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Cele Fichter DeSando, MPM Addiction Medicine Services, WPIC, UPMC Don’t Bet On It – Preventing Teen Gambling 1.

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Presentation on theme: "Cele Fichter DeSando, MPM Addiction Medicine Services, WPIC, UPMC Don’t Bet On It – Preventing Teen Gambling 1."— Presentation transcript:

1 Cele Fichter DeSando, MPM Addiction Medicine Services, WPIC, UPMC Don’t Bet On It – Preventing Teen Gambling 1

2 Today’s Training Teen Gambling: A Growing Epidemic 2

3 Explore adolescent problem gambling progression and risk and protective factors Define problem and pathological gambling including DSM-V stages and criteria. Identify the prevalence and relationship of problem gambling to alcohol, tobacco and other substance use as well as psychiatric disorders. Provide a survey review of research-based screening/interview tools and resources for treatment. Provide research-based prevention and intervention school and student assistance program strategies to prevent and delay adolescent problem gambling. Today’s Training 3

4 Gambling is an activity in which something of value is risked on the outcome of an event when the probability of winning and losing is less than certain. (Korn and Shaffer 1999). What is Gambling?

5 Disordered gambling is classified as persistent and recurrent maladaptive gambling behavior that disrupts personal, family, or vocational pursuits and is not better accounted for by a manic episode. Source: American Psychiatric Association (APA), Diagnostic and Statistical Manual, Revision IV – Text Revision (DSM-IV-TR), (APA, 2000). Previously categorized as an impulse control disorder but recently moved to addiction-related disorders in DSM-V What is Pathological (Disordered) Gambling?

6 Similarities to Addictions In DSM-V – Gambling is listed as addiction related disorder instead of old classification of impulse control disorder. The rationale for this change is that the growing body of scientific literature, especially on the brain’s reward center, has revealed commonalities between pathological gambling and substance-use disorders. –Loss of control –Preoccupation, urges, pathological “wanting”, cravings, associated “highs” –Negative impact on major areas of life –Major impacts on mood. Judgment and insight –Tolerance/ Withdrawal –Hereditary nature –Similar treatment success-12 step and cognitive behavioral therapy

7 Gambling in many different forms has long been a part of the history of the world 48 states have some form of legalized recreational gambling in the form of Bingo, Lottery, Race Track, Slots, Poker, Table Games, Sports Betting* New Frontier -Online Gambling is widespread, yet unregulated, technically restricted and under contention in the US – Regulations change rapidly – Nevada and New Jersey recently passed legislation to allow online, while in-state, is PA next? *Exception of Utah and Hawaii Gambling as Pervasive Recreation Increasing Opportunities

8 85% of U.S. adults have gambled at least once in their lifetimes (60% -80% in any given year ) 3-5% have a gambling disorder. (The National Council on Problem Gambling, 2010). The majority of the population can gamble without negative consequences Who Gambles?

9 1% + are estimated to be pathological gamblers (PG) 2-3% are considered problem or subclinical gamblers Disordered Gambling is a term used to describe the full range of gambling problems. Betting on a Sure Thing Who has a Problem?

10 2.8-8% of Adolescents and college students exhibit problem and pathological gambling (NORC,1999) Student athletes particularly vulnerable Affects all races – differences are found in the types of games played, belief about money, finances and self worth, Disproportionate number of smokers, substances abusers, mentally ill and poor are problem gamblers Upping the Ante: Teens and Gambling


12 Vulnerable Populations Adolescents –5-6% meet criteria –8-8% at risk for developing Elderly –Harder to recoup financial losses Military – All branches run oversees slots for recreation and to make money for social events Casino Workers –Chicken or the egg? Incarcerated –#1 pastime is gambling Substance Use Disorders –6-10x risk for PG Lower SES –Problems develop sooner

13 How much do adolescents gamble? 60-90% have gambled Similar, internationally Strong pop culture influences No monitoring system Societal, parental acceptance

14 Reasons for gambling Win money Social activity Excitement Competition Fantasy Family members

15 Low risk gamblers know that over time nearly everyone loses. The benefit is in the social and entertainment activity not an expectation of financial gain. Low risk gambling has limits on frequency and duration. Low risk gambling has predetermined, acceptable limits for losses as in the acceptable and affordable cost of an entertainment activity. Does PA have a gambling problem? Characteristics of Low Risk Gambling

16 Gambling Ambivalence Love the Money – Hate the Problems 16

17 Societal Approval and Fallacy 17

18 2002 U.S. legal gaming revenue was $68.7 billion. In 1999 the National Gambling Impact Study Commission estimated the annual cost to society of problem gambling was $5 billion. It is estimated that in 1997 Americans collectively wagered more than $1/2 trillion (National Research Council, 1999) Consumers spend more on legal gaming in the U.S. than most other forms of entertainment combined (1998 Gross Annual Wager Report, 1999) Sports betting -38 billion legally wagered-380 billion illegal Gambling and Spending How much is too much?

