Working with Youth with Co-Occurring Disorders

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Working with Youth with Co-Occurring Disorders

• Sharon Hunt, TA Partnership Interim Substance
  Abuse Resource Specialist
• Rachel Freed, Research Associate for the TA
  Partnership
• Rebecca Spotts, Research Assistant for the TA
  Partnership
• Cathy Ciano, Executive Director, Parent Support
  Network of Rhode Island
• Nick Vaske, youth presenter from Families First
  Foremost

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Overview

• Sharon R. Hunt
• 202-403-6914
• shunt_at_air.org

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Prevalence Chronicity

• Co-occurring mental disorders are common and
  serious (prevalence rates 20 - 80, depending on
  sample pool).
• Research indicates the onset of the mental
  disorder often precedes the addictive disorder.
  (Temporal order)
• The likelihood of adolescent substance use and
  dependence is strongly associated with younger
  age of onset, severity of emotional and
  behavioral problems, true across age and gender.
• Initially use is voluntary, thus the earlier the
  intervention the greater the impact on offsetting
  what later becomes a chronic, relapsing disease
  in which brain chemistry is altered.

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Most Common Presenting Problems

• Verbal/physical Aggressiveness
• Academic Difficulties
• Impulsivity
• Hyperactivity
• Depressed Mood
• Poor Social Skills

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Substance Use History at Intake by Age Category
Have you ever used
Substances
11 to 14 Years Old Number of children varied
from 2,440 to 2,452. 15 to 18 Years Old Number
of children varied from 1,571 to 1,575.
Substance use information was based on self
reports from youth 11 years or older.
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Multiple Co-occurring Problems Are the Norm and
Increase with Level of Care
Source CSATs Cannabis Youth Treatment (CYT),
Adolescent Treatment Model (ATM), and Persistent
Effects of Treatment Study of Adolescents
(PETS-A) studies
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Multiple Co-occurring Problems By Lifetime
Dependence Diagnosis
Source CSATs Cannabis Youth Treatment (CYT),
Adolescent Treatment Model (ATM), and Persistent
Effects of Treatment Study of Adolescents
(PETS-A) studies
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Adolescents in TreatmentSubstance Use Disorders

• 40 90 Report Victimization
• 20 25 Report Victimization in last 90 days, or
  current concern regarding reoccurrence
• Source Dennis, Stevens Chaffin, in press

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Clinical Diagnosis on any Axis at Intake by
Comorbidity Status
Clinical Diagnoses
No Comorbidity n 4,855. Comorbidity w/o
Substance Use n 4,633. Comorbidity w/
Substance Use n 697.
Percent
Because children may have more than one
diagnosis, the diagnosis variable may add to more
than 100. V Code refers to Relational
Problems, Problems Related to Abuse or Neglect,
and additional conditions that may be a focus of
clinical attention.
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Treatment Prognosis

• Prognosis is worse for youth with co-occurring
  disorders for many reasons motivation academic,
  family, and behavior problems and limited coping
  and social skills.
• May lag in important adolescent development tasks
  individuation, moral development and
  conceptualization of future family, vocational
  and educational goals.

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Cumulative Recovery Pattern at 30 months(The
majority vacillate in and out of recovery)
5 Sustained
Recovery
37 Sustained
19 Intermittent,
Problems
currently in
recovery
39 Intermittent,
currently not in
recovery
Source Dennis et al, in press forthcoming,
CYT, PETSA
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Adapting Treatment for Adolescents

• Examples need to be altered to relevant
  substances, situations, and triggers
• Consequences have to be altered to things of
  concern to adolescents
• Most adolescents do not recognize their substance
  use as a problem and are being mandated to
  treatment
• All materials need to be converted from abstract
  to concrete concepts

• Comorbid problems (mental, trauma, legal) are the
  norm and often predate substance use
• Treatment has to take into account the multiple
  systems (family, school, welfare, criminal
  justice)
• Less control of life and recovery environment
• Less aftercare and social support
• Complicated staffing needs

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MENTAL HEALTH INTERVENTIONS FOR CO-OCCURING
DISORDERS

• EVIDENCE-BASED INTERVENTIONS
• COGNITIVE BEHAVIOR-THERAPY(CBT)
• INTEGRATED COGNITIVE-BEHAVIOR THERAPY FOR
  TRAUMATIC STRESS SYMPTOMS AND SUBSTANCE ABUSE
• MULTI-SYSTEMIC THERAPY
• MOTIVATIONAL ENHANCEMENT THERAPY WITH CBT

• EFFECTIVE INTERVENTIONS
• SUPPORTIVE THERAPY
• SYSTEMIC FAMILY THERAPY
• INTENSIVE CASE MANAGEMENT
• COMMUNITY REINFORCEMENT
• NETWORK THERAPY
• METHADONE
• NALTREXONE

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Racial/Ethnic Disparities in Drug Prevalence
among Youth

• Rebecca Spotts
• rspotts_at_air.org
• 202-403-5847

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Racial/Ethnic Disparities in Drug Prevalence
among Youth

