CoOccurring Disorders, Best Practices and Adolescents

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Co-Occurring Disorders, Best Practices and
Adolescents

• Double Trouble - Early

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Main Points

• Section One Co-Occurring Mental Health and
  Substance Use Disorders in Adolescents Research
• Section Two Systems Issues - Parallel Treatment
  Systems
• Section Three Assessment of Co-Occurring
  Disorders
• Section Four Evidence Based Treatments for
  Adolescents with Co-Occurring Disorders
• Section Five Recommendations

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• Section One
• Co-Occurring Mental Health and Substance Use
  Disorders in Adolescents The Research

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INTRODUCTION

• The research tells us the majority of youth
  referred for substance abuse treatment have at
  least one co-occurring mental health disorder
  (COD), a DSM-IV-TR mental health disorder and a
  substance use disorder (SUD).

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Research

• Adolescents with substance use disorders are at a
  six times risk of having a co-occurring
  psychiatric disorder (Dennis, 2004)
• Co-Occurring disorders are associated with poorer
  treatment outcomes, both physical and
  psychological when either disorder is not treated
  (Riggs, 2003)
• Drug abuse changes the brain chemistry of
  developing brains.
• Psychiatric symptoms often precede the SUD

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Incidence of Co-occurring Disorders in System
of Care Adolescents (Turner, Muck, Muck et al,
2004)

• SOC sites (N 18, 290) 44 reported COD

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Co-Occurring Disorders at Intake SOC
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Co-Occurring Disorders Categories

• Co-occurring disorders in adolescents are usually
  categorized into internalizing and externalizing
  disorders. These should be the treatment targets
  for the mental health interventions.
• Internalizing anxiety, fear, shyness, low self
  esteem, sadness, depression (6) of COD
• Externalizingnon compliance, aggression,
  attention problems, destructiveness, impulsivity,
  hyperactivity, and antisocial behavior (18-35)
  -COD
• Both (38-65) COD

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Co-Occurring Disorders Categories

• Disruptive disorders and mood disorders are
  associated with earlier onset of use of
  substances and increased substance use disorders
• Internalizing disorders are associated with SUD
  and are an antecedent of the SUD.
• Trauma/victimization in youth with SUD range
  from 25 for males to 75 of females (Kanner,
  2004, Dennis, 2004)

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Average Scores of Child Behavioral and Emotional
Problems for children with Co-occurring
substance use problems at Intake, 6 Months, and
12 Months
Internalizing and Externalizing Scores
Internalizing n101 F(3,98)1396,
Plt.001. Externalizing n101 F(3,98)1706,
Plt.001. Child behavioral and emotional problems
were measured by the CBCL (Child Behavior
Checklist). Clinical range for internalizing and
externalizing scores is between 60 and 63, while
clinical range for the eight syndrome scales is
between 67 and 70.
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Gender Differences

• Girls
• Conduct disorder associated with SUD in both
  girls and boys, but girls with this combination
  had the highest CBCL scores for delinquency
• Caregivers report more of both internalizing and
  externalizing problems among girls (83) than
  boys (41)
• Girls are over represented in groups with poor
  outcomes

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Gender Differences

• Girls
• Females had higher rates of Co-Occurring
  disorders and were more likely to have suffered
  physical/sexual abuse
• Girls report significantly higher level of drug
  dependence vs abuse, (72 vs 43) in boys

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Gender Differences

• Boys
• Present more often with disruptive behaviors
  (ODD/CD)
• More often in juvenile justice settings (80)
  with COD referrals
• In juvenile justice settings 3/4 of males and
  half of all females have COD

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• Section Two
• Systems Issues - Parallel Treatment Systems and
  Colliding Cultures

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Systems Issues Treatment Pathways

• Different models in mental health and
  substance abuse treatment have resulted in the
  development of parallel but not intersecting
  treatment systems with different funding streams,
  mandates and treatment philosophy.