19 “Gambling Nation” $600 billion wagered annually Revenue Comparisons (2005) –Gambling (Legal) $83 Billion per year –DVDs: $22 Billion per year –Cigarettes: $19 Billion per year –NIH Annual Budget: $30 Billion per year (American Gaming Association, CDC, Hollywood Reporter)

20 Casino April 2014 Tables April 2014 Gross Revenue April 2013 Tables April 2013 Gross Revenue Sands Casino Resort Bethlehem200$15,028,894183$13,932,560 Parx Casino164$10,061,363164$10,153,193 SugarHouse Casino62$7,901,26158$7,316,611 Rivers Casino113$6,252,232114$4,992,447 Harrah's Philadelphia Casino and Racetrack126$6,154,439121$6,665,016 Mount Airy Casino Resort80$4,033,10172$3,135,321 Mohegan Sun at Pocono Downs87$3,684,36884$3,513,736 Valley Forge Casino Resort50$3,209,57450$2,790,101 Hollywood Casino at Penn National Race Course73$2,451,96169$3,423,756 The Meadows Racetrack and Casino77$1,914,96480$4,381,161 Presque Isle Downs and Casino46$1,130,26446$1,248,432 Lady Luck Casino Nemacolin (opened 7/1/13)28$362,370N/A Statewide Total1,106$62,184,7901,041$61,552,334 Pennsylvania Monthly Casino Gambling – Table games 20

21 CasinoApril 2014April 2013% Change Parx Casino$30,454,522.24$31,608, % Sands Casino Resort Bethlehem$23,702,187.99$24,465, % Rivers Casino$23,152,882.76$24,444, % Harrah's Philadelphia Casino and Racetrack$18,668,264.14$20,618, % Mohegan Sun at Pocono Downs$18,580,699.98$18,600, % The Meadows Racetrack and Casino$18,533,750.02$20,110, % Hollywood Casino at Penn National Race Course$18,297,057.66$20,372, % Sugarhouse Casino$15,042,414.67$15,467, % Mount Airy Casino Resort$12,120,975.73$12,262, % Presque Isle Downs and Casino$10,629,226.63$11,809, % Valley Forge Casino Resort$6,475,249.53$5,395, % Lady Luck Casino Nemacolin (opened 7/1/13)$2,103,745.41N/A Statewide Total$197,760,976.76$205,155, % Pennsylvania Casino Gambling Slot Machines 21

22 Table Games – $507,711,162 – $663,854,672 – $ 713,107,163 Slots $ 5,055,282, $17,288,615, /09 - $22,509,815, /10 - $29, , / $29,759,096, $ 31,164,547, $30,819,486,036 PA Casino Amounts Wagered – Gambler’s Fallacy 22

23 Nevada billion Pennsylvania billion New Jersey billion Of the 23 states with casinos Name the top three states for gambling revenue 23

24 Gambling Ambivalence and Distortion It’s all about the Marketing 24 Your chances of being murdered 1 in 18,000 Your chances of winning Mega Millions Lottery 1 in 135,145,920

25 Pathological gambling is hypothesized to be caused by a complex interplay involving neurobiological, genetic, psychological and social risk factors. (Shaffer et al. 2004c) There is evidence of associations between pathological gambling and a variety of neurotransmitters (e.g. noradrenaline, serotonin, glutamate, dopamine and endorphins); (Potenza 2008). What are the odds you’ll become a problem gambler?


