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Interviewer: What should you do if you suspect your child is doing drugs? It's a scary moment for any parent. I mean, how do you know for sure? What's the best strategy for talking to them about it? How much can you do on your own and when should you see a professional?

I'm going to answer those questions with our expert today, Dr. Mary Steinmann. She's a psychiatrist who specializes in child and adolescent psychiatry.

Dr. Steinmann, let's start at the beginning here. We're going to cover a lot of ground today. But what is the first thing a parent should consider if they have a reason to believe that their child may be using some sort of a substance?

Dr. Steinmann: So I think there's definitely a difference between experimenting with substances and actually developing a substance use disorder. And so it can actually be fairly normative or expected behavior in children and adolescents to be curious about or experiment with substances. But we also know that using substances can really place individuals at risk of developing later substance use disorders. So it's something that we want to take very seriously and be able to help parents identify signs in their own children that may warrant additional questioning or additional evaluation or perhaps even getting additional help and support and resources.

Interviewer: Yeah. So if experimentation can be normal . . . I would imagine as a parent, as soon as I saw my kids or had the idea my kids were using drugs at all, I would be like, "Oh, they've got a problem." But you're saying that that's not always the case?

Dr. Steinmann: That's right. It's definitely concerning behavior. It's not something that parents need to be complacent with. I think it's important to actually dissuade substance use and to talk to kids about the dangers of substance use and the potential consequences of substance use, because there are a lot of them.

Kids don't tend to think about long-term risks very much. Their brains aren't hardwired to think about long-term consequences until, honestly, sometimes their 20s. And so that's where I think it's helpful for parents to kind of take a role of, "These are the rules in our house. This is what our views are. These are what our values are. Here's what's acceptable and unacceptable behavior for our house. But I am also here and open to answer questions or listen to what you have to say. Or if you find yourself in trouble, intentionally or unintentionally, I am here for you."

Interviewer: So I'm a little confused. If you suspect that your child is using a substance and maybe . . . I don't know. Do parents generally have a good idea if it's early on? When you said, "Don't be complacent," do you just kind of sit back until you start seeing a problem develop, or do you jump right in as soon as there's some sort of substance use and say, "I understand this is just a natural thing. If you ever want to talk about it, we should"? I mean, I don't quite understand that differentiation.

Dr. Steinmann: I think a lot of the differentiation depends on families, right? So there are some families where even alcohol use or smoking is not a practice in the home, and so there might be a different baseline for a family addressing substance use and experimentation and how they approach that topic in their children, versus maybe a family where there is recreational alcohol use, or occasional nicotine use, or what have you. And so there are some baseline cultural differences that I think go into play.

We certainly want to educate our kids up front about what the dangers are, and say, even if you're comfortable as a parent, "This is kind of my own experience with using substances," talking about responsible use, if that is a value in your home. And in other homes, that might not be acceptable at all.

But kind of laying down, "This is what our family values here, our baseline. I understand you may be tempted to experiment with things. Here are my concerns about that."

And then also knowing your child and knowing their baseline and being able to identify if they're starting to behave differently, if they're starting to hang out with a different peer group, knowing what their peer group is and who their friends are. Having those consistent expectations is really important, but then also providing that guidance, that education, "This is what we value in our family."

That may be no substance use whatsoever. That may be, "This is the concern I have about you using substances right now as an adolescent." And that's the stance I tend to take as a child and adolescent psychiatrist. It's, "I'm concerned about the effect that any substance has on your developing brain. I understand you might be tempted to use. I discourage that, but I am also here if you have questions," and not to shut down that conversation prematurely.

If curiosity develops, if they're like, "Well, I see you drink all the time. Why can't I?" being prepared to kind of have those discussions so that then that increases your chances of having your child actually be honest with you if and when they start down that path, and being available to support and guide and eventually seek help, if needed.

Interviewer: So it sounds like if you suspect your child is using substances, and maybe they're just at the point where they're just kind of experimenting, that's a great invitation to have a conversation at that point?

Dr. Steinmann: Exactly. And even before use. I think sometimes we overestimate the age at which kids may actually be exposed to substances in schools, but we may be having these conversations too late sometimes and setting those expectations too late sometimes.

And so being aware that a lot of times, by middle school, kids are already exposed to peer groups or other folks who use, and maybe thinking about this for themselves. We may be wanting to even have those conversations earlier, depending on the environments in which our kids socialize.

Interviewer: And it sounds like a parent's kind of mindset is super important for this first conversation from the standpoint that I think . . . Well, first of all, what are some of the reactions that you see parents have when they find out their kids are using drugs? I can imagine there could be some anger that is probably born out of fear, because drugs can be detrimental to somebody's life. There's probably the thought that only bad kids do drugs. Are there some other reactions you see? Or what do you see?

Dr. Steinmann: Fear is a big one. And I love what you just said as far as anger often being born out of fear. Anger is a very reactive emotion. We all get angry over a lot of things. But if we dig deep, a lot of times it does come from that fear, either because we're terrified of . . . We just want the best for our child. We want them to grow up to be the best version of themselves that they can be, and there are serious consequences to problematic and ongoing substance use. There can be dangers to even intermittent substance use. And so fear is a very, very common and normal response to parents.

Also, that anger component of fear or fear that gets manifested as anger tends to be the emotion that then puts our kids on the defensive and shuts them down.

And so even though it's a completely valid emotion and an understandable one as a knee-jerk response on the parents' end, it may be the one that we want to kind of work on our own response to continue to invite that conversation instead of making the child feel that they're a bad kid because they thought of going to a party with their friends or even tried to ask a question or to get clarification for themselves or to seek help. Very often it's that fear of anger and punishment that keeps kids from seeking help.

Other common responses I get are often, "Only bad kids do that." And I think probably what parents often mean by that is the behavior is certainly concerning and undesirable, but that doesn't mean our child is a bad kid. There's a difference between the behavior and who someone is as a person, and sometimes kids can overly internalize that.

