Young people who are using illicit substances may simply be trying to cope in a world that feels threatening to them. Rather than reprimanding or punishing them, we should be seeking to understand and treat the root cause: their mental health.
The Cayman Islands Student Drug Use Survey (CISDUS), a biennial survey conducted by the National Drug Council seeks to establish the prevalence and pattern of substance use – alcohol, solvents, vapes, tobacco, marijuana – among young people ages 11-18. The 2022 survey revealed that some students are trying substances from as young as age nine.
The good news is that most students are choosing not to use substances, and the proportion of students who had used alcohol or marijuana in the 30 days prior to the survey was the lowest since the survey’s inception 25 years ago. Awareness of the harm illicit substances can cause is also fairly high.
Last year, for the first time, the survey included a series of questions about anti-social behaviour and potentially traumatic experiences – and it is the results of this section that has mental health professionals alarmed.
More than one in two boys report having been in a fight at least once and almost as many students report having experienced bullying at least once in their lifetimes. In addition, 19% have carried a weapon at least once and 18% have been threatened or injured with a weapon at least once.
In Cayman, 23% of students report experiencing four or more Adverse Childhood Events (ACEs). This figure is worrying because it is substantially higher than the global average of 16%, and ample evidence shows that this degree of trauma can affect how adolescents think, behave and react to situations and people – not only now but also into adulthood.
Measuring Trauma: ACEs
Adverse Childhood Experiences (ACEs) are potentially traumatising events that occur prior to age 18. These can be single or repeated events, and can be emotional, physical or sexual. They can occur at home, at school or in the community. Neglect, domestic violence, parental separation or divorce, parental substance abuse, or having a family member who is incarcerated or has mental health issues are all considered ACEs.
The term was coined in the late 1990s by Dr Vincent Felliti and colleagues at Kaiser Permanente, who set out to investigate if and how childhood experiences might affect health in later life. They suspected that trauma at a young age might be linked to risky behaviours such as overeating, gambling, alcohol and drug abuse in adulthood.
In order to assess this, they identified three broad categories of trauma – abuse, neglect and household dysfunction – with a total of 10 types of Adverse Childhood Events. It was a massive study, with over 17,000 adults questioned. Whether they had experienced a single potentially traumatising event, such as a car accident or natural disaster, or experienced chronic verbal or physical abuse, researchers counted the types of ACEs each respondent had experienced.
The results revealed that ACEs were very common. Two thirds of people had experienced one ACE, 20% had three or more ACEs, and 13% had experienced four or more ACEs.
When they looked at this in relation to adult health and wellbeing, they found a strong correlation between the number of ACEs experienced and the risk of developing physical and mental health problems.
The correlation was stronger the more ACEs a person had: someone with more ACEs was more likely to develop chronic conditions such as lung and heart disease, obesity or diabetes; they were more likely to experience mental health issues, including anxiety, depression and post-traumatic stress disorder, and they were at a significantly higher risk for developing substance abuse issues.
Since that ground-breaking study, numerous subsequent studies have broadly replicated these findings, and there is a particularly well-documented correlation between trauma in childhood and substance use disorders. Individuals with four or more ACEs have been found to be seven times more likely to develop alcoholism and four times more likely to begin using substances at a younger age; those with five or more ACEs are seven to ten times more likely to use or abuse illicit drugs.
According to the National Survey of Adolescents in the US, more than 70% of adolescents receiving treatment for substance abuse had a history of trauma exposure, and teens who had experienced abuse were three times more likely to report past or current substance abuse than those without a history of trauma.
How Trauma Impacts the Developing Brain
Clearly, what happens to us in childhood has a long-term impact on both our minds and our bodies. But why? To understand this, we need to understand how the brain develops and functions.
Most of the human brain develops in utero and in the first four years of life, says Dr. Erica Lam, a clinical psychologist specialising in trauma at Aspire Therapeutic Services. The events and experiences we have in our formative years shape how our brain grows and functions.
