Understanding the Connection: Youth & Co-Occurring Disorders

1. Understanding the Connection: Youth & Co-Occurring Disorders Presented by Marsha K. Middleton Lynne M. Saffell January 19th, 2007 For the Central East Addiction Technology Transfer Center Leadership Institute

2. Background • Co-Occurring Disorders State Incentive Grant (COSIG) • DC COSIG • APRA Psychosocial Rehabilitation Program • CEATTC Leadership Institute • Leadership Institute Project • Co-occurring Disorder Clinical Competency Training

3. Identified Problems In the District of Columbia • Limited Information for youth, ages 12 – 21 • Limited Prevalence Data • Limited Data Collection • Limited Resources • Universal Screening Does Not Exist • Limited COD Programs & Access • Lack of Funding/Blended Funds

4. The Project • The project will consists of two components. • A Public Town Hall Meeting • Continuing the Discussion Workshop

5. Purpose • Educate the community about the relationship between substance abuse and mental illness. • Provide an opportunity for open dialog, between clinicians, youth workers, educators, parents, policy makers and treatment providers on issues and concerns for youth with co-occurring disorders. • Examine existing services & gaps. • Discuss existing treatment options and services.

6. Town Hall Meeting: Understanding the Connection Youth and Co-Occurring Disorders District of Columbia Town Hall Meeting Understanding the Connection: Youth and Co-Occurring Disorders January 24, 2007 Agenda Facilitators: Marsha K. Middleton, Community Services Outreach Manager and Lynne M. Saffell, Public Health Analyst Office of Prevention and Youth Services 8:30 a.m. - 8:55 a.m. Registration 9:00 a.m. - 9:30 a.m. Welcome Gregg A. Pane, M.D., Director, DC Department of Health Opening Remarks Steven Steury, M.D., Clinical Director, DC Department of Mental Health Linda Y. Fisher, Interim Senior Deputy Director for Substance Abuse Services Addiction Prevention & Recovery Administration (APRA)

7. Agenda (continued) 9:30 a.m. - 9:45 a.m. The Occasion, Lynne M. Saffell 9:45 a.m. - 10:15 a.m. Understanding the Issues: Youth and Co-Occurring Disorders Ann Doucette, Ph.D. Senior Research Scientist, Department of Health Policy George Washington University 10:15 a.m. - 10: 45 a.m. Co-Occurring Disorders and Youth in the Juvenile Justice System Fred Dyer, Ph.D., Fred Dyer & Associates, Chicago, Illinois 10:45 a.m. - 11: 00 a.m. Break 11:00 a.m. - 11: 45 a.m. Panel I: Federal and Local Response to the Issue Moderator: Marsha K. Middleton, Community Services Manager, OPYS Anthony J. Ernst, Ph.D., Director of Technology Transfer at National Co-Occurring Center for Excellence (COCE) (SAMHSA)

8. Agenda (continued) Randy Muck, M.Ed., Lead Public Health Advisor/Team Leader, Adolescent Programs, Center for Substance Abuse Treatment , (SAMHSA) Elmore T. Briggs, MS, Clinical Director DC Department of Health, Addiction Prevention and Recovery Administration William J. Reidy, Deputy Director, Co-Occurring Disorders Systems Change, DC Department of Mental Health Doreen A. Cavanaugh, Ph.D. Research Assistant Professor, Health Policy Institute Georgetown University 11:45 a.m. - 12:30 p.m. Panel II: What We See and What We Need Moderator: M. Lynn Smith, COSIG Project Director, DC Department of Mental Health Madhu Bhatia, M.D., Medical Director, Riverside Hospital

9. Agenda (continued) Gwendolyn Dubuission, Mental Health Specialist DC Department of Youth & Rehabilitative Services Barbara Parks, MSW, Director School Based Mental Health Programs, DC Department of Mental Health Parent (invited) Steven Xenakis, M.D., Director Child and Adolescent Psychiatry Psychiatric Institute of Washington Questions Closing Remarks

10. PART 2: Part 2 Workshop: Continuing the Discussion Recognizing the Sign and Symptoms of Co-Occurring Disorders in Girls and Incarcerate Youth Facilitator: Fred J. Dyer Ph.D., Dyer & Associates Chicago, Illinois