And so, if a parent's response is, "Well, only bad kids do that," or, "My kid possibly can't do that," that's a form of denial that probably needs to be addressed, especially if you're starting to see telltale signs of substance use or behavior changes. And we can talk about that in a little bit.

Or it can be, "Well, why are you judging my friends? They're not bad people. I know who they are. You don't," which can also raise defensiveness and unwillingness on the part of the child to engage more in that conversation.

Interviewer: Let's say a parent has suspected that their child is using a substance. They've had the conversation, they followed your advice, but then they start noticing, like you mentioned, some personality changes or they start becoming more concerned that it is escalating to a different level. Is that the point that you would get your child help, or is there another intervention that a parent would do first?

Dr. Steinmann: I think there are a couple different routes to go. So we have that conversation. Maybe we were lucky enough to have that conversation upfront before use even started, and the conversation had exactly the effect that we intended to have, which is to deter use. That's kind of the best possible scenario. "Hey, let's talk about the dangers of this." The kid acknowledges, "Yep, that's not a behavior that is good for me," and we move on.

Maybe experimentation happened, and then I think it's important to have the conversation potentially of, "What was that like for you?"

Understand what drives a behavior. We don't tend, as human beings, to engage in behaviors that don't work for us, especially in the short term in teenagers.

And so some may admit, "Hey, I've been really stressed out and I tried alcohol," for example, "and it helped me to feel better." Wow. As a parent, I would want to know, "Well, what's been stressing you out? Is there something else that's healthier that we can kind of engage in? Because, once again, I have my concerns about kind of going this route to address stress and manage stress. Are there different things that we can work together on to help you out with?" and seeing if we can get to the underlying driver of that behavior.

If the behavior continues despite, "Hey, we have a house rule we don't smoke, we don't engage in underage drinking, we don't engage in any forms of substance use" . . . which again is my stance, really, as a physician, because I'm concerned about that brain development . . . and the use continues, then we might need to consider additional types of interventions and understanding what's underlying that continued substance use.

I'm also going to be keeping a close eye on function. Function is really, in psychiatry and in medicine and mental health, what we look for to really start to make that distinction of, "What's the difference between substance use and a substance use disorder?"

And when we say the word "disorder," what we really mean is there is some impairment in academic functioning, in relationships, and that could be friends, family, etc. Are we engaging in additional risk-taking behaviors? Are we putting ourselves in safety risk by result of use? Are there legal consequences? Are we carrying vape to school, for example? All of those things would be red flags for more serious problematic use and possible disorder that might warrant additional treatment.

Interviewer: When a child is using a substance, is there generally some other underlying cause? Is it really truly just kind of a symptom of something else going on? I mean, either experimentation out of curiosity or an underlying condition, or are there other reasons?

Dr. Steinmann: It can be all of the above, honestly. What can start as experimentation can then kind of just spiral out into use for other reasons.

Some people may never engage in use but may find themselves starting with symptoms of anxiety or depression and then are just trying to find a way out of feeling that way. And they may have tried other things or talking to friends or things like that, or hear that, "Well, taking this has helped for me. Maybe it would help you too." And so it can sometimes be a chicken-and-the-egg type of scenario, honestly.

Interviewer: All right. Sounds like we have two steps so far. A parent suspects their child is using a substance, they have a conversation because it's just experimentation. Then that behavior continues, they have another conversation again asking this time, "Is there something else going on?" or, "Why are you using it?" or, "How does it make you feel?" reiterating the rules or the policies in the household. What would be the third step if it continues on past that point?

Dr. Steinmann: I would say then it's probably time to get some external support and some help. And honestly, it's never too early to get external help and support. Again, if this is just a conversation that, for any reason, a parent might struggle to have with their child or not know how to approach it, it is perfectly fine to seek out professional help to help learn how to have that conversation.

And there are a lot of other internet resources that are available if you don't have the ability to talk to somebody.

But I would seriously then consider looking at other resources, including a therapist or a primary care physician.

Not all cases of substance use disorder have to go directly to a psychiatrist, just like not all cases of depression and anxiety need to go to a psychiatrist. Sometimes talking with external supports, such as your child's pediatrician or primary care provider, someone that has an established relationship with them and knows them, can be a good middle-ground next step to get additional support before jumping into subspecialty options, although those are definitely certainly available.

Interviewer: Is there a negative message given to a child when you say . . . because there's a certain weight to saying, "All right. We've got to go to the psychiatrist now." You know what I'm saying? For this problem. That comes with a whole bunch of other stigmas.

Dr. Steinmann: It can. And unfortunately, getting mental health care and having mental illness needs is still really stigmatized in our society. I think that's why I generally recommend starting out with primary care if someone is having questions.

Now, granted, there are times where you would want to bypass primary care. For example, if your child has been absolutely refusing to go to school or you're noticing that they're skipping school a lot or they're getting suspended or even expelled for issues related to substance use, or you're concerned that there's an imminent safety risk, such as heavy use or heavy binge use or physical consequences from that, or you suspect a really severe underlying driver for substance use, including depression or anxiety, perhaps even things like suicidal thoughts, or if you suspect another serious mental illness, those would be things that would be quite appropriate to go up to a higher, more specialized level of care.

It can take a while to access the mental health system as well, and you don't want to get stuck in the lurch while your child is really struggling, especially if their imminent safety is on the line.

Interviewer: When you talk about substances, drug use, what does that entail for you as a physician and a psychiatrist?

Dr. Steinmann: That's a great question. I think a lot of times, when we talk about substance use, our minds automatically go to the hard stuff like heroin or cocaine or methamphetamine. We also think about alcohol and nicotine and marijuana, which are a little more readily available.

But there are also, especially with teenagers . . . Think about access and what you're more likely to be able to get a hold of or afford. Or what are the underlying concerns that might be problematic in teenagers, such as anxiety or depression?