• Prevalence
• The role of culture
• Equal access to treatment

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Prevalence by Race/Ethnicity

• Evidence shows a significantly greater prevalence
  of substance abuse among Hispanics and Caucasian
  youth than African American youth at every grade
  level (National Institutes for Health)
• American Indian/Alaska Native youth had the
  highest rate of illicit drug use among youth age
  12-17 at 19.6, compared to 10.9 for Caucasian
  youth and 10.7 for African American youth(1999
  National Household Survey on Drug Abuse)

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Estimated Lifetime Prevalence of Selected Drugs
by Race/Ethnicity for Students in Grade 12 ()
2000.Source U.S. Department of Health and
Human Services National Institutes of Health
report Drug Use Among Racial/Ethnic Minorities
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• Dr. Gayle Porter, TA Partnership

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• Dr. Gayle Porter, TA Partnership

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What puts youth at risk for drug abuse? The role
of culture

• The cultures from which people hail affect all
  aspects of mental health and illness, including
  the types of stresses that they confront, whether
  they seek help, what type of help they seekand
  what types of coping styles and social supports
  they possess.
• (U.S. Department of Health and Human
  Services, 2001)

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Sources of Risk for Substance Abuse(www.safeyouth
.org)

• Three sources
• Individual child factors - biology, behavior and
  personality
• Youth with emotional and psychological problems
  are at greater risk for substance use and abuse
  (www.safeyouth.org)
• Family factors
• Do not perceive a strong parental disapproval for
  drug use
• Environmental factors
• Youth do not perceive appropriate risk involved
  with substance abuse

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Increased Risk Environmental Factors(www.safeyou
th.org)

• Community disorganization
• Lack of community bonding
• Community attitudes toward favorable drug use
• Inadequate services and opportunities for youth
• Pro-drug messages in the media

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Disparities for Children of Diverse Racial and
Ethnic Groups

• African American and Hispanic/Latino youth
  identified/referred at same rates as general
  population, but less likely to receive mental
  health or meds (Kelleher, 2000)
• Minority children tend to receive mental health
  services through juvenile justice and child
  welfare systems more often that through schools
  or mental health settings (Allegria, 2000)
• African American and Hispanic/Latino children
  have the highest rates of unmet need (Strum,
  2000)

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How do youth get access to substance abuse
treatment?

• Primary referral source by Racial and Ethnic
  Group in 1998-99 Funded SOC communities
  (Guilford, 2004 ORC Macro)

American Indian/Alaska Native Caregiver/Self (44.7)
African American Juvenile Justice (24.9)
White Non-Hispanic Education (20.1)
Hispanic/Latino Juvenile Justice (28.4)
Asian Juvenile Justice (28.2)
Native Hawaiian Child Welfare (22.2)
Multi-Race Mental Health (32.5)
Other Mental Health (22.4)
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Access to Services and Treatment

• SOC communities must develop a culturally
  competent strategy to reach out to at-risk youth
  in their area to combat substance abuse before it
  begins.
• www.preventioncurriculum.com/handbook/Chapter5Full
  Text.pdf

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Nick VaskeFamilies First Foremost

• 402-441-3803 (Number for Families First
  Foremost)
• nvaske_at_neb.rr.com

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Ecstasy and Club Drugs

• Rachel Freed
• 202-403-5389
• rfreed_at_air.org

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• I remember the feeling I had the first time I
  did Ecstasy complete and utter bliss. I could
  feel the pulse of the universe I let every
  breath, touch and molecule move my soul. It was
  as if I had unlocked some sort of secret world
  it was as if I'd found heaven. And I have to
  admit, I wondered how anything that made you feel
  so good could possibly be bad.
• Lynn Smith

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What Are Club Drugs?
The most widely used club drugs are GHB,
Rohypnol, Ketamine, and MDMA
Drug Street Name
GHB G, liquid ecstasy, Grievous Bodily Harm, gib, soap, scoop, nitro
Rohypnol Mexican valium, circles, roofies, la rocha, roche, rophies, R2, rope, forget-me pill
Ketamine K, special K, super K, vitamin K, kit-kat, keets, super acid, jet, cat valiums
MDMA Ecstasy, X, M, E, XTC, rolls, beans, Clarity, Adam, lover's speed, hug drug
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What Are Club Drugs?

• GBH
• GHB is usually abused either for its
  intoxicating/sedating/euphoria-inducing
  properties, or for its growth hormone-releasing
  effects
• Overdose may result in seizures, coma, and death
• May also produce withdrawal effects, including
  insomnia, anxiety, tremors, and sweating
• Ketamine
• Large doses cause reactions similar to those
  associated with use of PCP, such as dream-like
  states and altered perceptions or
  hallucinations. 
• At higher doses, can cause delirium, amnesia,
  impaired motor function, high blood pressure,
  depression, and potentially fatal respiratory
  problems
• Rohypnol
• Produces sensations of floating outside the body,
  visual hallucinations, and a dream-like state
• When mixed with alcohol, it can incapacitate
  victims and prevent them from resisting sexual
  assault
• Often produces anterograde amnesia
• May be lethal when mixed with alcohol and/or
  other depressants.