The brain develops in much the same way as a house is built: from the base up. The lowest regions of the brain, which develop first, are responsible for the most elementary functions, like breathing, regulating body temperature and heart rate. Higher parts of the brain, such as the amygdala and the hippocampus, have more complex functions, like regulating emotion, fear response and memory. The last area of the brain to develop is the pre-frontal cortex, which enables abstract thinking and cognition – it’s the part of the brain that allows us to make judgements, solve problems and consider consequences. But like a house, the foundations must be solid for the higher levels to develop optimally. When a child experiences trauma – particularly ongoing, repeated trauma – the development of these higher regions can be impaired, affecting its structure and functioning.
Trauma can affect development of the hippocampus, which can lead to impaired memory and learning abilities. It can also cause hyperactivity in the amygdala, the brain region responsible for processing emotions such as fear, anxiety and aggression, and impact development of the pre-frontal cortex, resulting in poor decision-making, impulse control and emotional regulation.
The most common, lasting consequence of childhood trauma is a dysregulated stress system. When we sense a threat, our stress system is activated. Our blood pressure increases, our heart beats faster and we feel alarmed. Blood is diverted away from brain structures that control executive functioning and self-regulation to those that will help us survive. This is the flight or freeze response that keeps us safe from danger: it readies us either to face the threat head on, to run for our lives, or to lay low and make ourselves invisible.
This is a useful response when the threat is temporary. But what if the danger is ongoing? When a child is raised in an environment where he or she experiences extreme or chronic stress, the brain develops to respond to that.
“In the brain, it's the circuit you use the most that becomes the most active” explains Dr Stenette Davis, consultant psychiatrist at the Health Services Authority. Continuous trauma strengthens neural pathways to the survival mechanisms in the brain and weakens the neural pathways to the abstract thinking part. The stress response system either becomes over-active (hyper-aroused), which manifests as constant anxiety, hypervigilance, restlessness or aggression, Dr Lam explains, or under-active (hypo-aroused), causing an individual to shut down, zone out and become excessively passive. “Either way leads to emotional dysregulation, where the person feels unable to control their emotions or to feel calm and able to deal with difficulties,” she explains.
The effect of toxic stress on the brain manifests as a very narrow ‘window of tolerance’ where the child feels grounded and able to self-soothe. Tiny events can trigger a fear response, tipping them into a state of either hyper- or hypo-arousal, which over time, can develop into anger, panic attacks or depression.
The Traumatised Mind & Drugs
So, what is the connection between trauma-induced changes in the brain and substance abuse?
Using substances can be a form of self-medication for a traumatised person, Dr Davis says.
Imagine being a teenager and all the angst that comes with it. Now add the effects of trauma: maybe you feel constantly on edge, restless and anxious, or maybe you feel numb and detached. At school, you struggle to understand new concepts, and questions that are put to you make you want to lash out, run away or become invisible. Perhaps you are being bullied, making you feel under attack from all sides. You go home, and maybe you are berated for your poor performance at school, exacerbating these feelings of tension and fear.
But what if you skipped class, or didn’t go straight home after school, but instead hung out with your friends? You could avoid many of those threatening, uncomfortable feelings and for a while enjoy a sense of community or connection with this group of peers. The part of your brain that considers consequences is not working optimally, so you do not pause to think about the trouble this behaviour will land you in.
Then imagine you are offered alcohol or marijuana and you feel the overwhelming intensity of those emotions subside. For a while, the world is not such a threatening, scary place.
If you are hyper-aroused, alcohol or marijuana may provide some temporary feelings of calm, whereas if you are hypo-aroused, a stimulant may lift that heaviness you feel and allow you to engage more with the world around you. Either way, these substances offer a reprieve from intense, extreme emotions.
Mental health professionals understand substance use in those who have experienced or are experiencing trauma in this light. Whether by neutralising negative feelings or by increasing pleasurable sensations, using substances is a way of coping with unmanageable emotions.
