Putting it Into Practice
Screening for problem gambling can be done either formally or informally. You can ask clients a few questions about gambling behaviour, and if any concerns emerge about their gambling, you can move on to using a formal screener. Screening tools can also be helpful in increasing awareness around clients’ behaviour and monitoring progress. Screeners are available that were originally developed for youth; however, screening tools adapted from adult screeners are seen as the best tools for adolescents:
When asking young people about their gambling, it can be helpful to use presuppositional language such as “How often do you gamble?” and “How much do you spend on gambling?” in order to normalize the activity and decrease any fears about being judged. You can also change your language from “gambling” to “betting with money or material belongings on events or outcomes,” using examples like a sporting event or a challenge with a friend. Young people may not relate to the word
gambling as it may conjure up images of traditional casino games.
Assessing gambling behaviours can happen in a variety of contexts. According to the Canadian Paediatric Society’s position statement on gambling in children and adolescents (2012), to screen for a gambling problem, health care providers should ask:
- about the frequency of their clients’ gambling, with at least once per week being the threshold for a gambling problem
- if clients gamble more than planned
- if clients present with behaviours that indicate they are hiding their gambling from others.
You can include specific questions about gambling within a mental health and/or addictions assessment, asking questions relating to:
- how long they have been gambling
- where they gamble
- when they gamble
- who they gamble with
- how much they spend
- how much money they owe/how much debt they have
- what type of gambling games they play
- what they like about gambling
- if anyone has expressed concern about their gambling
- what the negative impacts of gambling are on the various aspects of their life.
It can also be helpful to get collateral information from family members, particularly when youth are still living with their parents/guardians and siblings.
Using a motivational interviewing approach can elicit information about clients’ mental health history, including addictions, and can be helpful when offering feedback. Asking permission before providing impressions and information can promote an environment of respect. Ensuring confidentiality, even when parents are involved in the program, is also important in fostering trust and comfort.
Since problem gambling is not typically at the forefront of concerns for parents, teachers and mental health professionals, adolescents with problem gambling are unlikely to be referred for or seek out treatment. Currently there is also a lack of research on effective treatment options for adolescents with problem gambling and no clear guidelines on best treatment practices.
In addition, few specialized treatment options exist for adolescents. Given the low numbers of youth in most gambling treatment programs, they may be referred to groups with adults. However, youth-specific services are more effective than mixing young people with adults in a single treatment group. Depending on the age and maturity level of the clients and the lack of others close to their age within the treatment group, it may be more beneficial to treat younger clients individually.
Many of the treatment approaches for youth have been adapted from problem gambling treatments for adults. This can be problematic because it does not consider the diverse developmental aspects and challenges of adolescence. However, there is some evidence to support the effectiveness of
cognitive-behavioural therapy (CBT) and
motivational interviewing with this population. Motivational interviewing has an emphasis on autonomy, which may lend itself well to this particular age group.
Personalized feedback intervention (PFI) is a type of brief intervention that involves correcting misrepresentations of youth gambling behaviour by comparing their behaviours to normative behaviours of a peer group. Youth who believed their friends gambled more frequently, spent more money and thought that important people in their lives approved of their gambling were more likely to experience negative consequences related to gambling. Geisner and colleagues (2015) showed that one session of PFI was associated with less gambling and fewer mental health symptoms six months after the session. This could be related to the importance of peer relationships and self-image at this developmental stage.
Young people regularly use the Internet to access help and look for information related to mental health problems. Emerging evidence suggests that providing
online services for youth with problem gambling is advantageous and effective. An example of this was a pilot project by McGill University’s International Centre for Youth Gambling Problems and High-Risk Behaviors called
gamtalk4teens. It was a real-time chat line for teens and young adults using instant-messaging software. Anecdotal evidence indicated that it was helpful for users of the service.
The lack of youth representation in problem gambling treatment has made it difficult to study treatment efficacy. The research that has been done endorses CBT, motivational interviewing and PFI as showing some benefit. Given the comfort that youth have with technology and the likelihood they will look for help and information online, this could be a promising way to support youth with problem gambling. In addition to these modalities and delivery methods, helping youth develop good coping skills and providing support for families in treatment on improving relationships can reduce risks and help support recovery.
Responding to co-occurring issues
Youth with problem gambling are more likely to have other mental health problems―including addictions to substances and/or behaviours (e.g., gaming, etc.)―when compared to the general population. It is important to ask about any mental health diagnoses or problem behaviours they may be experiencing. They may not have a diagnosis when they come to treatment, but you may suspect the presence of other issues such as depression and/or anxiety. Screening tools can help identify co-occurring problems your client may be experiencing. An example of a screener that has been validated for use with adolescents is the
Global Appraisal of Individual Needs Short Screener (GAIN-SS; page 23). Learn more about
additional screeners for concurrent disorders.
Screening can help identify the need to refer your client for psychiatric consultation or to a specialized mental health clinic. It is important to work with these professionals and organizations to provide integrated care for your client’s problem gambling and concurrent disorder(s).
Offering education about the link between problem gambling and co-occurring mental illness can also be helpful in normalizing their experience and decreasing stigma. Learn more about
Other issues such as finances, legalities, housing and family conflict may also need to be assessed and included in a treatment plan. Often, if the issues connected to gambling are not addressed, it can be hard to recover.