This is another great example of a misperception, actually. Sometimes we think, "Well, my child is very high functioning and they do great in school. They can't possibly have issues with substance use." But I work with a lot of teenagers and young adults who may have some mild ADHD or anxiety who are very high performers and may feel compelled to be even higher performing. And so they may actually get wrapped up in overuse or misuse of cognitive enhancers, like caffeine or prescription stimulant medication.

And so having an idea of kind of the breadth of things that can be misused or abused is important.

It's scary and it can be overwhelming to think about, but it's important to, again, think about those underlying drivers of behavior and the type of direction that might lead even into substances we might not typically think about as being abusable.

Interviewer: And some of these ways of talking to the children about substance abuse might be kind of against a particular parent's parenting philosophy. We are all raised in our own ways by our own parents, and a lot of times, that's the way we raise our children. Is this evidence-backed stuff? Should somebody just go ahead and use their instincts instead going into this conversation? What are your thoughts on that?

Dr. Steinmann: I think that parents are the experts on their children, and so using your instinct can be a very powerful tool.

If you are noticing that your child is not acting like themselves, I do think it's important to ask more questions and probe. And again, by asking, you're kind of almost opening the door to, "I'm interested, I'm curious about you. I care about you."

Sometimes the hardest thing we can do, as parents, is to open the door to conversations that we might not be comfortable having, but by doing that, we're actually modeling for our kids that it's okay to talk about these things, that maybe their assumption that we're going to blow our stack or over-assume might be unfounded, that we want to be and try to be safe people to talk to because we have their well-being at hand.

I liken it in some ways to talking about suicide, for example, and suicide prevention. There's significant data that shows that simply asking about suicide does not increase the risk of suicidal behavior. And I think the same is very true for substance use.

Just because you're asking doesn't mean that you are giving permission or suggesting that they should engage in that behavior. All asking does is signaling your child that, "Hey, I'm aware that this is a problem and I want to be a person that you can rely on and trust to talk to about it."

Interviewer: For a parent listening to this interview that wants to go on to get some more information, what are some good reliable sources that they could go to online to get some help framing this or figuring out the approach or whether or not they should be concerned at this point? What do you recommend?

Dr. Steinmann: For reputable sources on the internet . . . because you're right, there are a lot out there and it can be really overwhelming to kind of weed through and find the best sort of reputable information. I really like the Substance Use Resource Center through the American Academy of Child and Adolescent Psychiatry. The Substance Abuse and Mental Health Administration, or SAMHSA, also has a lot of good resources.

And something that I found fairly recently as a resource, that I thought was very parent-friendly type of language, is through the Child Mind Institute. And they have various questions about how to talk to your teen about substance use for parents who may not be sure on how to start that conversation.

Interviewer: Using Imodium to treat opioid withdrawals: a bad idea. We'll find out more about this disturbing trend next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Doctor Troy Madsen on The Scope. On The Scope.

Interviewer: Doctor Troy Madsen is an emergency room physician at University of Utah Health Care and he said he'd seen a couple instances where people are using Imodium, which is an anti-diarrhea medication, as a way of trying to treat their withdrawal symptoms from opioids. I find this hard to believe. What's going on?

Dr. Madsen: Yeah. So this is really interesting. So as you may know, there's an opioid epidemic in our country and the Centers for Disease Control has acknowledged this and said we have so many people who are using opioids now. So prescription opioids, things like Percocet, Norco, Oxycodone are using that for to get high. Essentially what they may consider it legal high because they're getting a prescription or it's a prescription medication they're buying from someone.

So then, these individuals may then be saying to themselves, "I really can't be doing this. I need to get off this medication." So they're finding things on the Internet that discuss using Imodium or loperamide is the generic name and using that to sort of detox, taking that as a bridge to give yourself some of the same effects as the opioids give you while allowing your body to adapt and adjust and then gradually get off the medication.

Interviewer: So, first of all, bad idea trying to self-treat an addiction like that?

Dr. Madsen: Absolutely, not a great idea. But the reason they're doing this is because it's probably been out there for years and then I think it's just gained steam with some people posting things on the Internet about this. But Imodium or loperamide is actually an opioid. It doesn't give you the same high as things like Oxycodone, but it has kind of the same effects, acts on some of the same receptors in the body.

That's why it help with diarrhea because if you've ever heard of someone who says, "Hey, taking all these Percocets and I can't have a bowel movement. It constipates me." Well, that's kind of how this stuff works for diarrhea. Same kind of idea. It slows down the bowels but also then acts on somebody's same receptors in the body that opioids act on that people are using for highs.

Interviewer: Yeah. So self-treating bad but, above and beyond that, Imodium causes other problems that you see then?

Dr. Madsen: It does. And the big thing we're seeing is some of these people are just taking such incredibly high doses that it's been putting their heart into these arrhythmias, these abnormal heart rhythms that are life-threatening. And that's where we see it in the ER. I've seen cases of people coming in who are in just these crazy heart rhythms, these life-threatening heart rhythms and it's because they're taking large doses of Imodium and then that is triggering this heart rhythm.

And really, it's the kind of heart rhythm where you've got to shock their heart to get them out of it, get them on medication, do something for it or their hearts just not going to keep working and they're going to die from this.

Interviewer: That doesn't sound much better.

Dr. Madsen: It doesn't. It's not a great thing to do.

Interviewer: It doesn't sound like a great solution to the original problem.

Dr. Madsen: Yeah, there's not. There are much better solutions to opioid addiction and to getting off that. It's a sort of thing where you've come into the ER, we will often get people into in-patient detox programs. We can also prescribe medications that can help with this. So I would not recommend taking Imodium or loperamide. Again, that's the generic name for it. I would not recommend taking that to treat an opioid addiction because of the threat of these abnormal heart rhythms.

