Use one or more of these quick screens with every adolescent presenting for treatment—especially in substance abuse treatment settings. When results are positive, probe for gambling behaviors and consequences. Rely on DSM-IV-TR criteria and clinical presentation to differentiate social gambling from pathological gambling.
Gamblers Anonymous 20 questions (GA-20) for compulsive gambling behaviors
Most compulsive gamblers will answer “yes” to at least 7 of these questions:
- Did you ever lose time from work or school due to gambling?
- Has gambling ever made your home life unhappy?
- Did gambling affect your reputation?
- Have you ever felt remorse after gambling?
- Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
- Did gambling cause a decrease in your ambition or efficiency?
- After losing did you feel you must return as soon as possible and win back your losses?
- After a win did you have a strong urge to return and win more?
- Did you often gamble until your last dollar was gone?
- Did you ever borrow to finance your gambling?
- Have you ever sold anything to finance gambling?
- Were you reluctant to use “gambling money” for normal expenditures?
- Did gambling make you careless of the welfare of yourself or your family?
- Did you ever gamble longer than you had planned?
- Have you ever gambled to escape worry or trouble?
- Have you ever committed, or considered committing, an illegal act to finance
- Did gambling cause you to have difficulty in sleeping?
- Do arguments, disappointments, or frustrations create an urge to gamble?
- Did you ever have an urge to celebrate any good fortune by a few hours of gambling?
- Have you ever considered self-destruction or suicide as a result of your gambling?
Behaviors and comorbidities
Negative consequences. Pathological gambling often consumes 10 to 20 hours per week of the adolescent’s time,13 hurting school performance and delaying developmental milestones. Teen gamblers may abandon extracurricular school activities, and their few friends often gamble, too. They are at risk for delinquency, criminal activity, and antisocial behaviors (such as selling drugs, engaging in prostitution)14 unprotected sexual activity, drug use, reckless driving, and carrying weapons.15,16
Psychiatric comorbidity is the rule and often what brings adolescent gamblers to treatment. Substance abuse, major depression, attention-deficit/hyperactivity disorder, and personality disorders are most common (Table 2) Adolescent substance abuse at least triples the risk of pathological gambling.18
Adolescent pathological gamblers have increased rates of suicidal ideation and suicide attempts.17 They are at risk for other impulsive behaviors as well,19 although they are unlikely to volunteer this information. The Minnesota Impulsive Disorders Interview help identify comorbid pathological gambling, trichotillomania, kleptomania, pyromania, intermittent explosive disorder, compulsive buying, and compulsive sexual behaviors.19 Screen for these comorbidities during the first sessions or if a patient does not respond to treatment of gambling behavior.
Table 2
Risk factors for pathological adolescent gambling
| Component | Risk factors |
|---|---|
| Family history | Family history of gambling problems; possible genetic influences (neurotransmitter activity, risk-taking behaviors, risk perception, heightened physical response to rewards) |
| Psychiatric comorbidity | Substance abuse, mood/anxiety disorders, ADHD |
| Personality traits | Low self-esteem, competitiveness, sensitivity to stress or rejection, peer influences, immaturity, suicidal tendencies |
| Social factors | Early-age exposure to gambling, having peers who gamble regularly, increased access to gambling (such as via the Internet), chaotic home environment (divorce, neglect, abuse) |
| ADHD: attention-deficit/hyperactivity disorder | |
Treating adolescent gamblers
Matt’s answers to the gambling screening questionnaires (one “yes” to the Lie-Bet Questionnaire, a SOGS-RA score of 4, and a GA-20 Questions score of 5) indicate problem gambling but not pathological gambling. You recommend that he attend Gamblers Anonymous, but he refuses. He also rejects individual therapy or taking medications.
Matt acknowledges misusing methylphenidate, however, and agrees to consider an outpatient substance abuse program. He also agrees to six sessions with a gambling treatment specialist to learn about problem gambling’s signs and symptoms, how to cope with betting loses, and how to reduce his preoccupation with gambling.
No guidelines exist for treating adolescent pathological gamblers, and specialized teen treatment programs are rare. Most services are provided in mental health or substance abuse settings, using adult treatments modified for adolescents.
Cognitive behavioral therapy (CBT) can be successful for highly motivated gamblers, although adolescents might not want to change their pathological behaviors. In case reports, four adolescents achieved remission after 6 months of CBT.20,21 CBT appears to have long-term benefits for adults, but this has not been evaluated in teens. Even so, individual CBT may be ideal for adolescent gamblers because side effects are minimal.
Gamblers Anonymous (GA) in adults has shown a low retention rate and a 1-year abstinence rate of 22 Its effectiveness for adolescents lacks empiric support, but the 12-step program’s availability, structure, and fellowship may be useful.
Medications. Consider medication as first-line treatment for adolescents with psychiatric comorbidity. Try psychosocial treatment first for those without psychiatric comorbidity; consider medication as second-line therapy if response to psychosocial treatment is inadequate.