Tanuja Gandhi, MD (Host): Hi, everyone, and welcome back to MindCast, Healthy Mind, Healthy Child, a podcast from the children's mental health experts at Bradley Hospital. I'm Dr. Tanuja Gandhi, and I'm here with my co- host, Dr. Greg Fritz.

Greg Fritz, MD (Host): Thanks Tanuja. Today, we're diving into a topic that impacts a lot of families; substance use in teens. We'll look at how mental health issues and substance use can frequently go hand in hand, and then we'll talk a good deal about how we can best support teens in these situations.

Tanuja Gandhi, MD (Host): And to do that, today we've got a special guest, Dr. Robert Miranda, a clinician from Bradley Hospital, to help us understand more about this complex topic.

Bob runs VISTA, a virtual intensive outpatient program. Now, this program provides comprehensive evaluation and intensive treatment for teens with co-occurring mental health and substance use concerns, which means that there are a lot of teenagers who could be struggling with substance use and other mental health problems both at the same time.

Robert Miranda, Jr., PhD, MEd: Thank you so much. It's great to be here.

Tanuja Gandhi, MD (Host): So, Bob, let's start with some context. We're talking about substance use in teens. So, we'd love to hear what kind of trends are you seeing right now when it comes to teen substance use? Are there substances that seem to be more common these days than before?

Robert Miranda, Jr., PhD, MEd: That's a great question. And the good news is that following the pandemic, we've seen a decline in overall substance use among teenagers. And that decline, seems to be holding steady so far, which is a great sign. On the flip side, there are a number of teens who are still using substances. Alcohol remains the most commonly used substance among teens.

By the time kids graduate from high school, about half will have tried alcohol. The next most commonly used substance would be marijuana or cannabis. And about a third of, teenagers will have at least tried cannabis by the time they graduate high school.

Greg Fritz, MD (Host): That's interesting. I wonder, are there any factors that tend to make teens more vulnerable to substance use, especially when they already have a mental health condition?

Robert Miranda, Jr., PhD, MEd: You know, teens are different than adults. When we think of adults, we think of a lot of genetic liability or genetic risks, for potentially developing problems with substances. But in teens It tends to be largely socially driven. So it's about availability, it's about access, and it's about sort of having the opportunity and the right social context in which to use.

And then some teens for sure, teens with co-occurring mental health issues, for example, escalate more quickly, struggle with substances more so, and have more trouble sort of cutting back and quitting their substance use than teens without a co-occurring mental health issue.

Greg Fritz, MD (Host): But it's my understanding that the co-occurrence of this mental health issues and substance use, is the rule rather than the exception, right?

Robert Miranda, Jr., PhD, MEd: Very much so. So in the context of treatment where people like myself or other clinicians would see teens, the majority of teens, more than 90 percent of teens who are coming in for treatment related to a substance related issue; also struggle with a non-substance co-occurring mental health issue. When we look nationally, just at data in terms of how many kids who are struggling with substance use who maybe are not in treatment also struggle with a mental health issue, it's about a third of teens. But in their treatment context, it's a much higher number, majority of teens.

So what that means for us as clinicians is that understanding being able to address both substance use and mental health is the norm. That's what we would expect to have to work with when we're working with teens and their families.

Greg Fritz, MD (Host): So, let's talk for a minute about the typical versus concerning behavior in teens.

As we all know, the teen years come with a lot of changes, which can sometimes make it hard to know when behavior is a cause for concern, or whether it's just part of growing up. What should parents and other caregivers be on the lookout for to identify these concerning behaviors as opposed to just the stirrum and drang of uh adolescence.

Robert Miranda, Jr., PhD, MEd: Right. That is a great question and it's a question that I think caregivers, families, parents struggle with the most is how to understand what might be considered historically as just typical teenage behavior, teenage sort of exploring and experimenting with things versus when should there be a concern?

 I think one of the things to keep in mind is that half or more than half of teens don't use substances at all by the time they graduate from high school, and so the idea that all teens are using substances or all teens experiment with substances; is not a true statement. A large number of them do, but to say that they all do or even most do is not necessarily true. So the fact that a teen is using substances, or you know your teen is maybe trying substances or experimenting, is not necessarily something we would expect to be typical for that age group.