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What is Ecstasy?The Facts

• An illegal psychoactive drug
• Produces effects similar to hallucinogens and
  stimulants
• energizing effect
• distortions in time and sensory perceptions
• feelings of peace and happiness and empathy for
  others
• suppresses the desire to eat, drink, or sleep
• Popular at raves and other all-night party scenes

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Myths and inaccurate information about the
effects and long-term consequences of Ecstasy are
widespread among its users . . .
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Physical Effects

• In low doses . . .
• faintness
• dehydration
• muscle tension
• involuntary teeth clenching
• nausea
• blurred vision
• chills or sweating
• hypertension
• increases in heart rate, blood pressure, and
  temperature

• In high doses . . .
• liver, kidney, and heart failure
• strokes
• seizures

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Psychological Effects

• depression
• delusions
• mood swings
• lapses in memory

• anxiety
• panic attacks
• confusion
• disorientation

Research on animals suggests that Ecstasy use
can cause long-term damage to the parts of the
brain that use serotonin (NIDA, 2005).
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Other Risks

• There is no control over the pill ingredients
• The ingredients are difficult to obtain, so
  manufacturers often substitute ingredients
• ephedrine
• dextromethorphan
• caffeine
• Other, more dangerous drugs are sometimes sold as
  ecstasy.

• ketamine
• cocaine
• methamphetamine

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Mental Health and Ecstasy

• Strong correlation between Ecstasy use and
  depression
• 2 possible reasons
• Some users may be more vulnerable to the adverse
  effects of Ecstasy
• Users may have pre-existing mental health
  problems for which they self-medicate by using
  ecstasy
• Some ex-users experience a mental health
  impairment that persists for years after they
  stop using this drug. Verheyden SL, Maidment R,
  Curran HV (2003) Quitting ecstasy an
  investigation of why people stop taking the drug
  and their subsequent mental health. J
  Psychopharmacol., 17(4), 371-378.

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Mental Health and Ecstasy (cont.)
A study by Lieb and colleagues (2002) followed
the same 2,500 14-24 year olds for four years,
tracking changes in drug use and mental health

• Lieb R, Schuetz CG, Pfister H, von Sydow K,
  Wittchen H "Mental disorders in ecstasy users a
  prospective-longitudinal investigation." Drug
  Alcohol Depend 2002 68 195-207

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Mental Health and Ecstasy (cont.)

• The same study found that although most Ecstasy
  users had some form of mental illness during the
  study, in the vast majority of cases, the problem
  emerged before they began using Ecstasy.

Lieb R, Schuetz CG, Pfister H, von Sydow K,
Wittchen H "Mental disorders in ecstasy users a
prospective-longitudinal investigation." Drug
Alcohol Depend 2002 68 195-207
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Why is it Important to Get the Facts Out?

• Almost half of all parents in America (48) do
  not know the effects of Ecstasy
• 79 of parents do not know what is in Ecstasy
• Ecstasy is the least likely drug to be discussed
  when parents discuss specific drugs with their
  child.

Partnership for a Drug Free America (2003). 2003
Partnership Attitude Tracking Study. Retrieved
July 2005 from http//demo.pdfav3.somethingdigital
.com/Files/Full_Report_PATS_2003
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Why is it Important to Get the Facts Out?
3 of parents of teens think their teen has tried Ecstasy 11 of teens report trying Ecstasy
13 of parents of teens believe that Ecstasy would be very easy for their teen to get. 22 of teens say Ecstasy is very easy for them to get.
5 of parents of teens believe their teen has friends who have tried Ecstasy. 34 say they have close friends who use Ecstasy.
Partnership for a Drug Free America (2003). 2003
Partnership Attitude Tracking Study. Retrieved
July 2005 from http//demo.pdfav3.somethingdigital
.com/Files/Full_Report_PATS_2003
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Treatment Options

• There are currently no evidence-based treatments
  designed specifically for Ecstasy abuse.
• The most effective treatments for drug abuse and
  addiction in general are cognitive behavioral
  interventions.
• Substance abuse recovery support groups can also
  be effective in combination with behavioral
  interventions to support long-term, drug-free
  recovery.
• In addition, antidepressant medications might be
  helpful in treating the symptoms of depression
  and anxiety seen in Ecstasy users.

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• I hear people say Ecstasy is a harmless, happy
  drug. There's nothing happy about the way that
  "harmless" drug chipped away at my life. Ecstasy
  took my strength, my motivation, my dreams, my
  friends, my apartment, my money and most of all,
  my sanity. I worry about my future and my health
  every day.
• Lynn Smith

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Internet Resources

• http//www.clubdrugs.org/
• http//www.drugabuse.com/
• http//www.drugabuse.gov/drugpages/clubdrugs.html
• http//www.drugdigest.org/
• http//www.drugid.org/
• http//www.erowid.org/
• http//www.streetdrugs.org/

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Cathy CianoExecutive DirectorParent Support
Network of Rhode Island

• 401-467-6855
• CathyCiano_at_aol.com