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Clinical Barriers

• Mental Health Treatment
• The fundamental approach to clinical education
  has not changed appreciably since 1910 (ICM
  2000). Substance use disorders often are not
  seen as part of the care mandate.
• Medical model
• Emphasis on licensure
• Emphasis on minimal self disclosure.
• Treatment can not begin until abstinence is
  obtained

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Clinical Barriers

• Mental Health Treatment cont.
• Reluctance to medicate individuals with a
  substance use disorder
• Psychological treatments offered but with no
  substance abuse treatment component
• Clinicians are reluctant to treat substance
  abusing individuals
• Clinicians often not cross trained in SUD
• Individuals with SUD often minimize the disorder
  and vice-versa

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Clinical Barriers

• Substance Abuse Treatment
• Knowledge of mental health disorders is often
  limited and often out of scope of practice of the
  providers.
• Based on a peer relationship model
• Licensure not necessary (changing)
• Treatment provider often a recovering individual
• Willing to disclose substance abuse history
• Individual with substance abuse history treated
  as an expert valued.
• Often reluctance to allow any medication of any
  kind
• Treatment often ignores mental health problems
  and focuses on substance abuse
• Providers not cross trained in mental health
  treatments

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• Section Three
• Assessment of Co-Occurring Disorders

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Assessment and Screening for Co-Occurring
Disorders

• The process of screening, assessment, and
  treatment planning should be an integrated
  approach that addresses the substance abuse and
  mental health disorders, each in the context of
  the other and neither should be considered
  primary.
• Expect comorbidity as it is higher than realized
• Assess for trauma/victimization

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Assessment and Screening for Co-Occurring
Disorders

• Substance use assessment should include
• Onset, progression, patterns of use, frequency,
  tolerance/withdrawal, triggers.
• Assessment for patterns of use of multiple drugs
• Consequences of drug usage
• Motivation for treatment
• Family history regarding substance use including
  extended family

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Assessment and Screening for Co-Occurring
Disorders

• The assessment process ideally would include
• A brief screening assessment for substance use
  disorders as part of the standard mental health
  assessment at entry and throughout treatment
• A full substance abuse disorder assessment for
  adolescents with more complicated/ Co-morbid
  disorders and identified SUD

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Assessment Instruments

• Screening Instruments
• Adolescent Alcohol Involvement Scale
• Adolescent Drug Involvement Scale
• Problem Oriented Screening Instrument for
  Teenagers (POSIT)
• GAIN Short VersionSample attached.

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Assessment Instruments

• Substance Use Disorder Interviews
• Adolescent Diagnostic Interview (ADI)
• Diagnostic Interview for Children and Adolescents
  (DICA)
• Comprehensive Assessment Instruments
• Comprehensive Adolescent Severity Inventory
  (CASI)
• The American Drug and Alcohol Survey (ADAS
  classroom use)
• Personal Experience Inventory (PEI)

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Assessment Instruments

• General Checklists
• Achenbach YSR
• Revised Behavior Problem Checklist.
• Youth Outcome Questionnaire YOQ
• Youth Outcome Questionnaire Self Report YOQ SR

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• Section Four
• Evidence Based Treatments for Adolescents with
  Co-Occurring Disorders

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Evidenced Based Treatment

• the integration of the best research evidence
  with clinical expertise and patient (consumer)
  values
• Based on the definition used in Crossing the
  Quality Chasm A New Health System for the 21st
  Century (2001), by the Institute of Medicine

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Treatment

• New techniques and treatment modalities based on
  evidenced based research methodology are
  successful with Co-Occurring Disorders.

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Evidenced Based Treatments

• National Registry for Evidenced Based Programs
  and PracticesSAMSHA
• Treatment for Co-occurring Disorders
• Mental Health Treatments successful with
  Co-occurring disorders
• Treatments for Substance Use Disorders
• Preventative Practices
• Brief Manualized Treatments

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Evidence-Based Treatmentsfor Co-Occurring
Disorders

• Family Behavior Therapy
• Multisystemic Therapy
• Dialectical Behavior Therapy
• Seeking Safety
• TREM
• TARGET
• Integrated Community Treatment
• Family Treatment

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Family Behavior Therapy (FBT)

• Outpatient behavioral treatment aimed at reducing
  drug and alcohol use in adults and youth along
  with common co-occurring problem behaviors such
  as depression, family discord, school and work
  attendance, and conducts problems in youth.

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Family Behavior Therapy (FBT) Populations

• Adolescents ages 13 to 17
• Young adults ages 18 to 25
• Adults ages 26 to 55
• Male and Female
• Races White, Black or African American, Hispanic
  or Latino, Race/ethnicity unspecified.