However, I think a lot of teens do, and so when we're looking at how to react or how to be concerned or when to seek professional help; I think it's when you start to notice other changes in your teen's life. So maybe changes in peer group, changes in school performance, maybe getting in trouble in school, maybe changes in mood, changes in sort of their being social and being in the context of the family, maybe not finding things that they used to do, things that they used to enjoy as enjoyable anymore, things that you might be concerned about in adolescence overall that would signal maybe something's off, and it could be substances or it could be something else.

Tanuja Gandhi, MD (Host): So, if a teen starts showing these signs that you're talking about, raising red flags for substance use, what do you suggest parents should do or how they should approach them? Should they go talk to them directly and ask questions? I'm not sure how that's going to land, or is there a better way to approach the topic itself?

Robert Miranda, Jr., PhD, MEd: So I can answer it as a psychologist and I could say what I would do as a dad, maybe, but I think as a psychologist, I think, you want to create an open space to have these conversations and try to move away from stigmatizing substance use or maybe thinking of substance use or speaking in a way that would suggest substance use is like more of a deviant behavior or something that they're just doing that'ssort of against the rules and being able to have an open discussion where hopefully your teen gets to the point of being able to talk with you about what they're engaging in, what sort of the struggles are that they have or don't have in an open way.

And so how we react to our teens when we have concerns or in discussing substance use is really critical and it can be really hard because I think teen parents can sometimes be very worried, very stressed, parents also have many other things going on in their life besides being a parent.

And so, it can be really challenging to be able to get to a place where you're able to, in a calm way, have an open conversation. But if you don't do that, then the trick is that they quickly becomes something that they can quite effectively hide. And then in 2024, not that cannabis is not a concern or alcohol is not a concern, but teens certainly have access to a lot more than just those substances.

So I think trying to create a space where it's an open and in a supportive context, to be able to discuss things, I think, is critical.

Greg Fritz, MD (Host): So once a parent realizes that their teen might have a problem and really needs support, what's next? How do we make sure that they get the right kind of care?

Robert Miranda, Jr., PhD, MEd: So there's the question of how do we do our best to, as we do with any health concern, right? We, our goal is, you know, we identify that our teen is struggling with something or our child is struggling with something and we want to get the best possible care that we can to help them address that.

So that's a challenge and it's a challenge because there's not a lot here in Rhode Island, but I think nationally, I know nationally, I do a lot of speaking nationally, and there's a huge, treatment gap when it comes to teens and substance use, and teens are not just merely small adults who can benefit from the same approach that we might take with adults who struggle with substances.

They sort of require something a bit more developmentally tailored and appropriate, particularly when you add in the context of co-occurring issues. So it's sort of finding what's available. And then I think there's also the question that comes up a lot is not only what type of care does my child need, but what level of care does my child need, right?

Because, I think we all have ideas in our head of like residential treatment for substance use and is that needed? Very often it's not needed. So what are the various levels of care that are available and what sort of meets or matches my child's needs at this point? So it probably starts with reaching out to a pediatrician or if your child's in counseling or working with a psychologist or other mental health provider; opening that dialogue and saying you have concerns and helping them guide you, having them help guide you through that process, I think would be the first step probably.

And then there's the second piece of it, which you didn't exactly ask about Greg, but what happens when a teen is not motivated for seeking care, which is the vast majority of the time. And that's a different challenge.

Tanuja Gandhi, MD (Host): So it sounds like there's really no one size fits all approach, right?

Robert Miranda, Jr., PhD, MEd: No, there's not. There's both types. I mean, the types of treatment that we know are effective. So what do we know works? What we know works is taking a sort of a non confrontational, supportive approach in working. And this is true for all child and adolescent psychiatry, if you come at it from the perspective of I'm the adult and I know better, you're not going to make it very far with a teenager.

So it's really trying to understand where they're coming from, what their perspectives are. And, we have things like motivational enhancement therapy or motivational interviewing, which is a really, incredibly necessary tool when working with teens. And then, you know, it's teaching them skills in other ways to sort of cope with life and deal with things more effectively in the absence of substances.

 There's not necessarily, when we think about the various treatments that are available, at least those that have been studied, they all seem to work. They all seem to work better than no treatments. And if there's one that seems to have the edge, involving caregivers or families, yields the best outcomes.

