Co-Occurring Disorders, Best Practices and Adolescents “Double Trouble - Early”

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

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

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).

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

Incidence of Co-occurring Disorders in System of Care Adolescents (Turner, Muck, Muck et al, 2004) • SOC sites (N= 18, 290) 44% reported COD

Co-Occurring Disorders at Intake: SOC

ADHD Oppositional Defiant Disorders Mood Disorders and Depression Adjustment Disorders Conduct Disorders PTSD and Acute Stress Impulse Control Disruptive Behavior Disorders Anxiety Psychosis Autistic Disorders Learning and Related Disorders Mental Retardation Personality Disorder V Code Other 8.9% 6.8% 4.6% 3.5% 5.5% 7.5% 4.5% 2.3% 2.4% 1.8% 2.1% 0.1% 5.1% 4.3% 3.8% 2.4% 1.5% 3.8% 5.6% 3.3% 2.8% 7.6% 13.3% 13.2% 8.1% 9.9% 0% 20% 27.1% 25.2% 32.9% 28.4% 38.4% 34.0% Mental Health Problems Only (n = 10,541) Comorbid with Susbtance Use (n = 782) 40% 60% 80% 100%

• 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 • Externalizing —non compliance, aggression, attention problems, destructiveness, impulsivity, hyperactivity, and antisocial behavior (18-35%) COD • Both (38-65%) COD

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)

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:

100 90 Internalizing Behaviors Externalizing Behaviors 80 70 60 50 40 30 20 Intake 6 Months 12 Months Internalizing Behaviors 64.6

60.4

57.3

Externalizing Behaviors 71 67.0

64 Internalizing: n=101; F(3,98)=1396, P<.001.

Externalizing: n=101; F(3,98)=1706, P<.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.

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

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

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

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

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.

Clinical Barriers

A) 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

Clinical Barriers

A) 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

Clinical Barriers

B) 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

Section Three: Assessment of Co-Occurring Disorders

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

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

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

Assessment Instruments Screening Instruments: • Adolescent Alcohol Involvement Scale • Adolescent Drug Involvement Scale • Problem Oriented Screening Instrument for Teenagers (POSIT) • GAIN – Short Version—Sample attached.

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)

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

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

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

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

Evidenced Based Treatments National Registry for Evidenced Based Programs and Practices —SAMSHA 1 2 3 4 5 Treatment for Co-occurring Disorders Mental Health Treatments successful with Co occurring disorders Treatments for Substance Use Disorders Preventative Practices Brief Manualized Treatments

Evidence-Based Treatments for Co-Occurring Disorders Family Behavior Therapy Multisystemic Therapy Dialectical Behavior Therapy Seeking Safety TREM TARGET Integrated Community Treatment Family Treatment

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.

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.

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

Family Behavior Therapy (FBT) References & More Info • SAMHSA’s National Registry of Evidence based Programs and Practices (NREPP) • Bradley Donohue, Ph.D. Associate Professor • University of Nevada, Las Vegas • E-mail: [email protected]

• Web site: http://www.unlv.edu/centers/achievement

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.

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

Multisystemic Therapy (MST) Outcomes • Alcohol and drug use frequency reduced and higher rates of abstinence • Increased perceived family functioning cohesion • Decrease peer aggression

Multisystemic Therapy (MST) References & More Info • SAMHSA’s 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: [email protected]

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.

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.

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

Dialectical Behavioral Therapy (DBT) References & More Info • SAMHSA’s 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: [email protected]

• Web site: http://www.brtc.psych.washington.edu/

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.

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.

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

Seeking Safety References & More Info • SAMHSA’s 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: [email protected]

• URL: http://www.seekingsaftey.org

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.

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

Trauma Recovery and Empowerment Model (TREM) • Outcomes

Reduces severity of problems related to substance abuse

• Reduces psychological problems/symptoms • Reduces trauma symptoms

Trauma Recovery and Empowerment Model (TREM) References & More Info • SAMHSA’s National Registry of Evidence based Programs and Practices (NREPP) • Roger D. Fallot, Ph.D.

• Director of Research and Evaluation • Community Connections • E-mail: [email protected]

• Web site: http://www.ccdc1.org

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.

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

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

Trauma Affect Regulation: Guide for Education and Therapy (TARGET) References & More Info • SAMHSA’s 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: [email protected]

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

Evidence-Based Mental Health Programs that have had Success with Substance Abuse Treatment

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

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

Evidence-Based Practices Parent Training Adolescent 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

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

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

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 Child’s Behavior by Improving Family Interactions

Evidence-based Practices - Family Therapy Brief 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

Evidence-based Practices - Family Therapy Multidimensional 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

Evidence-based Practices - Family Therapy Multidimensional 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

Evidence-based Practices Functional Family Therapy (FFT) • Targets Youth 11-18 yrs at risk/ presenting behavior problems, substance abuse, conduct disorder • Effective Practice

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

Evidenced Based Treatment Aggression 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

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

Evidenced Based Treatment

ART-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

Cognitive Behavioral Therapy:

ART —Moral 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

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.

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 -

http://www.kap.samhsa.gov/products/manuals/p dfs/anger1.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

Evidence-based Practices – Multidimensional Treatment Foster Care • Patricia Chamberlain PhD – Oregon Social Learning Center

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 *

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)*

Manualized Brief Interventions Cannabis 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

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

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

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

Cannabis Youth Treatment (CYT) Series References & More Info • SAMHSA, Substance Abuse Mental Health Services Administration.

• www.samhsa.gov

• CYT—Website

Section Five: Recommendations

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

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

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

• • •

Treatment:

Recommendations 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

Treatment:

Recommendations • 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

• • • • Recommended Programs 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

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