27 The Brain and Addiction

28 Dopamine and Nicotine Dopamine is a brain chemical involved in many different functions including movement, motivation, reward and addiction. Altering dopamine levels alters the normal communication between neurons

29 Gambling as a Brain Disease

30 Neurobiology of PG (Neuroanatomy) Potenza’s Imaging Studies (PG vs Normals) Decreased activity in: –Left ventromedial PFC (Decision-making) –Orbitofrontal cortex (processing of rewards, dealing with uncertainty, inhibiting responses) –Anterior Cingulate (Decision-making) –Ventral striatum (NA, Limbic system)

31 Are brains of problem gamblers different? Pathological Gamblers exhibit lower activity in prefrontal cortex compared to Non-PGs In performing neuro-cognitive tests, PGs showed similar dysfunctions in prefrontal cortex as Methamphetamine addicts Potenza et al., 2003

32 This Is Your Brain on Gambling fMRI of subject anticipating a monetary win in simulated game fMRI of subject anticipating a small amount of cocaine Breiter et al., 2001

33 Differences from Addictions –No toxicology test to diagnosis it; easier to hide –Behaviors are not due to drug effects (thus, makes it more open to shame/guilt) –Directly associated with financial gains and losses – accolades and blame for same behavior –Greater uncertainty of outcome (i.e. anything can happen) –Ego related symptoms- gambling can boost ego or cause discord with self image –More Socially acceptable

34 Similarities / Difference Immediate gratification Addictive: preoccupation, inability to stop, tolerance & withdrawal, progressive Cravings & urges Denial is common Accompanying depression / anxiety Blackouts / brownouts Disassociation Mechanism for escape Dysfunctions in the family often present Gambling more hidden Impossible to overdose on gambling No ingestion of chemicals Labile financial situation More unpredictable outcome Generally not perceived as a disease Fewer resources for gamblers Faster progression

35 Gambling Disorder can be episodic or chronic, and the course of the disorder can vary by type of gambling as well as life circumstances (Hodgins and el Guebaly, 2004; Slutske, 2006). For example, an individual who wagers problematically only on football games may have Gambling Disorder during football season and not wager at all, or not wager problematically, throughout the remainder of the year. Gambling Disorder may also occur at one or more points in an individual’s life but be absent during other periods. Alternately, some individuals experience chronic Gambling Disorder throughout all or most of their lives. DSM-V Workgroup on Gambling Disorder 35

36 A. Persistent and recurrent problematic gambling behavior as indicated by four (or more) of the following in a 12-month period: 1.needs to gamble with increasing amounts of money in order to achieve the desired excitement 2. is restless or irritable when attempting to cut down or stop gambling 3. has repeated unsuccessful efforts to control, cut back, or stop gambling 4. is often preoccupied with gambling (e.g., persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) DSM-V Criteria 36

37 5. gambles often when feeling distressed (e.g., helpless, guilty, anxious, depressed) 6. after losing money gambling, often returns another day to get even (“chasing” one’s losses) 7. lies to conceal the extent of involvement with gambling 8. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 9. relies on others to provide money to relieve desperate financial situations caused by gambling B. The gambling behavior is not better accounted for by a Manic Episode. DSM-V Criteria 37

38 With all of the negative consequences why continue to gamble? Action – Looking for excitement “rush” Escape – Looking for relief from painful emotions or stress Lesieur and Rosenthal (1991). What are problem gamblers looking for?

39 Many adolescents think they can become professional 39

40 Gambles for excitement, competition More likely to engage in “skilled” forms of gaming. (sports betting, poker, etc). More likely to have early onset of gambling Longer progression from regular to out of control (addicted) gambling More likely to be male More likely to present narcissistic or antisocial traits Action Gamblers

41 BraggingDenialFallacy of Skill 41

42 Allure Appeals to Action and Escape Gamblers 42

43 Gambles for relief, escape from stress or negative affect More likely to engage in passive, luck forms of gambling (Lottery, slots, bingo) Shorter progression from regular gambling to out of control behavior More likely to be female More likely to be have experienced chronic depresssion Escape Gamblers

44 Escape - Gambling looks like fun – and it is! 44

45 Winning Phase- gamblers experience a big win or series of wins resulting in unreasonable optimism or belief in their ability to win. Losing Phase-gamblers begin bragging and thinking about past wins, secretly gambling and begin to chase their losses. Desperation Phase- gambling increases in time, frequency and amount. Remorse, alienation and problems increase. Hopeless Phase – Gambler no longer believes there is help or hope. Lesieur and Custer (1984). Problem Gambling Progression: When it stops being fun

46 Several studies have documented the relationship between problem gambling and specific health issues. Mental Health – Gamblers are at increased risk for major depression, anti-social personality disorder, phobias and other mental conditions. Problem gamblers were also identified as being at increased risk for alcohol, nicotine, and other drug abuse. Potenza, (2008). Upping the ante: What’s the Problem with Problem Gambling?