And this really comes up because there was actually just a study published or report in one of the big emergency medicine journals talking about increasing cases of this and increasing calls to poison centers for people who are taking more and more of these medications to try and treat opioid addictions and then are having very bad effects from this.

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Interviewer: How to treat addiction based on what we understand about the neuroscience of addiction. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah. Neuroscience is looking at a new way of thinking about addiction which then would guide how we would treat addiction. Give me a little background, how the school of thought in neuroscience treats addiction right now or thinks about addiction.

Eric: Sure. So there's really a way of understanding addiction that has emerged out of the past couple of decades, and there's been a lot of research and time and energy put into understanding this problem, and what we're coming to realize is that addiction is really a process of normal learning gone awry. The same processes in the brain that facilitate normal learning get hijacked by drugs of abuse.

Normally when we learn things, when we have an experience and the experience is rewarding, this tells the brain to do this thing again. And so we learn that that activity or that experience is valuable. We get some sort of pleasure or reward out of it.

In everyday life that might be good relationships with people that we care about, doing activities and hobbies that we love. It might be something simple like enjoying the pleasure of a tasty, healthy meal or a beautiful sunset or the snow on the mountains, but as a person becomes addicted, the effects of addictive drugs on the dopamine system in the brain cause changes in this normal learning pattern such that what was once rewarding becomes less rewarding and the brain becomes more and more dependent on drugs to receive the same amount of pleasure and reward.

Even drug use itself in the beginning is highly stimulating and rewarding to the brain. It produces a surge of dopamine release. But over time, the drug itself produces less reward and drug use becomes more and more of an automatic habit. People start to use drugs on automatic pilot without getting any pleasure out of it. It's just like any other habit we have that we do. The more you do it, the easier it becomes, the more automatic it becomes, the less you have to think about it, and that habit starts to become triggered by cues. For example, if you're an alcoholic driving past the bar or driving past a liquor store, or if you're a smoker and you smoke in social situations.

Interviewer: Or just even driving. I've known smokers that I could predict when they pull a cigarette out based on where we were in a trip.

Eric: Exactly.

Interviewer: By the time we hit the stop sign at the end of the street, a cigarette is going to be out. By the time we hit here, another cigarette's going to be out.

Eric: Exactly.

Interviewer: So wow, okay.

Eric: And they may not even intend to be smoking it. They may not even realize that they're smoking it. A lot of smokers have the experience of sort of looking down and seeing that half their cigarette's gone up and they don't even remember smoking it. It just becomes an automatic habit. It doesn't even give them pleasure anymore.

Interviewer: And then worse yet, the other things that didn't give them pleasure, don't give them pleasure anymore.

Eric: That's right.

Interviewer: So what do you do with that point? How do you break this cycle?

Eric: Right, and so the cycle, it gets worse because the things that used to give them pleasure are no longer giving them pleasure and the drug isn't giving them pleasure. The person is in a deficit. They're in a negative mood state and that really drives them to take higher and higher doses of the drug just to feel okay. And there's the addictive cycle right before you.

Interviewer: So how do you solve that?

Eric: Well, if this is the problem then it seems that we need treatments that can do two things. One, they can help a person become aware of the automatic habit of addiction, to become aware of when cues are triggering this automatic habit so that the person can begin to exercise some self-control over the automatic habit.

And then two, we need treatments that can help people to find a way to enjoy pleasure in life again, to teach the brain to relearn how to feel a sense of pleasure and reward from everyday activities that used to bring them pleasure.

Interviewer: And what are some of those things that you can do to start discovering pleasure in life again?

Eric: Yeah, so that is where a technique called mindfulness comes into play because mindfulness is really, although it's based on some ancient techniques for training the mind, we're coming to realize now with neuroscience that this approach actually strengthens both of those processes, both self-control over automatic habits as well as increasing attentional focus that might enhance the experience of reward.

Interviewer: Let me jump back for a second. So this is just one way of looking at addiction, what you've described to me. How sure are we that this is the way it is? I mean, how have they figured out this much?

Eric: There've been multiple millions of dollars invested by the National Institutes of Health, specifically the National Institute on Drug Abuse and the National Institute on Alcoholism devoted to this topic. These studies range from studies with animals, studies with humans and even studies down to the cellular level to understand how neurons communicate to each other and how drugs actually affect neurotransmission.

One simple way that this has been shown to be the case is by putting people in a brain scanner and watching how their brains respond when they're shown drug-related cues on a screen, for example, pictures of cigarettes, and showing activations in brain circuits in the reward center of the brain, and as addiction progresses seeing activations in the dorsal striatum which is the part of the brain that's involved in habit responses, and conversely seeing the opposite effects with regard to naturally rewarding queues.

So if you put somebody in a brain scanner and this person has developed addiction and you show them, for example, cues of smiling babies or beautiful sunsets or couples holding hands, the brain responds less sensitively to those cues.

Interviewer: It seems like some people are more prone to addiction. With this way of thinking, why would that be, or is that a false statement to begin with?

Eric: No, there's quite a bit of research looking into, for example, the genetic factors that predispose somebody to addiction, but in the line of discussion that we're talking about, people vary to the extent to which they're naturally sensitive to rewards. They vary to the extent to which they seek out novelty, they're sensation-seeking is the term, and they also vary to the extent to which they can control their impulses. Some people are just better naturally at stopping themselves and exerting self-control than others.

But my interest as a therapist is how people can train those capacities so that no matter where you start from, you can train your mind to strengthen self-control and strengthen your ability to experience pleasure in everyday life.

Interviewer: Are there any resources that if somebody wanted to learn more on their own that you could steer them towards?

Eric: There are a number of practitioners in the community that are practicing mindfulness-based therapies and there are also a number of providers in the community that are practicing other evidence-based treatments for addiction like motivational interviewing and cognitive behavioral therapy.

Interviewer: How is this way of treating being approached right now by the rest of the addiction community, people that don't subscribe to this philosophy?