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Family Behavior Therapy (FBT) Outcomes

• Decreases illicit drug use
• Decreases frequency of alcohol use
• Improves quality of Family relationships
• Reduces symptoms of Depression
• Reduces symptoms of Conduct Disorder
• Improves School / Employment attendance

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Family Behavior Therapy (FBT) References More
Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Bradley Donohue, Ph.D. Associate Professor
• University of Nevada, Las Vegas
• E-mail bradley.donohue_at_unlv.edu
• Web site http//www.unlv.edu/centers/achievement

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Multisystemic Therapy (MST)

• A family and community-based treatment for
  adolescents presenting serious antisocial
  behavior and who are at imminent risk of
  out-of-home placement.

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Multisystemic Therapy (MST) Populations

• Children ages 6-12
• Adolescents ages 13-17
• Male and Female
• Races American Indian/Alaska Native, Asian
  American, Black or African American, Hispanic or
  Latino, Race/ethnicity unspecified, White

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Multisystemic Therapy (MST) Outcomes

• Alcohol and drug use frequency reduced and higher
  rates of abstinence
• Increased perceived family functioning-cohesion
• Decrease peer aggression

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Multisystemic Therapy (MST) References More Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Scott W. Henggeler, Ph.D.
• Dept of Psychiatry and Behavioral Sciences
• Medical University of South Carolina
• E-mail henggesw_at_musc.edu

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Dialectical Behavioral Therapy (DBT)

• A cognitive-behavioral treatment approach with
  two key characteristics a behavioral,
  problem-solving focus blended with
  acceptance-based strategies, and an emphasis on
  dialectical processes.
• Dialectical refers to the issues involved in
  treating patients with multiple disorders and to
  the type of thought processes and behavioral
  styles used in the treatment strategies.

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Dialectical Behavioral Therapy (DBT) Populations

• Young adults ages 18-25
• Adults ages 26-55
• Older adults ages 55
• Male and Female
• Race American Indian/Alaska Native, Asian
  American, Black or African American, Hispanic or
  Latino, Race/ethnicity unspecified, White.

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Dialectical Behavioral Therapy (DBT) Outcomes

• Decrease suicide attempts
• Decrease nonsuicidal self-injury (parasuicidal
  history)
• Increase psychosocial adjustment
• Increase treatment retention
• Reduces drug use
• Reduces symptoms of eating disorders

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Dialectical Behavioral Therapy (DBT) References
More Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Marsha M. Linehan, Ph.D., ABPP
• Professor and Director of Behavioral Research and
  Therapy Clinics
• Dept of Psychology University of Washington.
• E-mail linehan_at_u.washington.edu
• Web site http//www.brtc.psych.washington.edu/

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Seeking Safety

• A present-focused treatment for clients with a
  history of trauma and substance abuse. The
  treatment was designed for flexible use group or
  individual format, male and female clients, and a
  variety of settings. (i.e., outpatient, inpatient
  residential).
• Treatment and intervention focuses on coping
  skills and psychoeducation and has five key
  principles.

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Seeking Safety Population

• Adolescents ages 13-17
• Young adults ages 18-25
• Adults ages 26-55
• Male and Female
• Races American Indian/Alaska Native, Asian
  American, Black or African American, Hispanic or
  Latino, Race/ethnicity unspecified, White.

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Seeking Safety Outcomes

• Reduces Substance abuse
• Improved trauma-related symptoms
• Improved psychopathology
• Increased treatment retention

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Seeking Safety References More Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Lisa M. Najavits, Ph.D.
• Director, Treatment Innovations
• Professor of Psychiatry, Boston University School
  of Medicine
• Lecturer, Harvard Medical School
• E-mail Lnajavits_at_hms.harvard.edu
• URL http//www.seekingsaftey.org

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Trauma Recovery and Empowerment Model (TREM)

• TREM is a fully manualized group-based
  intervention designed to facilitate trauma
  recovery among women with histories of exposure
  to sexual and physical abuse.

