Full Slideshow - California Institute for Behavioral Health Solutions

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

13.3%

13.2%

8.1%

9.9%

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%

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


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


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/ Comorbid 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.


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)


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 Treatment for Co-occurring Disorders

2 Mental Health Treatments successful with Cooccurring disorders

3 Treatments for Substance Use Disorders

4 Preventative Practices

5 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 cooccurring problem behaviors such as depression, family discord, school and work attendance, and conducts problems in youth.


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.


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


References & More Info

• SAMHSA’s National Registry of Evidencebased Programs and Practices (NREPP)

• Bradley Donohue, Ph.D. Associate

Professor

• University of Nevada, Las Vegas

• E-mail: bradley.donohue@unlv.edu

• 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.


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


Outcomes

• Alcohol and drug use frequency reduced and higher rates of abstinence

• Increased perceived family functioningcohesion

• Decrease peer aggression




• Scott W. Henggeler, Ph.D.

• Dept of Psychiatry and Behavioral

Sciences

• Medical University of South Carolina

• E-mail: henggesw@musc.edu

Dialectical Behavioral Therapy

(DBT)

• A cognitive-behavioral treatment approach with two key characteristics: a behavioral, problemsolving 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.


(DBT) Populations

• Young adults ages 18-25

• Adults ages 26-55

• Older adults ages 55+

• Male and Female

• Race: American Indian/Alaska Native,



Race/ethnicity unspecified, White.


(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


(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: linehan@u.washington.edu

• 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



• Male and Female

• Races: American Indian/Alaska Native,



Race/ethnicity unspecified, White.

Seeking Safety

Outcomes

• Reduces Substance abuse

• Improved trauma-related symptoms

• Improved psychopathology

• Increased treatment retention

Seeking Safety


• 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


Population



• Female

• Race: American Indian/Alaska Native,

Black or African American, Hispanic or

Latino, Race/ethnicity unspecified, White

Trauma Recovery and


Outcomes

• Reduces severity of problems related to substance abuse

• Reduces psychological problems/symptoms

• Reduces trauma symptoms

Trauma Recovery and




• Roger D. Fallot, Ph.D.

• Director of Research and Evaluation

• Community Connections

• E-mail: rfallot@ccdc1.org

• 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.



Therapy (TARGET) Population

• Young adult ages 18-25


• Male and Female

• Race: Black or African American, Hispanic or Latino, Race/ethnicity unspecified,

White



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



Therapy (TARGET) References

& More Info


• Julian D. Ford, Ph.D.

• Associate Professor

• Dept of Psychiatry, MC1410

• University of Connecticut Health Center

• E-mail: ford@psychiatry.uchc.edu

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


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


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


Functional Family Therapy (FFT)

• Targets Youth 11-18 yrs at risk/ presenting behavior problems, substance abuse, conduct disorder



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


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


(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, reinstruction 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 It’s Free!

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

Evidence-based Practices –

Multidimensional Treatment

Foster Care


• 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


(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


(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


(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


(CYT) Series


• 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

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