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 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: 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 • 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 • 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 • 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 • 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 Treatmentsfor 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@example.com • 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: firstname.lastname@example.org
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@example.com • 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 SafetyPopulation • 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 SafetyOutcomes • Reduces Substance abuse • Improved trauma-related symptoms • Improved psychopathology • Increased treatment retention
Seeking SafetyReferences & 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: Lnajavits@hms.harvard.edu • 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