47 Individuals with mental and/or substance use disorders are 17 times more likely to develop pathological gambling Pathological Gamblers are 5.5 more likely to have to have had a substance use disorder (Kessler et al. 2008) 75% of pathological gamblers have had an alcohol disorder; 38% have had a drug use disorder; 60% have had nicotine dependency (Petry et al. 2005). Recreational Gamblers smoke at same rate as general population, 60-80% of pathological gamblers smoke. Double or Nothing

48 Genetic and Familial Factors Research consistently shows higher rates of pathological gambling in teens whose parents gamble too much (Gupta & Derevensky, 1997; Jacobs, 2000; Wallisch & Liu, 1996) Children of problem gamblers have been shown to have higher levels of use for tobacco, alcohol, drug use, and overeating than do their classroom peers (Gupta & Derevensky, 1997) The Hidden Vigorish

49 Co-occurring disorders In treatment-seeking pathological gamblers, % of patients evidenced other mental health problems, with anxiety, depression, and suicide being most common. Problem gamblers are 4 times more likely to have major depression than non-problem gamblers Suicide attempt rates are 17% -24% for problem gamblers (US DHHS,SAMSHA, 2005) The Hidden Vigorish

50 Gambling problems may be major impediments to recovery and contributors to relapse in mental health and substance abuse disorders. The Hidden Vigorish

51 Mental Health, Substance Abuse and Primary Care Professionals and school professionals can help identify, intervene, and refer/treat problem gamblers. Treatment and intervention can be incorporated into existing substance abuse and mental health programs. Beating the System- Hedge Your Bets

52 Early onset of gambling experiences/early win Biochemical factors associated with increased physiological resting state, increased sensation seeking, increased arousal during gambling. Depression Poor Coping Skills Substance Use/Abuse What are the Odds? Risk Factors Marotta and Hynes (2003)

53 Accessibility/Awareness* Lack of community awareness of dangers Social Acceptance Family History of Addiction and/or illegal activity Competitive Home Environment Family History of gambling activity and attitudes. Poor Impulse Control * There is much discussion as to the extent of accessibility leading to risk and there are theories related to exposure and adaptation (Shaffer and Martin) Risk Factors for Gambling Problems

54 Teen Gambling by Derevensky 54

55 Risk Factors for Adolescents Despite not being of legal age to gamble on regulated forms of gambling, adolescents are at risk for developing gambling problems (Derevensky & Gupta, 2004; Dickson, Derevensky & Gupta, 2004; Jacobs, 2004; National Research Council, 1999; Shaffer & Hall, 1996; Shaffer, Hall & Vander Bilt, 1999). Early research suggests adolescents perceive their parents to generally approve of their gambling, are not concerned about getting caught gambling, and report that gambling with family members is a fairly common occurrence (Gupta & Derevensky, 1997; Ladouceur & Mireault, 1988; Moore & Ohtsuka, 1997).

56 Our current state of knowledge concerning youth gambling problems…. Gambling is more popular amongst males than females (Derevensky, Gupta & Della Cioppa, 1996; Fisher, 1990; Govoni, Rupcich, & Frisch, 1996; Griffiths, 1989; Gupta & Derevensky, 1998a; Jacobs, 2000; Ladouceur et al., 1994; NORC, 1999; NRC, 1999; Stinchfield, Cassuto, Winters, & Latimer, 1997; Volberg, 1994, 1996, 1998; Wynne et al., 1996) Probable pathological gamblers are greater risk- takers (Arnett; 1994; Breen & Zuckerman, 1996; Derevensky & Gupta, 1996; Nower, Derevensky & Gupta, 2000; Powell, Hardoon, Derevensky, & Gupta 1999; Zuckerman, 1979, 1994; Zuckerman, Eysenck, & Eysenck, 1978) Adolescent prevalence rates of problem gamblers are 2-4 times that of adults (Gupta & Derevensky, 1998a; Jacobs, 2000; Shaffer & Hall, 1996)