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Trauma Recovery and Empowerment Model (TREM)
Population

• Young adults ages 18-25
• Adults ages 26-55
• Female
• Race American Indian/Alaska Native, Black or
  African American, Hispanic or Latino,
  Race/ethnicity unspecified, White

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Trauma Recovery and Empowerment Model (TREM)
Outcomes

• Reduces severity of problems related to substance
  abuse
• Reduces psychological problems/symptoms
• Reduces trauma symptoms

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Trauma Recovery and Empowerment Model (TREM)
References More Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Roger D. Fallot, Ph.D.
• Director of Research and Evaluation
• Community Connections
• E-mail rfallot_at_ccdc1.org
• Web site http//www.ccdc1.org

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Trauma Affect Regulation Guide for Education and
Therapy (TARGET)

• Is a strengths-based approach to education and
  therapy for survivors of physical, sexual,
  psychological, and emotional trauma.

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Trauma Affect Regulation Guide for Education and
Therapy (TARGET) Population

• Young adult ages 18-25
• Adults ages 26-55
• Male and Female
• Race Black or African American, Hispanic or
  Latino, Race/ethnicity unspecified, White

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Trauma Affect Regulation Guide for Education and
Therapy (TARGET) Outcomes

• Decreased severity of PTSD symptoms
• Decreased PTSD diagnosis pre to posttreatment
• Reduced negative beliefs related to PTSD and
  attitudes toward PTSD symptoms
• Reduced severity of anxiety and depression
  symptoms
• Improved self-efficacy related to sobriety
• Increased emotional regulation
• Improved health-related functioning

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Trauma Affect Regulation Guide for Education and
Therapy (TARGET) References More Info

• SAMHSAs National Registry of Evidence-based
  Programs and Practices (NREPP)
• Julian D. Ford, Ph.D.
• Associate Professor
• Dept of Psychiatry, MC1410
• University of Connecticut Health Center
• E-mail ford_at_psychiatry.uchc.edu

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Evidenced Based Practices

• Integrated Co-Occurring Treatment Model (ICT)
• Family Integrated Transitions (FIT)

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Evidence-Based Mental Health Programs that have
had Success with Substance Abuse Treatment
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Evidenced Based Mental Health Treatment that has
success with COD

• MST
• Adolescent Transitions Program
• Strengthening Families Program
• Brief Strategic Family Therapy (Promising)
• Multidimensional Family Therapy (Effective)
• Functional Family therapy (effective)
• ART
• Dialectical Behavior Therapy
• Anger Management for substance abuse and mental
  health clients
• Multidimensional Treatment Foster Care

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Adolescent Transitions Program

• Promising Practice
• Outcomes
• Reduces Negative Parent/Child Interaction
• Decreases Antisocial Behavior at School
• Reduces Smoking at 1 Year Follow Up

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Evidence-Based PracticesParent
TrainingAdolescent Transitions Program

• School-based Universal, Selected, Indicated
• Twelve Group and Four Family Meetings
• Social Learning Theory Skill Devel
• Est cost to Implement 2,000 - 5,000
• Thomas Dishion PhD, Kate Kavanaugh PhD
  University of Oregon

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Evidence-based Mental Health Treatments
Strengthening Families Program

• Effective Practice
• Targets high-risk children 6-12 yrs / parents
• Created for children of parents with AOD
• Improves Parenting Skills, Child Social Behavior,
  and Family Relationships
• Decreases Parent/Child Substance Use, Child
  Behavior Problems, Parent/Child Depression
• Up to 2-year longitudinal

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Evidence-based Practices Treatments
Strengthening Families Program

• Adapted African American, Asian/Pacific
  Islander, Hispanic, Native American, Rural
  Families
• Adapted to 10-14 year olds ( V.Molgaard)
• Three Part Curriculum Parenting Skills, Child
  Skills, Family Life Skills 14 sessions
• Separate Parent and Child Groups
• Combined Parent and Child Group
• Training - 2,700-3,700
• Karol Kumpfer PhD University of Utah

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Evidence-based Practices Brief Strategic Family
Therapy

• Targets child/adolescents 8-17 years exhibiting,
  or at risk of behavior problems including
  substance abuse
• Promising Practice
• Improve Childs Behavior by Improving Family
  Interactions

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Evidence-based Practices - Family TherapyBrief
Strategic Family Therapy

