Improving Outcomes for Court-Involved
Youth with Co-occurring Disorders
October 24, 2014
Moderator:
Joseph J. Cocozza, Ph.D.
Director, National Center for Mental Health and Juvenile Justice
Coordinator:
Tom Templeton, M.S.Ed.
Project Assistant II, National Center for Mental Health and Juvenile Justice
FYI…
 The recording of this webinar, along with the PowerPoint
slides, will be available at ncmhjj.com
 If you experience technical issues during the webinar,
please use the chat feature to ask for help
 The format of today’s webinar will include three
presentations
 A follow-up Ask the Expert series will be held to allow
sufficient time for questions and discussion
 An eBlast with registration information for the Ask the
Expert sessions is forthcoming to all webinar participants
Ask the Experts Schedule
 Wednesday, November 12, 2014 2:00 PM EDT – 3:30 PM
EDT
Robert Kinscherff, Ph.D., J.D.
 Friday, December 5, 2014 2:00 PM EDT – 3:30 PM EDT
Holly Hills, Ph.D.
 Wednesday, December 17, 2014 2:00 PM EDT – 3:30 PM
EDT
Richard Shepler, Ph.D., PCC-S
Improving Outcomes for Court-Involved
Youth with Co-occurring Disorders
October 24, 2014
Sponsored by the
National Center for Mental Health
and Juvenile Justice
and the
National Council of Juvenile
and Family Court Judges
Objectives
This webinar is designed to
 identify the need for addressing court-involved youth with
co-occurring disorders
 suggest new directions for improving policies and programs
 describe effective treatment models that address the needs
of youth with co-occurring disorders
 offer examples of model programs that have demonstrated
success
Why Focus on Youth with Co-occurring Disorders?
 Many youth involved in the juvenile justice system
simultaneously experience both mental health and
substance use disorders, also known as co-occurring
disorders
 Research shows that these youth present multiple, complex
issues, and demonstrate poor treatment outcomes
 Their presence creates unique challenges for juvenile drug
treatment courts
 Changes in policy, practice, and treatment are necessary to
successfully address the needs of youth with co-occurring
disorders
Advancing Juvenile Drug Treatment Courts
(Briefs available at ncmhjj.com)
Developing Effective Policies for Addressing the Needs of
Court-Involved Youth with Co-occurring Disorders
Robert Kinscherff, Ph.D., J.D. and Joseph J. Cocozza, Ph.D.
Providing Effective Treatment for Youth with Co-occurring
Disorders
Patrick Kanary, E.Ed., Richard Shepler, Ph.D., PCC-S, and Michael Fox, M.A., PCC
New Directions to Address Co-occurring Mental Disorders
Holly Hills, Ph.D., and Karli J. Keator, M.P.H.
Presenters
Robert Kinscherff, Ph.D., J.D.
Senior Associate at the National Center for Mental Health and Juvenile Justice; Associate Vice
President for Community Engagement at the Massachusetts School of Professional
Psychology
Richard Shepler, Ph.D., PCC-S
Senior Research Associate at the Begun Center for Violence Prevention Research and
Education, the Jack, Joseph, and Morton Mandel School of Applied Sciences, Case Western
Reserve University
Holly Hills, Ph.D.
Associate Professor in the Department of Mental Health Law and Policy at the Louis de la
Parte Florida Mental Health Institute in the College of Behavioral and Community Sciences at
the University of South Florida
Developing Effective Policies for Addressing
the Needs of Youth with Co-occurring
Disorders
Robert Kinscherff, Ph.D., J.D.
Increasing Awareness of COD
 Recognition that policy and program
changes are needed to address courtinvolved youth with co-occurring mental
and substance use disorders
 Develop the local capacity for
integrated care to effectively treat these
youth
Key Decisions in Building COD Capacity
Establishing Eligibility and Exclusion Criteria
Screening and Assessment
Youth and Family Involvement
Integrated Treatment Services
Violations, Sanctions, and Rewards
Graduation Expectations
Adapting Policy for Youth with COD
Eligibility Criteria
 Criteria broadly excluding youth with MHD should be
changed to permit inclusion of youth with MHD
 Avoid using criteria exclusively based upon specific
diagnosis and focus instead upon degree of
functional impairment arising from the MHD and the
SUD
Adapting Policy for Youth with COD
Screening and Assessment
 Screening of all potentially eligible youth for both MHD and SUD
using consistent protocols and empirically validated tools for
screening
 Refer youth screened “positive” for individualized assessments:
• Administered by clinicians trained in COD assessment
methods
• Attentive to trauma-informed assessment
• Geared toward case-specific plans, “treatment “matching”
• Focused upon effective, integrated treatment
Adapting Policy for Youth with COD
Youth and Family Involvement
 Better outcomes with higher level of family engagement
 Consider requiring family participation in screening, assessment, and
treatment by at least one “family” member (not necessarily a parent)
 Family-Friendly practices including
• Scheduling when working parents can attend
• Assisting with transportation, child care
• Being sensitive to cultural issues
• Recognizing family members who support recovery
• Recruiting parents with “lived experience” as supports
• Inviting parents with “lived experience” as JDC team members
• Inviting former youth participants (graduates) as JDC team members
Adapting Policy for Youth with COD
Integrated Treatment Services
 Better outcomes with integrated EBP treatment
 Avoid settling for what is available if inadequate
 “Something is better than nothing” = FALSE
 Work with community-based clinical services
providers to develop capacity for evidence-based
integrated COD treatment
•
•
•
•
Bring insurers and other funders into the conversation
Consider incentivizing a provider with sole referrals
Access technical support and consultation
Avoid “parallel” or “serial” treatment approaches
Adapting Policy for Youth with COD
Violations, Sanctions and Rewards
 Just as SUD recovery is characterized by relapse
along the way to recovery, MHD may have a waxing
and waning course of symptoms despite
participation in treatment (especially in early phases
of treatment).