Eric: This is a really hot topic right now in the addiction research field in terms of the importance of reward, the importance of sensitivity to natural reward as a predictor of addiction-related problems, but the idea that we could actually improve this capacity in somebody who is addicted and has lost the ability to feel pleasure in everyday life, this is a brand new thing. So it's a pretty hot topic and controversial.

Interviewer: Yeah, and not only overcoming addiction but actually maybe even be happier than they were ever before.

Eric: Exactly. It has a lot of applications to other issues, too, like depression or chronic pain and just improving the healthy response in life.

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Interviewer: Using mindfulness to overcome pain pill addiction. We'll tell you how, next on The Scope.

Announcer: Medical news and research from University of Utah Physicians and Specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: You or somebody you know suffers from chronic pain and as a result now has an addiction to the pain pills. Eric Garland is a clinical researcher and practicing licensed psychotherapist at the University of Utah, and there is a technique called mindfulness that could actually help get rid of the addiction and manage the pain as well. Tell me a little about that. First of all, does it really work?

Dr. Garland: It seems like it works. We have a body of research that's building that indicates that mindfulness is a really useful treatment for addiction. We're still actively studying this area, and really, it's an emerging research area, but there have been some pretty big well-controlled trials to show that it's helpful for this problem. I myself have done some of them.

Interviewer: I think sometimes people think of mindfulness and they think, "Oh, mind over matter. If it was only that easy." Right?

Dr. Garland: Right, and it's certainly not easy and I don't want to be flippant about it. This is tough stuff. We're talking about deeply entrenched habits. And it takes a lot of energy to change a deeply entrenched habit. But if you think about it, what mindfulness really is, it's a form of mental training.

So think of it this way. If you wanted to build up your bicep, you would curl a dumbbell and you have to put in a lot of energy, rep after rep, week after week, grueling workout after grueling workout to build the strength of your bicep. Well, if you want to build the strength of your mind to enhance your self-control over addictive habits, then you have to apply the same principle of repetition after repetition of mindfulness practice over and over again, day after day, week after week and you build up your mental strength through a very similar type of process.

Interviewer: So tell me, then, now. With somebody with pain pill addiction, how do they use mindfulness to overcome it? What would they do? Walk me through that process.

Dr. Garland: Yeah, let me walk you through the process. So let's assume that we have someone who's taking pain pills for a chronic pain condition but their use of the pain pills has sort of gotten out of control. One of the techniques we teach them is to practice mindful breathing before taking their opioid medicine. What that means is when the person is getting ready to take the opioids, instead of just popping the pill they stop, they pause, and they begin to focus on their breathing, and as they begin to focus on their breathing they begin to notice thoughts and feelings and urges, for example, the urge to take the pain medicine. In practicing mindfulness like this, the person may begin to realize whether their taking opioids is a means of alleviating pain or perhaps they're taking opioids as a means of getting rid of a craving, satisfying an urge as opposed to satisfying a genuine need for pain relief.

Interviewer: So then at that point what do you do? You just make the decision that wait, it is a craving. I'm not going to take this pill.

Dr. Garland: Well, in the case of somebody who is really dependent on opioids that would be dangerous to just stop taking the pill at that point, but by gaining that awareness the person might decide that they want to change their opioid use habit, so they might be able to work with their doctor to gradually decrease their dosage.

Now, if a person is really dependent and they start to decrease their dosage of opioids under a doctor's supervision, they may experience withdrawal or they may experience craving, and mindfulness techniques can be useful to help a person cope with the unpleasant feelings in their body and the unpleasant emotions in their mind during that process.

Interviewer: So it's really just kind of coming into touch with, "What am I feeling right now," and not just assuming that you're feeling pain or whatever, and then assessing that, and then deciding what you're going to do with that.

Dr. Garland: That's definitely a part of it. That's a big part of it. Another part of it is this process that we call mindful savoring, which is using your attention and your awareness to experience greater pleasure out of everyday activities and events. So again, as we discussed, from a neuroscience perspective addiction involves a process where the person becomes less sensitive to natural pleasure. When practicing mindfulness we can teach people to focus their attention on the positive and good aspects of their life so that they can actually enjoy it more. So let me give you an example of that.

In this mindfulness technique we have patients practice by focusing their attention on a bouquet of flowers. So they focus on the beautiful sights of the flowers, the colors, the textures, the touch of the pedals against their skin, the scent of the flowers, and whenever their mind wanders off to random thoughts they notice that their mind has wandered and they bring the focus of their attention back to the pleasant features of the flowers; the scent, the smell, the texture, the color. As they do this, they become aware of positive feelings in their mind and their body, and then the positive feelings and thoughts that arise in their mind and body become the focus of mindfulness practice. So we encourage the patient to focus their attention on any positive emotions or thoughts that come up.

This technique involves practice both in sessions with a therapist but also practice at home with other enjoyable things in the person's everyday life, and this technique is designed to help them to re-learn how to experience pleasure.

Interviewer: So with somebody with a pain pill addiction, the first thing that they would do is use mindfulness to just kind of become aware of, "Why am I popping this pill," and then if they've decided, "I want to do something different about that," you would recommend going to their physician and telling them, "I would like to get myself off these pain pills."

Dr. Garland: That's right

Interviewer: And a therapist would probably likely be involved as well with some mindfulness training.

Dr. Garland: That's right. So as the person goes to the process of reducing their use, they may experience craving for opioids, and mindfulness can be used to cope with the craving, again by first helping the person become aware of the sensations in their body, their craving-related thoughts and emotions. As the person becomes aware of the craving the feelings may start to get overwhelming, so they can use mindfulness techniques to focus on their breathing as a way to calm down the mind and relax the body to help the person to cope with the difficult thoughts and feelings without giving in to opioid use. And when this process is repeated over time, the craving can become weaker and weaker.