And so I think there is not one size that fits all, but I think involving caregivers, helping caregivers understand how to best support their child, I think is a critical component to working with teens who struggle with substances and other mental health issues.

Greg Fritz, MD (Host): So the old, if you only got the hammer, everything looks like a nail, there's a lot of tools in the toolbox and you shouldn't take that approach that, right?

Let's talk a little bit more about treatment. What kinds of treatment tend to work best for co-occurring mental health problems with substance abuse, which you said is the most normal or common situation?

Robert Miranda, Jr., PhD, MEd: Right. I think going back a minute and answering your question from the motivation perspective, sometimes the mental health component can be very helpful because while teens may not be, in my experience, always open to wanting to change their substance use, they're always open to a discussion usually, as long as you come at it from a respectful sort of, you know, I appreciate your autonomy perspective and thinking about how you, might want to begin to think about changing rather than telling them what to do.

I think they're open to that, but what teens are almost always open to is, I'm depressed and I don't want to feel that way, or I'm anxious and I don't want to feel that way. And so it can be, an initial in like, okay, so let's work on that, as you're building that therapeutic relationship and you're building trust with a teen and with their family; the mental health piece can be very helpful in the sense of you won't usually ever get push back about I don't want to feel better.

They usually almost always want to feel better and they'd love to learn strategies. Thinking about medication as an option, potentially. They tend to be open to the idea of taking a different approach to sort of address the depression or, address anxiety or other things. And we know that integrated care works best. So when you're addressing both the mental health component as well as the substance use in tandem, using best practices or evidence based treatments, we get the best outcomes. And so, working with a team of people who's prepared and skilled in addressing all of those things is best.

Tanuja Gandhi, MD (Host): I have a question about vaping. It's so common in the community and knowing that a lot of our listeners are people in the community and parents, how do you have conversations around vaping with kids? Because sometimes kids are like, oh, no doctor, but that's not a problem because it's just flavored liquid or it's just flavored, whatever substance. It's not really bad for you. How do you deal with that?

Robert Miranda, Jr., PhD, MEd: Yeah so vaping is common and kids use it as a means to take in a number of substances. Nicotine, for sure, but also cannabis is very commonly vaped, as well as other substances.

And the concern is I guess for parents who would say, well, they're just vaping flavor. How do we know that, would be my first question. And then my second question would be what is the point of vaping just flavor? Like, what is the, so there's, there's a, there's a degree to which I don't know that I'm buying it really, I guess.

 And some do. Typically I've seen that as a way, they used to be vaping, say nicotine, especially with cigarettes or nicotine and vaping. It's a lot of like the behavioral, it's like something you do, it's sort of the movement of it.

So teens will sometimes try to shift to flavor as a harm reduction strategy, in a way to sort of reduce their nicotine use. But I think if it's a teen who out of the gate is just vaping and it's just flavor, my questions would be why and how do we know that that's what it is?

And just because a teen thinks that's what it is, we had this issue in the clinic recently does not necessarily mean that that is what it is. So, there's this idea that teens don't always have great insight into what exactly it is that they're using.

Tanuja Gandhi, MD (Host): I agree. I've been meaning to say, oh, I agree the whole time, because many times kids tell you, oh, it's just flavor and vaping. And I want to agree, but I have no clue, because you really don't know what they're getting. And I'm not sure half the time children know what they're getting either. And that brings us to the next question. Please tell us about the services available at Bradley Hospitals. If parents are concerned about a teen's mental health, possible substance use, what can they expect from the programs here?

Robert Miranda, Jr., PhD, MEd: So, I've been at Brown as a professor for a number of decades. And during all of that time, my research was focused on how do we advance treatments for adolescents with substance use related issues. And so, a number of years ago, Greg and others sort of approached me and said, well, can we take what we know works from an evidence base and apply that in a real world setting with fidelity and see what we see in terms of outcomes.

And so, back in 2017, we opened the doors to Bradley VISTA, which is an intensive outpatient program. It's specifically for teens with co-occurring mental health and substance related issues. And we provide evidence based care through a combination of group therapy, individual therapy, family based therapy, with caregivers, as well as, medication management when it's appropriate, both for substance related issues as well as mental health issues. And the program meets three afternoons a week, so it does not interfere with school. And kids can stay with us for as long as they need to, to achieve their treatment goals.