• Severe Conduct Disorder and Substance Abuse
  24-30 Sessions
• Implementation Three Day Training, Two Day
  Booster, Monthly Phone/Video Consult (1 yr) --
  18,000
• Jose Szapocznik PhD - Spanish Family Guidance
  Center, Center for Family Studies, University of
  Miami

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Evidence-based Practices - Family
TherapyMultidimensional Family Therapy

• Targets Adolescents (11-18 years) with drug and
  behavior problems.
• Effective/Promising Practice
• Outcomes include improvements in
• Rates of drug Use 42-70 abstinent at followup
  
• Behavior Problems
• School Performance
• Family Functioning

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Evidence-based Practices - Family
TherapyMultidimensional Family Therapy

• Superior outcomes to CBT, Family Group Therapy,
  Peer Group Therapy, and Residential Treatment
• Superior outcomes to Residential Treatment for
  Adolescents with Co-Occuring Conditions at 1 yr
  follow up
• Howard Liddle PhD University of Miami

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Evidence-based PracticesFunctional Family
Therapy (FFT)

• Targets Youth 11-18 yrs at risk/ presenting
  behavior problems, substance abuse, conduct
  disorder
• Effective Practice

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Evidence-based Practices Functional Family
Therapy (FFT)

• Average duration of service is 3-4 months
• Cost effective
• On average costs 2,100 per youth
• 8-30 sessions of direct service
• Full time therapist will serve 12-15 families at
  one time
• Site certification and training
• Teams of 3-8 interventionists - 25,000
• James Alexander PhD University of Utah

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Evidenced Based TreatmentAggression Replacement
Training (ART)

• Promising Practice / Proven Approach
• Assumes aggression is related to
• Weak or absent personal, interpersonal and
  social-cognitive skills for pro-social behavior
• Impulsive and over reliance on aggressive means
  to meet daily needs
• More egocentric and concrete moral reasoning
• Consists of three coordinated components
• Skillstreaming - Anger control training - Moral
  reasoning

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Evidenced Based Treatment(ART)Skillstreaming

• Arnold Goldstein, Ph.D.
• Procedures to enhance pro-social skill levels
• Small group instruction
• 50 pro-social skills
• Modeling expert use of the behaviors
• Guided opportunities to practice and role-play
• Provided performance feedback praise,
  re-instruction and feedback
• Transfer training encouraged to practice and use
  in real world situations

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Evidenced Based TreatmentART-Anger Control
Training

• Eva Feindler, Ph.D.
• Teaches youth alternatives to aggression
• An emotion oriented component
• Involves modeling, guided practice, performance
  feedback, and homework
• Youth are taught to respond to provocations
• Triggers
• Cues
• Reducers
• Reminders
• Use of appropriate skillstreaming alternatives
• Self evaluation

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Cognitive Behavioral TherapyARTMoral Reasoning
Training

• Group discussion of moral dilemmas
• Group rules
• Group process
• Introduce the problem situation
• Cultivate mature morality
• Remediate moral development delays
• Consolidate mature morality

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Anger Management for Substance Abuse and Mental
Health Clients

• Outcomes for Consumers with Substance Dependence,
  Many of Whom had PTSD
• Significant reductions in self-reported anger and
  violence
• Decreased substance use
• Positive impacts across ethnicities and gender
• Successful with Consumers w/o substance abuse,
  who have mood and thought disorders.
• Studies for youth younger than 18 in process.

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Anger Management for Substance Abuse and Mental
Health Clients

• Patrick M. Reilly Michael S. Shopshire PhD San
  Francisco Treatment Research Cntr
• Center for Substance Abuse Treatment, SAMHSA
• Promising Practice (Probably) / Proven Approach
• Bargain Basement Award - Its Free!
  http//www.kap.samhsa.gov/products/manuals/pdfs/an
  ger1.pdf

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Evidence-based Practices Multidimensional
Treatment Foster Care

• Effective Practice
• Targets Adolescents with Delinquency and their
  Families.
• Alternative to Group Home Placement and
  Incarceration

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Evidence-based Practices Multidimensional
Treatment Foster Care

• Patricia Chamberlain PhD Oregon Social Learning
  Center

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Evidence Based Practices for Adolescents
Substance Use Disorder Treatment