Interviewer: Any tips for somebody that's listening and they're convinced, "I want to do this". Do you have any tips for them, anything they should watch out for, anything they should absolutely do?

Dr. Garland: They should absolutely work with a trained and licensed therapist through this process. I don't think it's something that somebody could do so easily on their own in the beginning, but as a person learns these techniques with a skilled teacher they can begin to practice them at home alone by themselves, and that'll help them overcome the problem.

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Dr. Gellner: It's hard to imagine someone intentionally hurting a child, yet nearly a million children are abused every year just in the United States alone. Child abuse is today's topic on The Scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kid Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Child abuse happens when a parent or other adult causes serious physical or emotional harm to a child. Child abuse can take the forms of physical abuse, sexual abuse, neglect and abandonment, or emotional or psychological abuse. The most serious cases of child abuse can end in death. Those who survive may suffer emotional scars that can linger long after the physical bruises have healed. Kids who are abused are more likely to have problems building and maintaining relationships throughout their lives and they are also more likely to have low self-esteem, depression, and thoughts of suicide.

When people think of child abuse their first thought is of physical abuse, such as striking, kicking, or shaking a child. But physical abuse can also include holding a child underwater, tying a child up, intentionally burning a child with scalding hot water or other objects like cigarettes, using an object to beat a child, starving a child, or failing to provide a child with food intentionally. Abusive head trauma or Shaken Baby Syndrome is a specific form of child abuse and is the leading cause of death in child abuse cases in the United States. Most incidents last just a few seconds but that's enough time to cause brain damage and kill a baby.

Sexual abuse happens when a child is raped or forced to commit a sexual act. It's also any sort of sexual contact with a child that is meant to sexually arouse the abuser. So in addition to having sex with a child or even just inappropriate touching with a child, sexual abuse includes making a child pose or perform for pornographic pictures or videos, showing a child pornographic material, forcing a child to undress, not just normally like changing your clothes, but forcing a child to undress in front of you for gratification purposes, and flashing a child or showing one's privates.

Neglect is any action or inaction on the part of a caregiver that causes a child physical or emotional harm such as withholding food, withholding warmth in cold weather, or not providing proper housing. Basically anything that interferes with a child's growth and development constitutes neglect. This also includes failing to provide medical care when a child is injured or critically sick, locking a child in a closet or a room, and placing them in a dangerous situation that could lead to physical injury or death. Abandonment is a type of neglect.

Emotional abuse or psychological abuse is a pattern of behavior that has negative effects on a child's emotional development and sense of self-worth. Ignoring a child or withholding love, support, or guidance is considered emotional abuse. Just like threatening, terrorizing, belittling, or constantly criticizing a child.

Child abuse due to substance abuse problems include allowing a child to drink alcohol or take illegal drugs, manufacturing, ingesting, or distributing illegal drugs in the presence of a child, and in some states, exposing a fetus to illegal drugs or other substances while pregnant.

It would be easier if all child abusers followed a pattern and were easy to recognize, but the truth is that child abusers come from all walks of life. It's also sometimes difficult to tell the difference between ordinary scrapes and scratches of childhood and a physical sign of child abuse. Pediatricians often can tell the difference but not always.

Some ways that kids who are being abused might act include sad or angry, they may act withdrawn, fearful, have low self-esteem, or engage in self-harm, and many have persistent nightmares. Those who are abused usually have trouble developing and maintaining relationships. They are often unable to love or trust others, especially adults with whom they can be afraid of. A telling sign that something is just not right is when a child fails to seek comfort from a parent or other caregiver who happens to be their abuser.

Kids who are abused sometimes act out. They may lose interest in activities they once loved. They may turn to drug and alcohol abuse as well as sexual promiscuity. Other kids might not act out in the typical ways but will avoid going home after school or doing any activity that would cause them to spend time alone with the abuser. But just because a child is showing these signs doesn't necessarily point to abuse. Children who are going through stressful situations, like a parent separation or divorce, a family move, or the loss of a friend or family member, may also may undergo changes in their mood or disposition.

So what should you do if you suspect some child that you know is being abused? Remember that abuse is not a private family matter, although it most often occurs within families and is often kept as a family secret. Once you suspect child abuse, you need to act to protect the child from further possible harm.

It is your responsibility to contact your local child protective services agency, police, hospital, or emergency hot-line. You may remain anonymous. Pediatricians, by law, are required to call child protective services if there is any concern that a child has been abused. If you think you may have abused your own child or you're worried that you might make sure the child is somewhere safe away from you. Speak to a trained professional and that can be an effective way to work through the reasons behind your abusive feelings.

If you suspect that someone you know is abusing a child, keep the child away from that person until authorities have been notified. Never threaten a person or take the law into your own hands. Let the legal system decide an appropriate punishment for the abuser.

Pediatricians recommend that children who are suspected abuse victims be taken to a local children's hospital where the initial diagnosis can be made and treatment can be given. Hospitals often see abused kids, especially battered children, and they can do the needed X-rays or cultures for a diagnosis to be made. They also work very closely with social workers, child protective services, and the police department to file all the necessary paperwork for the child abuser to be charged.

Psychological help is also strongly recommended. Without it, children who may have been abused may suffer emotional problems or repeat the pattern of abuse with their own children.

Abuse does not have to ruin a child's life as long as it is stopped and dealt with. The earlier abuse can be identified and stopped, the less destructive it will be.

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Interviewer: For victims, admitting to domestic violence is the first step to ending the abuse. But what about the abuser? Coming up next on The Scope, we're talking about whether or not abusers really want to stop being abusive.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: We're talking today with Wendy James, a social worker at the University of Utah. Wendy, in my knowledge, not knowledge necessarily, just what I've seen, abusers kind of just don't really care. That's probably not the case though, right, from your experience?

Wendy: I don't think that is the case. I think they may act like that, in a macho way like they don't care, but most of them are filled with shame and guilt.