57 Teen Gambling 57

58 Adolescent pathological gamblers have lower self esteem compared with other adolescents (Gupta & Derevensky, 1998b) Adolescent problem gamblers have higher rates of depression (Gupta & Derevensky, 1998a,1998b; Marget, Gupta & Derevensky, 1999; Nower, Derevensky & Gupta, 2000) Adolescent problem gamblers dissociate more frequently when gambling (Gupta & Derevensky, 1998b; Jacobs, Marsten & Singer, 1985) Adolescents with gambling problems, ages 14-17, are at heightened risk for suicide ideation and suicide attempts (Gupta & Derevensky, 1998a)

59 While adolescents with gambling problems report having a support group, old friends are often replaced by gambling associates (Derevensky, 1999; Gupta, 1999; Gupta & Derevensky, 2000) Adolescent problem gamblers remain at increased risk for the development of an addiction or polyaddictions (Gupta & Derevensky,1998a,1998b; Kusyszyn, 1972; Lesieur & Klein, 1987; Nower, Derevensky & Gupta, 2000; Winters & Anderson, 2000) Adolescent problem gamblers score higher on excitability, extroversion, and anxiety & lower on conformity and self-discipline (Gupta & Derevensky, 1997b,1998a; Vitaro, Ferland, Jacques & Ladouceur, 1998)

60 60

61 Pathological gamblers and youth in general report early gambling in the home and with family members (Derevensky & Gupta, 1997; Gupta & Derevensky, 1997a, 1997b) Problem and pathological gambling has been shown to result in increased delinquency and crime, disruption of familial relationships and decreased academic performance (Gupta & Derevensky, 1998a; Ladouceur & Mireault, 1988; Lesieur & Klein, 1987; Wynne et al., 1996)

62 Pathological gamblers report greater major and minor life stressors (Gupta & Derevensky, 2002; Kaufman, Gupta & Derevensky, 2002) Problem and pathological gambling has been shown to have greater levels of trait and state anxiety (Ste- Marie, Gupta & Derevensky, 2002)

63 Using schools as a basis for prevention through promotion of social/personal competence (Haggerty, Sherrod, Garmezy, & Rutter, 1994)  at-risk vs. general population  target appropriate age groups with developmentally appropriate interventions  focus not merely on gambling but on social skills, coping abilities, & problem solving skills

64 Predominantly Male Significant anxiety Familial problems Poor peer relationships Preoccupation with gambling – repeated attempts to stop Different forms of gambling sports betting, online, cards, dice Serious financial difficulties Failure in school/work Lying to family friends Profile of the Adolescent Problem Gambler (Derevensky, 2010) 64

65 Friends usually have similar gambling problems Stealing from family, friends, stores etc Depression or feeling dead inside Gambling to escape and feel better General lack of coping abilities Confused and conflicted about whether to stop or cut down Need for arousal or strong sensations (possible ADHD) Profile cont. 65

66 Card Playing for money Betting on activities for money Sports betting, sports pools Online gambling – Internet for $ and Internet no $ Lottery/Scratch off tickets What gambling activities do teens do? 66

67 67

68 4 A’s Anyone (Anonymity) Any Age (No ability to check age – sites prompt underage users) Anytime ( Accessibility 24/7) Anywhere (Availability – Work, Home, Online, Mobile) Internet Gambling Risks 68

69 Internet problems – more research needed 69

70 Escape Allure 70

71 Action – Learn the Skill 71

72 Buddy Bet – Betting on Anything 72

73 What is BuddyBet? BuddyBet is a social betting site -- one that lets you match wits with living, breathing, communicating people rather than geeky gambling experts and their supercomputers. In short, people bet against each other on BuddyBet rather than against the website itself. You set your own odds and choose your own Betting for BuddyBucks If you'd rather not bet for cash or for actions/forfeits, you can bet for fun (and pride) using BuddyBucks, BuddyBet's virtual currency. Social media 73

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75 Acceptance and Availability 75

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78 Online Gaming 78

79 Online Gambling is PA Next? 79

80 Online gaming is PA next? 80

81 Substance Abuse Counselors and Student Assistance Professionals are very well poised to offer identification and help with gambling problems based on understanding of addictions and the link between the disorders. However: Substance Abuse and Mental Health counselors cannot assume knowledge of gambling and must learn the similarities/ differences, language and specifics of gambling, specific screening and treatment tools and resources for help. Don’t Bet on It

