Panel: Promising Practices in Addressing

Problematic Gambling and Concurrent

Challenges

Dr. Daniela Lobo

Dr. Amanda Sawyer

Dr. Flora Matheson,

Louise LeBlanc, RSW

Moderator: Judith GlynnMay 9, 2019

Gambling Disorder

and

Technology Overuse

Daniela Lobo, M.D., Ph.D., FRCPC

Staff Psychiatrist, Addictions Division

Assistant Professor, University of Toronto

Most Common Comorbidities

Population and clinical samples based studies

• Nicotine Dependence: 60.1%

• Substance Use Disorders (SUD): 57.5%

• Mood Disorders: 37.9%

• Anxiety Disorders: 37.4% (including OCD)

• Adult ADHD not investigated

• Results similar to clinical samples

• PTSD and trauma underinvestigated

Mood Disorders and Risk for GD• Population Study – US (Kessler et al., 2008)

• Major Depression (MDD) predicted the subsequent onset and persistence of PG with an odds ratio of 6.6

• Clinical Study – Kennedy et al., 2010 (U of T)• 579 participants (200 males)

• PG: 19.5% males x 7.8% females (2% population)

• Mood disorder - primary onset condition in 71% of cases (both Bipolar Disorder and MDD)

• Risk increased if comorbid with panic disorder, OCD, phobias, alcohol and SUD

Gambling Availability and Harm

• Welte et al., 2016: the concentration of casinos within 30 miles of the respondent's home was positively related to the respondents' chance of being a frequent or problem gambler. If a respondent had no casinos within 30 miles, he or she had a 2.7 % chance of being a problem gambler; if one casino, a 3.9 % chance; if six or more, a 6.2 % chance.

• Abbott et al. 2014 (Australia): changes over 5 years• Overall decrease

• Increase in specific groups: males, lower level of education

• Abbott et al., 2016 (Sweeden): rates between 1998 – 2009• Overall decrease

• Increase in males, youth, and immigrants

Gambling Availability and Harm

Gambling and Harm Prevention

• Several responsible gambling strategies, few studies on its effects

• Rossow et al., 2016: • Norway: increase of EGM gamling in 1990’s

• 2006 – 2009: restriction on EGM availability – temporary EGM banned and re-introduction of fewer, less aggressive machines

• Resulted in fewer gambling and gambling problems.

Technology Overuse

• No DSM diagnostic criteria yet

• Increased demand for treatment over the past 5 years

• Mostly young: 16 – 25 year-olds

• Significant psychiatric comorbidity

• “Failure to launch”

Technology Overuse - Treatment

• Skills for limiting use

• Development of better social skills

• Understanding connection between the type of game and development of overuse

• Treatment of comorbidities

• Involve family whenever possible

Resources

Overview

• Review of what autism is

• What we know about autism and technology use

• Treatment: Unique considerations

Step 1: identifying ASD

What is ASD?

1. Social reciprocity

2. Nonverbal communication

3. Initiating and maintaining

friendships

1. Repetitive movements and

phrases

2. Intense and circumscribed

interests

3. Insistence on sameness

4. Hypo/hyper

sensitivity

symptoms

Deficits in social

communication and

social interaction

Repetitive and stereotyped

movements and behaviours

Why does ASD matter?

• Impacts assessment

• Impacts formulation

• Impacts treatment

What do we know about technology use and ASD?

• Those with ASD play fewer types of video games and use internet less for social media

• They start using electronics, internet etc at an older age than their counterparts.