Interviewer: Why do they continue then?

Wendy: Because it's a pattern that they've learned either growing up and witnessing this, and they don't know how to do anything different. They need counseling. They need intervention. Some of them are just bullies, okay. And they want . . .

Interviewer: Bullies are not nice.

Wendy: No, and they want power and control, and they will blame anyone, not just their wives, but they will blame anyone in their lives about their problems. They don't accept their own problems, and they don't want help. But a larger majority do feel shame and guilt and want to do something different, and they love their wives, and they feel tremendous remorse.

Interviewer: Because isn't it true that a lot of the times why women stay is because their partner promises that it's going to stop, but it doesn't stop.

Wendy: But it doesn't stop, and I believe at that very moment, they may really want it to stop. Some of them may be just manipulative and say that and make promises that they don't intend to ever keep. Some really want it to, but they need help and counseling in order to do that. On the other hand, there's people who have mental illnesses that have impulse control problems and issues, and they may need medication and intervention in that form.

Interviewer: For the abusers that do genuinely want to stop, and they go to counseling and they get the help to stop abusing other people in their lives, do you think that relationship will work out? Do you think the woman should still stay with their partner?

Wendy: That's debatable. I think if women stay, they put themselves and children at risk. Oftentimes counselors will suggest that they live separately and then do counseling together. So that oftentimes works better. The other piece is some men won't get help unless there are allegations against them. So truly the most loving thing a woman can do is press charges, because they're often surprised that what they're doing is wrong. That can be helpful in them getting help as well.

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Interviewer: What to do if you know a friend is being physically abused by their partner. That's next on The Scope.

Announcer: Medical news and research from University of Utah, physicians and specialists you can use for a happier and healthier life. You are listening to The Scope.

Interviewer: To talk today, with Wendy James. She's a social worker at the University of Utah. Wendy, women are being abused, that's just the state of the fact of it and many of them, a lot of them are not really telling people that they are being physically abused by their partner at home. If you know someone that's been physically abused, how do you help them?

Wendy: Well, if they come to you, it's difficult to approach them if they don't approach you, because there's a lot of shame and guilt associated, more to the reasons women don't leave. But if she does, assure her that it's not her fault and that she needs to set limits in the relationship.

Interviewer: Define those limits.

Wendy: I will. And they are not just for herself and her safety, but her children's safety and also a loving thing to do for her husband. Oftentimes women are frightened to do this, but it is a loving thing to keep everyone safe. What I would do is give her information about she can call the police. They can actually arrest her husband. Then there are women shelters that she and her children can go to where they can be safe, where they can get the legal consultation and help. I would tell her that if the abuse occurs that she needs to go to the hospital, that she needs to document that if there are any injuries, get pictures. If she ever wants to file an assault case, which she should do. A lot of women hesitate to do that for lots of reasons.

Interviewer: Right. I guess what I'm curious about now is that you're mentioning all these things that more of being there for her. What can a friend do physically? Can I drive her to the hospital? Should I be the one to go with her? Should I be they want to contact the police if she's scared to?

Wendy: That has happened. People can call the police and of course if she has a support to take her to the hospital and reassure her. Find a counselor, give her information about the shelter. Any kind of information in any way that you could support her. Just assure her that it's not her fault because abusers usually have lots of reasons they tell women why... well, women or men, but usually it's women, that are abusing them and often time women self-esteem is so low that the start to the believe it.

Interviewer: So first things first, you've got to get her confidence back to make her aware this isn't her fault.

Wendy: Correct.

Interviewer: Any final thoughts on what to do if you know a friend is being physically abused at home by their partner.

Wendy: One thing is just to educate her and let her know that abuse is not going to stop no matter how much she wants it to without some kind of intervention and help. And that the abuse will get more severe and more frequent.

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Interviewer: Four thousand women die each year from domestic violence and about 75% of those deaths occur when the victim finally decides to leave the relationship. Why is domestic violence happening in the first place? We're talking about that next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: We're here today with Wendy James, social worker at the University Utah and the topic is domestic violence. Why does this even happen? We know it's bad. It's a terrible thing but yet it still happens and it happens often. Why?

Wendy: Unfortunately a lot of the time it's a learned pattern that it is witnessed...

Interviewer: From the abuser?

Wendy: From the abuser. Well and it can be from the abused, the victim as well that's why she stays but we'll... but poor self image. They don't feel good about themselves so they bully and take it out on the underdog. A stereotype view of women that wives should be submissive and that it's okay to beat them into submission. Poor childhood experiences, like I said they came from violent homes. Fear of change, when a woman is pregnant she's more vulnerable to abuse and that tends to be when the abuse may occur.

Interviewer: When she's pregnant? Really?

Wendy: Oftentimes men are challenged by having another child either jealousy or they're concerned about financial responsibility, emotional responsibility, so it's a challenge for them. Sometimes lack of communication between the two. Women can be more passive and a man doesn't have the words perhaps to say how he feels or is frustration or anger and it comes out physically. Economic pressures for sure. Loss of jobs. Yeah, not adequate jobs provide for the family and their beliefs that they want to be good providers.

Interviewer: We just went through some of the trigger points for men as to why and I know you say that, not all the time but most of the time are the abuser. That they're included and they're involved in this terrible pattern. What about the women? Are they doing anything that might put them at harm for this?

Wendy: Unless they're really into a pattern of abuse there's a cycle of abuse where a woman gets abused and beat up and then the husband feels guilty and shameful, brings flowers, whatever. Then the tension builds and the abuse happens again. Often times it's if there's an event coming up or a woman wants to get this over with that she will actually do some things to irritate and aggravate the other person so that the abuse will occur.

Interviewer: So taking it back a step then let's assume that the woman is not provoking domestic violence here.

Wendy: Exactly.

Interviewer: Are there some things though that she might be doing that she doesn't know is provoking?