 Violations and sanctions should focus on treatment
engagement, not solely fluctuations of symptoms
 Violations, sanctions, rewards should consider:
• Treatment attendance and participation
• Degree of progress in SUD recovery
• Indications of functioning at home, school, community
Adapting Policy for Youth with COD
Graduation Expectations
 Ordinarily hold youth with COD to same criteria as those with just
MHD or SUD
 Consider whether failure to achieve some expectations (e.g.,
school attendance) reflects functional impact of active mental
disorder beyond the ready control of the youth
 Focus upon ultimate markers of success in COD which include
• Active participation in integrated treatment
• Evidence of SUD recovery over time
• Improved functional capacities, reduce impairment
• Reduced re-arrest and violations of JDC expectations
Adapting Policy for Youth with COD
Emerging Models for Court-Involved Youth with COD
 Are promising but still developing
 Require key modifications in JDC policies
 Should provide access to integrated COD treatment
Providing Effective Treatment for Youth with
Co-occurring Disorders
Richard Shepler, Ph.D.,PCC-S
3 Types of Treatment for
Co-Occurring Disorders
Sequential: traditional belief that symptoms of one disorder (SU/MH) can’t
be resolved until the symptoms of the other disorder are addressed
Parallel: both services provided at same time by different professionals in
different systems or agencies, with different treatment plans
Integrated: mental health and substance use treatment is provided by one
provider with one assessment and one treatment plan
Youth with co-occurring disorders are best served through an integrated screening,
assessment, and treatment planning process that addresses both mental and substance
use disorders, each in the context of the other
Treatment of Youth with Co-occurring Disorders:
What We Have Learned
• Look for treatment programs that offer both substance use and mental
health approaches delivered in home and community environments:
•
•
•
•
•
Integrated Co-Occurring Treatment (ICT);
Family Integrated Transitions (FIT),
Multidimensional Family Therapy (MDFT),
Functional Family Therapy-CMT (FFT-CMT),
Multisystemic Therapy-SU (MST-SU).
• Optimal effects require interventions that impact youth symptom
patterns (behaviors, cognitions, emotions), trauma, risk and safety
issues, family systems and recovery environments, peer relationships,
school and community functioning, and positive development.
Influence, Interaction, and Manifestation of
Multiple Occurring Conditions
Contexts (Home,
School, Peers,
Community, etc.)
Substance Use
Disorder
Mental Health
Disorder
Family
Trauma Factors
Youth
Risk & Resiliency
Factors
Developmental
Factors
Safety Concerns
Salient
Behavior/
Symptom
Integrated Co-Occurring Treatment
Integrated Co-Occurring Treatment (ICT) is a promising practice that
utilizes an integrated treatment approach, embedded in an intensive
home-based service delivery model, to provide both mental health
and substance abuse treatment services to youth with co-occurring
disorders of substance use and serious emotional disability and their
families. Services are provided in the home, school and community
where the youth lives, with the goal of safely maintaining the youth
in the least restrictive, most normative environment.
Main Purpose:
 Placement prevention
 Reunification
 Stabilization and safety
ICT Core Assumptions
1. Youth with COD present with multiple and complex symptom
patterns and behaviors, which adversely affect their functioning in
developmentally important life domains.
2. COD presentation in youth is affected by brain development;
and conversely, brain development is impacted by substance use.
3. Traumatic stress experiences contribute to impaired emotional
and behavioral functioning and to the adoption of risk behaviors,
which in turn may lead to further exposure to victimization,
violence, and trauma experiences.
4. Safety concerns and risk behaviors are elevated and need to be
intensively managed and monitored.
ICT Core Assumptions (cont.)
5. Contextual factors (peers, family, school, neighborhood,
and the risk and protective factors associated with them)
play a mediating role in youth behaviors, use patterns, and
recovery trajectory.
6. The stressors associated with co-occurring disorders
negatively strain family emotional, interpersonal, and
material resources.
7. Treatment engagement and readiness to change are more
difficult to attain and sustain.