11. CONTINUING THE DISCUSSIONRecognizing the Signs and Symptoms of Co-Occurring Disorders in Girls and Incarcerated YouthJanuary 25th, 2007 Agenda 8:30 a.m. - 8:55 a.m. Registration/ Continental Breakfast 9:00 a.m. - 9:10 a.m. Welcome Constance H. Bush, Interim Chief Office of Prevention and Youth Services 9:30 a.m. - 10: 35 a.m. Profiles and Trends of Adolescent Girls With Co-Occurring Disorders 10:35 a.m. – 10:45 a.m. Break 10:45 a.m. - 11: 45 a.m. Competing Paradigms and Un-Coordinated Service Systems 11:45 a.m. - 12: 15 p.m. Future Challenges & Creative Re-Direction 12:15 p.m. - 1:00 p.m. Lunch (on your own)

12. CONTINUING THE DISCUSSIONRecognizing the Signs & Symptoms of Co-Occurring Disorders in Girls and Incarcerated YouthAgenda (continued) • 1:00 p.m. - 1:30 p.m. Prevalence of Co-Occurring Disorders in Youth in Detention Centers • 1:30 p.m. - 2:30 p.m. Signs & Symptoms • 2:30 p.m. - 2:40 p.m. Break • 2:40 p.m. - 3:30 p.m. Treatment Options • 3: 30 p.m. - 4:00 p.m. Wrap – Up

13. Target Audience • Youth Substance Abuse & Mental Health Counselors and Providers • Juvenile Justice Counselors/Providers • Community-based Organizations • Faith-based Organizations • DC Public and Public Charter Schools • Parents • YOU!!!

14. Understanding The Connection. . . “Co-occurring disorders are an expectation not an exception” K. Minkoff

15. Definitions • Substance Use: The ingestion of alcohol or other drugs without experiencing negative consequences • Substance Abuse: The continued use of alcohol or other drugs despite negative consequences • Addiction: The compulsive behavior by an individual regardless of consequences (e.g., - gambling, shopping, alcohol and other drug use)

16. Definitions (continued) • Substance Use Disorders: (SUD)- A physical or mental illness that is the result or side effect of the use or abuse of drugs (e.g., alcohol, cannabis, cocaine, opioids, nicotine); to the side effects of a medication; to toxic exposure • Mental Disorders: Intense emotions, thoughts, and or behaviors occurring over extended periods of time & result in impairment in functioning (DSM-IV-TR) • Co-Occurring Disorders: When an individual is diagnosed with at least one mental disorder as well as an alcohol or other drug use disorder. • Co-Occurring Disorder exist when at least one disorder of each type is established independently of the other; not simply a cluster of symptoms resulting from a single disorder

17. Serious emotional disturbance (SED) birth to 18 current or past year diagnosed mental, behavioral, or emotional disorder that meets DSM-IV diagnostic criteria resulting in functional impairment interferes/limits functioning in family, school or community activities Serious mental illness (SMI) 18+ currently or past year diagnosable mental, behavioral, emotional disorder that meets DSM-IV diagnostic criteria results in functional impairment Interferes/limits 1+ major life activities Distinction Between Mental Disorder and Serious Mental Illness

18. III Less severe mental disorder/more severe substance abuse disorder IV More severe mental disorder/more severe substance abuse disorder High Severity Alcohol and other drug abuse I Less severe mental disorder/less severe substance abuse disorder II More severe mental disorder/less severe substance abuse disorder Mental Illness Low Severity High Severity The Four Quadrants

19. Multiple Co-occurring Problems Are the Norm and Increase with Level of Care Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies

20. Mental Health Disorders In Youth • Attention Deficit/Hyperactivity Disorder • Learning Disorders • Oppositional Defiant/Conduct Disorder • Depression • General Anxiety Disorder • PTSD and Acute Stress • Bipolar • Substance Abuse

21. What is the relationship between substance abuse and mental health disorders? • Substance abuse disorders can mask mental health symptoms. • Mental health symptoms canmimic substance use.