Wendy: I don't think, you know what, overall no. I do not believe. It's not just me. Research indicates as well that it's not that these men are provoked by anything that she does. She is not at fault for this. There's reasons she stays.

Interviewer: So in the final end of this women still stay regardless of how painful and bad for them and their kids. They're still staying in these harmful relationships. Why?

Wendy: A lot of them fear that if they leave that their husband will take the children and they'll be without their children. They feel fear and shame themselves. A failure of a broken marriage. They have low self esteem so they don't know if they can survive without their partner. They have hope that their partner will change and it doesn't happen. Financially often times they're very dependent on the man and there's family pressure that the children need a father and they disapprove of divorce. There's societal pressure. Oftentimes people will blame the victim for provoking it and that's just not true. I know I said something earlier about that and that happens rarely that...

Interviewer: The provoking?

Wendy: ...but it does happen. The provoking. Yeah, and they want to be able to just... the people will tell them just to forgive and forget about this. People who don't understand and aren't educated about domestic violence.

Interviewer: So it all comes full circle. In order to end domestic violence both sides, especially the woman need to be educated and know that it's not their fault.

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Dr. Jason Hunziker: Today we're going to talk about the long-term consequences of child abuse and neglect.
I'm Jason Hunziker from the University of Utah Department of Psychiatry and this is what's coming up next on The Scope.

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Dr. Jason Hunziker: Information from the Child Welfare Gateway and the U.S. Department of Health and Human Services suggests that in the physical year of 2011 over 650,000 children were the victims of abuse and neglect. Those injuries that those children suffer can take many different forms, including physical, behavioral, societal, and psychological and have consequences that ripple through their families for generations to come.
It is often difficult at times to separate out which of the physical, behavioral, societal, or psychological injuries are responsible for the signs and symptoms that we see in our children as they are growing up and turn into adults.
An example of this would be let's say a child gets brain injury and ends up causing significant psychological issues such as depression, emotional problems, and cognitive problems. Those emotional problems or cognitive problems can then go on to lead to poor decision making and risk taking behavior that we wouldn't normally see. And those then can lead on to more societal problems such as long-term disability or crime.
There are several different factors that can lead to these consequences from abuse and neglect that we can possibly see and a few of those include age and developmental status when the abuse occurred. So if the abuse occurs younger we could see different problems than if it occurs at an older age.
The types of abuse or mistreatment; physical abuse leaves different long-term scars than sexual abuse would. The frequency, the duration or severity of the abuse; if it happens more often or if it's very severe that trauma can also be significant in long-term consequences.
And then of course who the perpetrator is makes a big difference. Often it's a family member and that is much worse than someone that you don't know who is causing this severe abuse.
While it is not yet really understood why some children have long-term consequences and others don't, even when they have similar circumstances, so often siblings will experience the same abuse in the same household environment, and may not have the same consequence. And they postulated that resilience is often used or the term used to describe why these children are able to cope with this abuse or neglect. Most children are not born with the resilience; it comes from either within themselves or from the family environment or from the community in which they live.
There are often a lot of different things that can contribute to resilience including good self esteem, having a good sense of humor, strong positive attachments with people around you, and good emotional regulation.
Some of the psychological consequences of abuse can occur immediately after the abuse. These things that we would see are children isolating from their friends or from their family or having extreme fear around strangers; or the loss of ability to trust anyone. These immediate emotional effects can lead to depression, anxiety, long-term trust issues, relationship instability, and self doubt. When the abuse occurs in an infant and in younger children it primarily affects their ability to form strong healthy attachments.
In a document titled, Call to Action On Behalf of Maltreated Infants and Toddlers it reported that half of infants in foster care who have been mistreated experience some type of cognitive delay. Of these they all have lower IQ scores, language difficulties, learning disabilities, and other challenges compared to other children who have not been abused.
Later in childhood the abuse can lead to formation of borderline personality disorder, severe major depression, anxiety disorders, and in some cases PTSD. There have been some studies that show a connection in suicide rate and depression rates in women associated with child and adolescent sexual abuse. Other studies have shown that over 50% of women that have an eating disorder have suffered some type of sexual abuse.
While not all children of abuse will struggle with emotional or behavioral problems, more than half of the youth reported some type of abuse and therefore were at increased risk of emotional or behavioral problems.
Some of those behavioral problems that can occur in adolescents include having to repeat a grade because they keep failing and have to start over, using illicit substances, alcohol, tobacco, prescription drugs, criminal activity of any type, skipping school and early teenage pregnancy.
Some studies have also shown an increase in this high-risk sexual behavior and there is a nine times increase in the criminal activity of adolescents and in adults who have suffered childhood abuse or neglect.
As mentioned briefly, substance abuse is a huge problem in this population. There is a lot of research that consistently reports the increased likelihood of abuse and neglect will lead to cigarette smoking, drinking alcohol, and using street drugs and other prescription drug abuse in men that have greater than six episodes of abuse or neglect in their lifetime. They have an increased likelihood of more than 4,000% that they will use IV drugs later in their life.
Lastly this abuse behavior seems to create a cycle of abuse that is passed down from generation to generation to generation. Girls from physically abusive homes were 1% to 7% more likely to perpetrate youth violence; and 8% to 10% more likely to perpetrate interpersonal violence.
In boys who experience sexual violence in their adolescence or childhood were 3% to 12% more likely to commit youth violence, and 1% to 17% more likely to commit an interpersonal violence.
Abuse and neglect in childhood clearly leads to a range of different consequences later in life. Even though some children seem to escape the long-term problems from abuse, everyone suffers the short term. The cost to the individual, the family, the community is so high when abuse or neglect goes unnoticed, and the symptoms go untreated. It is important to recognize when abuse is happening and to seek help from counselors, primary care providers, pediatricians, psychologists, psychiatrists, and anyone who can help and perhaps avoid more long-term problems from childhood abuse and neglect.

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