• Motivational Interviewing (MI)Explain
• Adolescent Portable Therapy
• Behavioral Therapy for Adolescents
• Brief Strategic Family Therapy
• Multidimensional Family Therapy
• Multisystemic Therapy
• Seeking Safety

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Evidence-Based Preventative Programs for
Substance Use Disorder

• Integrated Dual Diagnosis Treatment Model (IDDT)
• Seeking Safety
• Strengthening Families
• Dialectical Behavior Therapy (DBT)
• Trauma Affect Regulation (TARGET)
• Trauma Recovery and Empowerment Model (TREM)

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Manualized Brief InterventionsCannabis Youth
Treatment Series

• Resource for substance abuse treatment
  professionals that provide a unique perspective
  on treating adolescents for marijuana use. These
  volumes present effective, detailed, manual-based
  treatment resources for teens and their families.
• These brief treatments can be transposed easily
  to the mental health setting

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Cannabis Youth Treatment (CYT) Series

• Motivational Enhancement Therapy and Cognitive
  Behavioral Therapy for Adolescent Cannabis Users
  5 Sessions, Vol. 1. Sampl, S., Kadden, R.
• Uses both motivational enhancement therapy and
  cognitive behavioral therapy

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Cannabis Youth Treatment (CYT) Series

• Motivational Enhancement Therapy and Cognitive
  Behavioral Therapy Supplement 7 Sessions of
  Cognitive Behavioral Therapy for Adolescent
  Cannabis Users, Vol.2. Webb, C., Scudder, M.,
  Kaminer, Y., Kadden, R.
• Uses cognitive behavioral therapy and
  Motivational Enhancment 7 sessions
• Family Support Network for Adolescent Cannabis
  Users, Vol.3. Hamilton, N.L., Brantley, L.B.,
  Tims, F. M., Angelovich, N., McDougall, B.
• Provides additional support for families

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Cannabis Youth Treatment (CYT) Series

• The Adolescent Community Reinforcement Approach
  for Adolescent Cannabis Users, Vol.4. Godley, S.
  H., Meyers, R. J., Smith, J. E., Karvinen, T.,
  Titus, J. C., Godley, M. D., Dent, G., Passetti,
  L., Kelberg, P.
• Outlines 12 individual sessions for adolescents
  and their parents or caregivers
• Multidimensional Family Therapy for Adolescent
  Cannabis Users, Vol.5. Liddle, H. A.
• Integrates family therapy and primary substance
  abuse treatment

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Cannabis Youth Treatment (CYT) SeriesReferences
More Info

• SAMHSA, Substance Abuse Mental Health Services
  Administration.
• www.samhsa.gov
• CYTWebsite

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• Section Five
• Recommendations

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Recommendations

• It is clear that there are enormous mental
  health needs for adolescents with Co-Occurring
  Disorders.

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Recommendations

• Assessment
• Comprehensive biopsychosocial assessment
• Assess Mental Health Issues using standard mental
  health intake process/evaluation
• Assess for SUD using a brief screening tool for
  substance use disorders in ALL adolescents
  entering system

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Recommendations

• Assessment
• Follow up with a comprehensive substance use
  disorder assessment for adolescents who have a
  co-morbid substance abuse disorder
• Assess for trauma/victimization
• Assess readiness for change

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Recommendations

• Treatment
• Implement science based psychotherapies for
  co-occurring disorders into routine practice
• Target most common co-morbidities ,i.e.
  Depression, ADHD, PTSD, CD
• Target most common substances abused marijuana
  alcohol/cigarettes

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Recommendations

• Treatment
• Conceptualize SUD as a process waxes/wanes,
  relapse expectable. Unrealistic to expect total
  remission in all cases.
• Medication has a place in treating co-morbid
  disorders, particularly the internalizing
  disorders

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RecommendedPrograms

• Assessment format that includes standardized
  SUD instruments, screening and more comprehensive
  when indicated
• GAIN
• Sassi
• Preventive Program
• Strengthening Families
• Family program
• Multisystemic Therapy
• Or Family ----free on e
• Trauma treatment paradigm
• Seeking Safety

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Recommendations

• Substance abuse treatment protocol
• Motivational Enhancement and Cognitive Behavioral
  Therapy (5 or 7 sessions)
• Motivational Interviewing.
• Individual Treatment
• Social Skills Treatment
• ART
• Placement
• MTFC