Problem gambling impacts all families, including those of adolescents. Families can also have an impact on the person with problem gambling; therefore, whether or not they are involved in treatment will impact their loved one’s recovery. Parenting issues and family conflict are both linked to adolescent problem gambling. Involving family in treatment will not only provide support and information to impacted family members but may also help address conflict and parenting issues. In situations where parents have insisted the youth present for treatment, focusing on familial issues may take priority over gambling behaviours.
Families can be involved in a number of ways, such as receiving psychoeducation, being invited into session(s) with their loved one, having their own counsellor, attending a group for families and/or engaging in family therapy. It can be helpful to let the youth and their loved ones know how family involvement in treatment can positively impact recovery from problem gambling.
It can be common for parents to “bail out” their youth when they find out about gambling debts. It is important that families know what they can do to support change and how minimizing consequences for the person with a gambling problem can negatively impact motivation and recovery. Involving parents in treatment may include discussions about limit setting, communication strategies and rebuilding trust with their child.
Role of technology
Young people have always known a world with Internet access and technology such as Smartphones, computers and tablets. They often have a great deal of comfort with these media and spend a lot of leisure time online. In addition to comfort, the level of access and pervasiveness of the Internet and technology has increased availability of online activities, including gambling. Adolescents can access online gambling sites more easily than other gambling venues because they can pass the age verification more easily.
In addition to online gambling, gambling games exist that can be played online for points (known as social casino games) as well as online video games with gambling elements embedded within them, which may prime youth for gambling at a later age.
In recent years, the gambling industry has used technology to develop more online games and gambling sites that are accessible, affordable and more attractive to younger audiences. This “gamification of gambling” includes but is not limited to adding gambling elements to games on social media and adding social/video gaming features to online gambling sites. There are growing concerns surrounding the blurred lines between gaming and gambling, as this could increase the risk of developing problem gambling.
Motivation and engagement
Youth that present in treatment may have been forced to be there by their parents and may be reluctant to engage. Time should be spent working on engagement, building an alliance and gaining trust. Many adults that attend treatment for gambling do so because they are dealing with serious financial and relationship consequences. They may be at risk of losing their spouse/partner, their job and/or their housing. Youth are not likely to be dealing with the same consequences as adults and as a result may be less motivated to get treatment. Building a relationship with a young client and being curious and non-judgmental about their gambling behaviour can help create opportunities to explore why gambling has become problematic for them and how they can minimize risks in the future.
Working with clients through a health equity lens
Social factors can play a crucial role in our overall physical and mental health. These can include one’s education, income, job security/working conditions, childhood development, food insecurity, housing, health services, Indigenous status, gender, race and disability status. These social factors, known as the social determinants of health, can affect how people―including clients seeking problem gambling treatment―view their symptoms, what symptoms they report, when and what treatments they seek and who may be involved in their care. Social factors of both the client and the health care practitioner can also lead clients to experience systemic disparities in the quality of health care received as well as access to services. For instance, the rate of hospitalization for mental illness among people in the lowest income level is two times higher than the rate in the highest income level.
Health equity is an important perspective with which to evaluate our health care practices to reduce or remove the avoidable, unjust and unfair disparities that exist for specific populations. In providing care, it is essential to consider all factors that may affect your clients’ health, including their gambling problems, concurrent disorders and social determinants of health.
Social factors can play a role in the development, assessment and treatment for adolescent problem gambling. Below are a few examples.
- Given that most adolescents are often still living with and dependent upon their caregivers, the social determinants of health must be considered for
both the adolescents and their caregivers when assessing and treating youth with problem gambling. For example, caregivers who have to work multiple jobs may not be able to see their adolescent child as often, thereby making it more difficult to identify a problem as quickly. Socioeconomic status, location, access to transportation and other factors may also mean that caregivers are unable to attend treatment with their child and/or that the youth may be unable to attend extra-curricular activities or other treatments recommended for their gambling problems. It is crucial to learn more about your client and how the social determinants of health may apply to them.
- Social factors can also play a role in why youth gamble. Gambling is more prevalent in certain cultures and may be embedded in how they socialize and celebrate, which may have implications for the detection of the problem, youth’s comfort level of telling someone they have a problem and the potential for relapse if exposure to gambling is ongoing. Adolescents who grow up in cultures where gambling is a highly normalized activity may be at increased risk of developing problem gambling.
Conversely, gambling is prohibited or frowned upon in certain religious and cultural communities, which can be protective for youth. However, if a young person does develop a problem with gambling, this can create distance and isolation from their parents, family and community.
- Cultural background, among many other factors, can influence help-seeking behaviour as well as beliefs about addiction and mental illness. Adolescents might be fearful about their family finding out they have a gambling problem. They may also have been given strong messaging about dealing with things
within the family as opposed to seeking outside professional help. It is important to have some cultural awareness and responsiveness when responding to adolescent problem gambling.
- First Nations, Inuit and Métis youth face additional social factors that may put some at higher risk for problem gambling. According to a review by Wardmann and colleagues (2001), prevalence rates of problem gambling for Indigenous adolescents in North America commonly range from 10.1% to 21%, with an additional 25% of youth being at risk. Subsequent studies have examined why problem gambling prevalence may be elevated in Indigenous youth in Canada, including youth living in urban settings, and social factors such as low family income, stress, abuse, intergenerational trauma, feelings of isolation, racial discrimination and exposure to one or both parents who gamble have been linked to problem gambling. Therefore, it is important for treatments, programs and services to consider these social determinants of health as they pertain to Indigenous youth as well as the diversity of peoples, cultures, languages, histories and experiences of Indigenous youth in Canada.
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