• They spend more time using electronic devices

• Higher levels of compulsive video game and internet use,

• Negative impacts on them and their families

MacMullin, Lunsky & Weiss, 2015 Autism

Benefits of technology for ASD

• Reading and writing

• Organization

• Planning

• Keeping in touch with people

Step 2: Identifying function of excessive tech use• Boredom

• Skills

• Positive reinforcement

• Other mental health issue

• Stress relief

• Entertainment

• Social

• Cognitively stimulating, interesting

• Sensory experience (just the right volume)

• Avoidant behaviour of difficult activities

• A learning environment (SAFE)

Step 3: Identify stages of change

Motivational interviewing in ASD

• Limited research on MI and ASD

• Barrier: concrete thinking and inflexibility

• Advantage: promotes autonomy within individual, can help individual understand why change needs to occur

• Requires increased patience and time from therapist

Step 4: Identify natural consequence of excessive tech use

• Loss of friends

• Loss of income

• Debt

• Decline in grades

• Loss of other interests

• Reduced tolerance for social activities

• Parents less motivated to support individual

• Increase in other mental health symptoms

Step 5: Implement Behavioral Strategies

Step 5: Implement Behavioral Strategies

Technology use is a privilege, not a right

• Need to earn tech time

• Need to use it responsibly to keep it

How are these strategies different from neurotypical excessive technology treatments?

Therapy modifications

• Concrete, specific

• Take increased time

• May involve family

CBT modifications

• Smaller group size

• Additional attention to group skills

• More B, less C

• Concrete aids to use at home to change behaviours

• Can be more challenging to modify thoughts

• Benefits of bringing caregiver on board despite adult age

Linking poverty & problem gambling

• The prevalence rates of problem gambling

in homeless populations (10 to 35%)

(Matheson et al., 2014; LePage et al., 2000)

is significantly higher at roughly 9 times the

rate of the general population (0-5%)

(Ferris, 2016)

• A relationship between problem gambling

and poverty is identified in the academic

literature

• Sharman et al., (2016) attempted to

determine temporal order

• By asking clients about their life history they

found that for those who gamble

excessively, the majority report gambling

problems preceded homelessness (82.4%)

• Two important life events may lead to

homelessness according to the authors;

gambling problems and job loss

Housing

instability

Mental illness &

substance use

Physical illness &

disability

Trauma

Problem

gambling

Criminal Justice

Involvement

Job &

financial

insecurity

Peer support workersEssential in the care process

Lessons from Services Providers and People with Lived Experience of

Gambling, Poverty, Homelessness

Service providersLack awareness problem gambling among their clients

Feel they lack knowledge and training to address problem gambling

PhysiciansUncomfortable screening and engaging patients with problem

gambling in their practice.

Gambling

Increase awareness of

the link between problem

gambling and homelessness

Incorporate communication

s training into existing services

and supports for vulnerable populations

Provide integrated services for those

experiencing complex social and

health concerns including problem

gambling

Create general

awareness of services and supports for

problem

Develop technological

solutions to support self-

management of problem gambling

Scoping Review

CAC Feedback

Client Interviews

Staff Focus Group

Competitive Analysis

“Design Sprints”

Staff Feedback

UX Research

Client Testing

App Development

LEARNING

Goals

•PG goal

•Personal goal

Triggers

•Emotional (identify emotions/ moods)

•Time (identify time of day; days of the week; days of the month)

Social Support Circle

•Identify and create contact list

DETECTION

Mood Tracking

•Clients are prompted to rate their current mood, urge level

Time

● Certain time triggers (evenings, weekend)

*Trigger moods and times will prompt Intervention

INTERVENTION

Pushed Content

•Goal reminders

•Information/ resources (e.g., coping strategies to use to manage triggers)

•An option to connect with a support from contact list

Additional Features and Resources

● SOS urge button

● Self-help materials; videos and other curated content

● PG help lines; crisis support; links to self-exclusion sites/ site blockers

● Daily positive messages and/ or motivational quotes and/ or interesting facts about PG (e.g., odds of winning)

● Gratitude list

Created By: Louise LeBlanc Choices for Change, 2018

Balanc

e Wheel Sex

15%

Physical

Emotional

Spiritual

Social

Legal

Community

Financial

Occupation

Relationship - Primary

Family

Environment/ Housing

15%+

_85%_100%

ON BEHALF OFGAMBLING RESEARCH EXCHANGE ONTARIO