22. Signs & Symptoms: Mental Illness vs. Substance Abuse • Depression • Mania • Anxiety & Panic • Psychosis Alcohol; Heroin & Inhalants Cocaine; Methamphetamine & Prescription Drug (PDA) Abuse: Stimulants PDA: Benzodiazepines & Barbiturates; & Marijuana LSD & PCP

23. National LevelPrevalence Data In Adults • Presence of a mental disorder triples the risk of having a co-occurring substance use disorder. • Presence of an addictive disorder quadruples the risk of having a co-occurring mental health disorder • Eighty percent of the time the mental disorder precedes the addictive disorder • Few get treatment for both disorders

24. National Youth Prevalence Data • Forty-three percent of youth who receive mental health services in the US have a co-occurring substance use disorder • (CMHS (2001) national health services study) • Sixty-two percent of males and eighty-two percent of females entering substance abuse treatment have emotional disorders, including behavioral problems • (SAMHSA/CSAT 1997-2002 study) • Thirteen percent of adolescents with significant emotional & behavior problems reported substance dependence • SAMHSA 1994-96 National Household Survey

25. National Youth Prevalence DATA (continued) • Seventy-five to eighty percent of adolescents receiving inpatient substance abuse treatment have a coexisting mental disorder • National Mental Health Association (NMHA), 2005 • Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder • As many as fifty-percent of substance abusing juvenile offenders have Attention Deficit Hyperactivity Disorder (ADHD)

26. Sources of Adolescent Referrals Nationally Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS)

27. Youth Treatment System ReportDistrict of ColumbiaCentral Intake Division for YouthFY06 Total number of Intake Completed 612 Percentage • Outpatient Referrals 313 51 % • Detoxification (Acute 7-14 days) 182 30.4% • Inpatient Referrals 42 7.6% • Drug Testing/Toxic Screens 73 11 % • Mental Health Evaluation 140 23 %

28. DC Central Intake Division for YouthReadmissions FY06 Ethnicity • African American 581 95% • Caucasian/White 13 2% • Hispanic/Latino 17 2% • Other 1 1%

29. DC Central Intake Division for Youth Primary Drugs of Choice FY06 • Marijuana 280 93% • PCP 10 10% • Cocaine 4 1.3% • Other 6 2.0% • Alcohol 2 0.6%

30. DC Central Intake Division for Youth Referral Sources FY06 • Courts 23739% • Community Based Organizations (CBO 29 5% • Faith Based Community 0 0 • Government Agencies 200 33% • CFSA54 9% • DYRS 146 24%

31. DC Central Intake Division for Youth Referral Sources (continued) • Schools15 3% • Self/Family 60 9% • Youth Treatment Vendors 11 2% • Unknown 60 9%

32. DC Central Intake Division for YouthReferral Percentages by Wards FY06 • District Wards: 1 2 3 4 5 6 7 8 6% 5% 1% 14% 17% 8% 19% 30%

33. What is needed • More data on District Youth with co-occurring • Universal/integrated screening for mental health and substance abuse • Increased crossed agency collaboration • Review of public school policies that promote punishment over treatment • Increased community education concerning the issue and reducing the stigma associated with mental illness. • A central agency to co-locate substance abuse and mental health services

34. Final Thought The mental health and substance abuse problems of youth are embedded and exacerbated by the conditions of their environment, the stresses of poverty and limited access to services. Marsha K. Middleton and Lynne M. Saffell

35. Resources

36. Resources (continued)

37. Resources: Websites • SAMHSA • www.samhsa.gov • Co-Occurring Center for Excellence • www.coce.samhsa.gov • Office of Applied Science • www.oas.samhsa.gov • Project Cork • www.projectcork.gov

38. Resources: Ad Campaign Unveiled

39. References • American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. • Deloe, T., Ph.D., & Mason, M.K., MSW, 2006 (slide presentation). Prevention of Co-Occurring Disorders. • SAMHSA, 2006. Co-Occurring Center for Excellence (COCE) Overview Paper 1, Definitions and Terms Relating to Co-Occurring Disorders. • SAMHSA, 2001. National Household Survey. • The Joint Commission on Mental Health of Children, 1970. Crisis in Child Mental Health. • Mora, M., Porter, G., Freed, R., & Turner, W. (slide presentation). Mental Health and Substance Abuse: Getting Down to the Basics.

40. Acknowledgements • Linda Y. Fisher, Interim Senior Deputy Director of Substance Abuse, Department of Health, Addiction Prevention and Recovery Administration • Carroll Parks, MPA, Director of Adult Services, D.C. Community Services Department of Mental Health • Julia Maxwell, LICSW, CAS, Clinical Administrator, D.C. Community Services Department of Mental Health • Constance H. Bush, Interim Director, Office of Prevention & Youth Services D.C. Department of Health, Addiction Prevention & Recovery Administration • DANYA Institute • D.C. Department of Mental Health

41. Contact Information Addiction Prevention & Recovery Administration Office of Prevention & Youth Services 3720 Martin Luther King, Jr., Avenue, SE 2nd Floor Washington, DC 20032 (202) 645-0344