Intensive Home-Based Service
Delivery Modality
Cross-System Collaboration and
Service Coordination
Multidimensional and Integrated
Assessment and
Conceptualization
Comprehensive and Integrated
Treatment Array Matched to
Needs and Strengths
Resiliency-Oriented Developmental
Perspective
Culturally Mindful Engagement and
Family Partnerships
ICT Model Components
ICT Core Services
•
•
•
•
•
•
•
Crisis intervention and stabilization
Individually-focused cognitive, emotional, and
behavioral treatments
Skill building and psycho-education
Motivational interviewing
Family-focused, systemic interventions
Cross-system coordination and supports
Asset and support building activities (e.g. linkage to
recovery mentor)
Target Outcomes
Increase functioning in major life contexts so that
the youth is:
• Living at home or in a permanent home setting
• Attending and achieving at school/work
• Reduced involvement in the JJ system
• Reduced use/no use of substances
• Participating in positive family, peer, and community life
• Improved family recovery environment
• Accessing resources and natural supports as needed to
maintain gains and prevent recidivism
Realistic Outcomes and Expectations
• Think trajectory of wellness not cure
• Youth living with mental health and substance use disorders
often have ongoing treatment and/or support needs
• Substance use is a chronic relapsing disorder (Dennis)
 Completion rates low
 High rate of treatment drop-out
 Relapse common
• Measure what you do: risk reduction across life domains
 Track multiple outcomes
• Conversation with key stakeholders about realistic outcome
expectations (increased functioning; decreased level of care
needs; etc.)
New Directions to Effectively Address
Co-occurring Mental Disorders
Holly Hills, Ph.D.
Program Modifications to Address Co-Occurring
Disorders
•
Evaluate the available service continuum and build
relationships to fill needs
•
Consider altering program policies and criteria
•
Modify the content of screening and assessment tools
Examples of Program Modifications
•
Summit County, OH: Crossroads Program
•
Ouachita Parish, LA: 4th Judicial District Juvenile Drug
Treatment Court
Summit County, OH: Crossroads Program
• 70 youth annually, aged 12-17, post
adjudication
• Can get records expunged if they successfully
complete
• 4 phases of contact, from weekly to monthly
meetings, over a year’s time
Summit County, OH: Crossroads Program
• Youth receive services in their home
• 3-5 hours of contact with their counselor per
week
• Probation Officers are trained in Motivational
Interviewing and Cognitive Behavioral Therapy
• POs meet with youth under their supervision 2-3x
per week
Summit County, OH: Crossroads Program
• Sanctions: electronic monitoring, suspension
of driver’s license, changes in curfew
• Incentives: Field trips, movie / sports tickets,
gift cards
Ouachita Parish, LA: 4th Judicial District
•
Youth, age 10-17 get a clinical eligibility screening to
determine program course
•
Youth with CODs participate for approximately 9
months
•
Utilize structured screening and assessment measures
Ouachita Parish, LA: 4th Judicial District
• 2 contacts with Case Manager weekly
• 2 contacts with Probation Officer weekly
• Evolving to 2x month over program term
Ouachita Parish, LA: 4th Judicial District
• Two Program “Tracks”
• Track 2 has four phases with an additional
aftercare phase
Ouachita Parish, LA: 4th Judicial District Juvenile Drug Treatment Court
Program Elements
• Cannabis Youth Treatment (CYT) and Solution
Focused Brief Therapy (SFBT)
• Collaboration between the Court and the
University of Louisiana, Monroe
• Family member / Guardian must complete a
‘Family Action Plan’
Ouachita Parish, LA: 4th Judicial District Juvenile Drug Treatment Court
Program Elements
• Incentives = gift cards, sports tickets, decreased
time spent in a Phase
• Sanctions = writing assignments, increased
frequency in court
• Graduation requires 8 weeks with no positive
drug screens, and compliance with interventions
Conclusion
• Recognition of significant numbers of youth with
CODs may require
• Modification of mission
• Review / expansion of Screening and
Assessment Measures
• Adoption of Evidence-based Practices
• Expanding Access to Psychopharmacology
• Review of Outcome Measures
Reminder…
 The recording of this webinar, along with the PowerPoint
slides, will be available at ncmhjj.com
 A follow-up Ask the Expert series will be held to allow
sufficient time for questions and discussion
 An eBlast with registration information for the Ask the
Expert sessions is forthcoming to all webinar participants
Ask the Experts Schedule
 Wednesday, November 12, 2014 2:00 PM EDT – 3:30 PM
EDT
Robert Kinscherff, Ph.D., J.D.
 Friday, December 5, 2014 2:00 PM EDT – 3:30 PM EDT
Holly Hills, Ph.D.
 Wednesday, December 17, 2014 2:00 PM EDT – 3:30 PM
EDT
Richard Shepler, Ph.D., PCC-S
Contacts
Robert Kinscherff: rkinscherff@prainc.com
Richard Shepler: Richard.Shepler@case.edu
Holly Hills: hhills.tpa@gmail.com
Tom Templeton: ttempleton@prainc.com