for Problem Gamblers
The McGill Model
33
Intake assessment
  • Semi-structured interview (general information),
    including DSM-IV criteria
  • Allow them to ask questions about procedures and
    expectations
  • Completion of forms- personal information,
    questionnaire pertaining to their gambling
    behavior, frequency and severity of problem,
    family history, academic/work history, medical
    history, and identification of co-existing
    addictions.

34
  • Risk-taking measures (SSS and AISS)
  • Personality assessment (HSPQ- selected subscales)
  • Depression, suicide ideation, suicide attempts,
    and hopelessness assessment (RADS, BHS)

35
The Stages of Change
  • Stage 1 Precontemplation
  • gambling is not viewed as a problem
  • Stage 2 Contemplation
  • beginning to think about gambling as an
    activity to change
  • Stage 3 Preparation
  • decision to change gambling behavior

36
  • Stage 4 Action
  • the gambler takes steps to stop gambling
  • Stage 5 Maintenance
  • long-term success requires continued work to
    sustain initial changes
  • Stage 6 Termination
  • gambling no longer represents a temptation or
    problem

37

When you treat an individual with a gambling
problem, you must take into account their entire
person. Not just the fact that they gamble
uncontrollably.
38
Gambling Problems
Gamble to Escape
Truancy/ Delinquency
Chase Losses
Preference for Gambling
Stealing Money
Problem Gambling
Lying about Gambling
Family/ Peer Problems
39
Clinical practice
40
Clinical implications
  • Gambling is a form of maladaptive coping
  • Identification of underlying stressors
  • Assessment for depression and anxiety
  • Assessment for substance abuse

41
Treatment
  • Emphasis on the importance of honesty and mutual
    respect.
  • Provide a non-judgmental environment.
  • Allowing them to feel understoodthat their
    beliefs, perceptions and behaviors are common
    among young problem gamblers.
  • Discussion of reasons underlying the need to
    gamble.

42
Treatment
  • Emphasize the importance of honesty and mutual
    respect.
  • Provide a non-judgmental environment.
  • Allowing them to feel understoodthat their
    beliefs, perceptions and behaviors are common
    among young problem gamblers.

43
  • Discussion of reasons underlying the need to
    gamble.
  • Discussion of gambling as a consequence of the
    need to escape and feel better.
  • Emphasize that it must be their decision to stop
    gambling.
  • Discussion of abstinence vs. reduction.
  • Encourage a decrease in gambling participation
    (time and money).
  • Have individuals record their gambling
    activities (including wins and losses, time
    spent, and type of activity) on a daily basis.

44
Essential therapeutic goals
  • Acceptance of gambling as a problem.
  • Identifying and clarifying the irrationality of
    their though processes when gambling (beginning
    of cognitive restructuring).
  • Building social support systems for the
    adolescent. This can include involving parents,
    siblings, and close friends in the treatment
    process. As well, we make ourselves available for
    social support, by providing a pager number.

45
  • Reconstruct a healthy peer environment. This
    includes having them stop socializing with
    friends who gamble. In order to accomplish this,
    they may have to contact childhood friends, and
    friends that were present before the gambling
    onset. Techniques to develop to make and maintain
    new friends are discussed.
  • Restructure their free time so that they remain
    busy engaging in activities other than gambling.
    These include participating in sports, exercise
    programs, hobbies, returning to school, and/or
    obtaining and maintaining a job.

46
Therapeutic tools
  • Incorporate an eclectic and flexible approach.
  • Use significant individuals (i.e., parents,
    siblings, friends) in the adolescents
    environment as a support network.
  • Work in conjunction with a psychiatrist or
    general physician.

47
  • Encourage them to experience other age
    appropriate activities. This is particularly
    difficult as they are often depressed and
    anxious, and have difficulty deriving pleasure
    from non gambling-related activities (e.g.,
    movies, restaurants, dating, etc.).
  • In general, most adolescents receiving treatment
    report that in comparison to their gambling,
    nothing approximates the pleasure and enjoyment
    received when gambling (independent of the
    financial outcome).
  • Provide a reality check. Adolescents have a
    distorted perception of the amount of money and
  • time they spend gambling.

48
Final outcome
  • Once therapy is completed the adolescent should
    be abstinent for several months.
  • Success is not complete until the adolescent had
    adopted a healthy lifestyle. This includes
    maintaining friendships with individuals who
    would not be considered to be a negative
    influence. Newly acquired coping skills should
    result in enhanced emotional stability.

49
  • The adolescent should be aware of his or her
    ongoing high risk for relapse. In the ideal
    setting the individual will choose abstinence
    over controlled gambling.
  • Relapse prevention is critical-problem solving,
    coping and adaptive behaviors.

50
  • Alternative approaches?????

51
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