Approaching Teens Who Use Substances
This ‘theory of self-medication’ does not condone drug and alcohol use, but is key to understanding why it is happening, Dr Davis stresses. Although substance use is commonly seen as a problem, it is an expected response to childhood trauma. It’s a mental health issue, and it needs to be treated as such.
Punishing a child who is already feeling anxious or under attack is like pouring fuel on a fire – it will only add to the stress they are already feeling. Telling or commanding a person to stop doing the very thing that provides some relief is equally unlikely to have the desired effect.
More importantly, when the brain functions optimally, it can understand the cause-and-effect principle of punishment – if I skip school or use drugs, then I will get in trouble – but when trauma has switched off the part of the brain that deals with planning and reasoning, there is no ability to anticipate consequences, so traditional methods of discipline are no deterrent.
Rather than chastising a teenager for using substances, a far more constructive approach, says Dr Davis, is to seek to understand the reasons they are using the substances in the first place. If you say “I don’t think you’re bad, but help me to understand what this substance does for you”, you will have a far more useful dialogue.
Of course, relying on substances as a primary coping mechanism can hinder the development of healthier strategies, the National Drug Council points out, while the use of substances, in turn, puts individuals at a higher risk of physical and mental illness. For parents and caregivers, open communication, addressing the underlying causes of trauma, ensuring young people are aware of the risks, and equipping them with alternative coping strategies are all constructive steps to guide adolescents towards a better way to cope with the difficulties life throws at them.
Prevention is always better than a cure, and ensuring children are raised in safe, stable, nurturing environments – at home, at school and in the community – is the best way to avoid trauma. However, adverse events can also come from outside: an accident, a hurricane, a fight, even something one witnesses or hears about, so it is impossible to shield children from trauma completely – instead we need to give them the tools to cope with it.
Just as not all smokers go on to develop lung disease, not all children who are exposed to trauma go on to suffer from mental illness or substance abuse. Some are more resilient to trauma than others.
A 2021 study comparing traumatised people who both did and did not have substance use issues showed certain characteristics were common among those who did not use substances. These included optimistic traits, mindfulness, a strong sense of connection with others – be it through school, sports, church or the community – a desire to stay healthy, strong anti-substance beliefs, and parental awareness of drug abuse. Fostering these traits is key to building resilience in young people.
Another, says Dr Davis, is to provide mental health education from a young age. This includes teaching primary school children what abuse or neglect look like, encouraging them to talk about it, and letting them know where they can get help.
Emotional Literacy Programmes such as Apple’s Friends and Zippy’s Friends help children communicate feelings and cope with anxieties through stories, discussions and games. These programmes are delivered in primary schools through the Alex Panton Foundation.
Where to Find Professional Help
For children and teens who are struggling with trauma and/or substance use, professional help is available. You can find a full list of mental health specialists here.
Free mental health care is available at the following organisations:
Alex Panton Foundation
In addition to its emotional literacy programmes, the foundation runs support groups for people ages 13-17 and 18-30 struggling with mental health. The foundation also provides financial assistance for young people under age 30 with limited health insurance coverage for mental health treatment.
Alex’s Place, Adolescent Mental Health Hub, George Town Hospital
Opened in January 2023, Alex’s Place is a comfortable and youth-friendly outpatient centre staffed by HSA, providing care and support to children and adolescents (ages 10-20) experiencing mental health issues. Alex’s Place's hours are Monday to Friday 10am–6pm. Walk-ins and referrals are welcome. For more information, visit www.hsa.ky or call (345) 244 7856 or (345) 949 8600.
Department of Counselling Services
Free counselling sessions for children and adults. Call (345) 949 8789.
Family Resource Centre
Provides a variety of workshops, programmes and skills sessions to promote confident parenting and healthy family relationships. Call (345) 949 0006.