Tanuja Gandhi, MD (Host): And this is for children older than 12 years of age, I'm assuming?

Robert Miranda, Jr., PhD, MEd: Yes, 13 to 18, as long as they are living at home and still in high school, or an equivalent of high school, doesn't have to be high school for sure. And I should also add it's a Telehealth program. In the midst of COVID, when many programs moved to being virtual out of necessity, VISTA did as well. In the context of that, I quickly realized that there was a large number of teams that we were not reaching. In person, three days a week, intensive outpatient, the program's hours are three to six.

That's a big lift for a lot of families to be able to commute and bring their kid to Bradley Hospital and then pick them up from Bradley Hospital and participate in therapy. And so when we moved to virtual, I really became very obvious to me that there's a whole host of teens who are not able to access this level of care, who now could.

And so even though we are past COVID, we've remained virtual for that reason. We are local still, so we definitely see kids in person. We meet with kids in person as needed, but on the whole, the program is a virtual program. So the reach that we're able to have is so important, particularly since we're the only program around in the region.

Greg Fritz, MD (Host): It's somewhat unusual for a person with a stronger research background as you have as an expert in substance abuse research, to be also running a clinical program. I wonder if just for the interest of the audience and me, you can mention an example of something that you learned from your research that is incorporated into some aspect of the treatment program.

Robert Miranda, Jr., PhD, MEd: Yeah, for sure. I mean, a lot of my research is medication development, and so it takes a lot to get a medication approved by the FDA, but we certainly have done clinical trials with medications that sometimes can be used off label, that we've shown to be efficacious in our work.

I also have been increasingly interested, in part because of the telehealth component of VISTA now and sort of how do we leverage digital technologies to really expand reach to services. And so one of the things we're working on now is developing as an evidence based program, a lot of what we do is teach skills.

That's a lot of what evidence based therapy is. And so, we teach skills and I think sometimes we make the false assumption that A, teens learn the skill when we taught it, and B, that they'll actually be able to use it in daily life in moments when they need to. And so we've been using sort of a lot of mobile technologies, apps that we're developing as a way to help, hopefully help teens learn the skills more quickly, which I think they do.

But I think it's then, how do you actually use this in daily life in moments when you need to? I think that's a challenge for everyone, not just teens, and so that's another aspect of a line of research that we have going on in our group, that we're currently bringing over to VISTA.

 In addition to VISTA, there's also the WAVE clinic, which, with the support of CVS, I've written a lot of grants in my life. That was the first grant I wrote for like a can you help us start a clinical program? And, they were incredibly generous. And so the WAVE clinic is the outpatient sister program to VISTA.

So the WAVE is just a standard outpatient therapy program. To be honest, in a fairly selfish way, I did this in the sense of, okay, kids finish VISTA, they're doing well, where do we refer them? There's a huge lack of service providers in the community that are qualified and willing to see teens with substance related issues.

And so the WAVE Clinic was really developed with that in mind, of like, when kids discharge from VISTA. Because it's not to no care, it would be to a lower level of care, which would be standard outpatient. But the WAVE clinic, which is run by an amazing psychologist, Selby Conrad, takes people from the community.

It's not just for VISTA patients. So that's an amazing outpatient program. Standard outpatient if there isn't a need for intensive outpatient like VISTA.

Tanuja Gandhi, MD (Host): Oh, that's so helpful to know. Although I've been working at Bradley for such a long time, today I have a better understanding of what VISTA does and the other options in the community and the struggles that our kids face with substance use. So thank you for all this information.

Robert Miranda, Jr., PhD, MEd: You're welcome. I've enjoyed this. It's always helpful to share information with the community and, hopefully someone will learn about services or opportunities for care that they weren't otherwise aware of.

Tanuja Gandhi, MD (Host): For our listeners here, we hope this episode has helped you understand a bit more about teens and substance use and how to support teens dealing with these challenges. And for other helpful podcasts from the experts at Bradley Hospital, as always, please visit bradleyhospital.org/podcast and take care. Until next time.