82 Using schools as a basis for prevention through promotion of social/personal competence (Haggerty, Sherrod, Garmezy, & Rutter, 1994)  at-risk vs. general population  target appropriate age groups with developmentally appropriate interventions  focus not merely on gambling but on social skills, coping abilities, & problem solving skills

83 Gambling Prevention Prevention through risk-reduction –individual –family –peer and social contexts –community context Risk-reduction by enhancing protective factors –attributes of the individual –family support –environmental support Using schools as a basis for prevention through promotion of social/personal competence (Haggerty, Sherrod, Garmezy, & Rutter, 1994

84 Responsible prevention efforts include...  Incorporating knowledge acquired from scientific research  Taking a wide-angled approach (multi-faceted)  Adjusting the material to the developmental level of the recipient  Testing for program effectiveness PRIOR to widespread implementation  Conducting focus groups with teachers and children for input on program development and to evaluate teacher willingness to implement the prevention format

85 Use evidenced based prevention,assessment and treatments and existing supports such as gamblers anonymous Include gambling screen/questions in student assistance and mental health and substance abuse assessments Include a comprehensive risk assessment (suicide/harm to others) Offer multi-model approach to include, legal financial and family issues Keep updated on gambling research A Winning Program

86 Am. Psychiatr. Assoc Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: Am. Psychiatr. Assoc. Am. Psychiatr. Assoc Pathological Gambling. In Proposed Draft Revisions to DSM Disorders and Criteria, Arlington. VA: Am Psychiatr. Assoc Gross Annual Wager Report. International Gaming and Business Wagering (IGBW) Trade Magazine. (1999, August). Retrieved 2/21/02, from Gupta, R., & Derevensky, J.L. (1997). Familial and social influences on juvenile gambling behavior. Journal of Gambling Studies, 13(3), Kessler RC, Hwang I, LaBrie RA, Petukhova M, Sampson N, et al DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychol. Med. 38: References

87 Korn, DA, Shaffer HJ Gambling and the health of the public: adopting a public health perspective. J.Gambl, Stud. 15: Lesieur HR, Coster RL Pathological Gambling: Roots, Phases and Treatment. The ANNALS of the American Academy of Political and Social Science, 474: Lesieur HR, Rosenthal RJ Pathological gambling: a review of the literature (prepared for the American Psychiatric Association Task Force on DSM-IV Committee on Disorders of Impulse Control Not Elsewhere Classified). J. Gambl. Stud. 7:5-39 Natl. Counc. Problem Gambl What is problem gambling? National Opinion Research Center (NORC). (1999). Gambling Impact and Behavior Study, Report to the National Gambling Impact Study Commission [Electronic Version]. Chicago, IL: Author. References (cont.)

88 National Problem Gambling Awareness Week Problem Gambling Information: Facts and Figures. National Research Council (NRC). (1999). Pathological Gambling: A Critical Review. Washington, D.C.: National Academy Press. Petry NM, Stinson FS, Grant BF Comorbidity of DSM-14 pathological gambling and other psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J. Clin. Psychiatry 66: Potenza M The neurobiology of pathological gambling and drug addiction: an overview and new findings. Philos. Trans. R. Soc. 363: References (cont.)

89 Shaffer HJ, LaPlante DA, LaBrie RA, Kidman R, Donato A, Stanton M. 2004c. Toward a syndrome model of addiction: multiple expressions, common etiology. Harv. Rev. Psychiatry 12: Shaffer HJ, Martin R Disorders & Gambling: Etiology, Trajectory and Clinical Consideration. Annual Review of Clinical Psychology Thompson, W., Gazel, R., Rickman, D. (1996). The social cost of gambling in Wisconsin. Wisconsin Policy Research Institute Report, 9, 144. References (cont.)

90 Unwin, B.K., Davis, M.K., & Leeuw, J.B. (2000). Pathological gambling. American Family Physician, February 2000, 61, US Dept of Health & Human Services, SAMHSA, Substance Abuse Treatment for Co-Occurring Disorders Publication No ,2005 Wallisch, L., & Liu, L. (1996). Drug use and gambling behavior among adults and youths in Texas: Survey findings. In: Epidemiologic Trends in Drug Abuse. Rockville, MD: National Institute on Drug Abuse. Volume II: References (cont.)

91 Web Resources for A Winning Program

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