Co-Occurring Disorders, Best
Practices and Adolescents
Webcast
Thursday June 26, 2008  11:00 AM – 12:30 PM
Dial-in Number: (866) 633-8010
Conference Code: 4449499285
For technical assistance please contact Maria Lovato, MBA at mlovato@cimh.org or
(916) 379-5351.
Co-Occurring Disorders, Best
Practice and Adolescents
• Please if you have any questions regarding this webcast
please email mlovato@cimh.org or you can call 916379-5351
• Please mute your phones by pressing *6 once the
training has started. Thank you for your participation.
• All questions will be answered at the end, so please
email Maria Lovato at mlovato@cimh.org with all your
questions.
Co-Occurring Disorders
Best Practices and Adolescent
“Double Trouble - Early”
Mary Jane Alumbaugh, Ph.D
Main Points
• Section One: Co-Occurring Mental Health and
Substance Use Disorders in Adolescents: Research
• Section Two: Systems Issues - Parallel Treatment
Systems-Colliding Cultures
• Section Three: Assessment and Treatment of CoOccurring Disorders
• Section Four: Evidence Based Mental Health
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).(Turner,
Muck,et al, 2004)
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. (Degenhar &Hall, 2006,Smit 2004)
• Psychiatric symptoms often precede the SUD
Incidence of Co-occurring
Disorders in System of Care
Adolescents
(Turner, Muck, Muck et al, 2004)
•
CSAT Sites 74% of youth with SUD also had a cooccurring mental health disorder
•
SOC Sites 21.7% had five or more presenting
problems; at least one of which was a SUD (Turner,
Muck, 2004)
Co-Occurring Disorders
Categories
•
Co-occurring disorders in adolescents are usually categorized
into internalizing and externalizing disorders. These should be
the focus of treatment for the mental health interventions.
•
Internalizing disorders–symptoms of anxiety, fear,
shyness, low self esteem, sadness, depression (6%)
•
Externalizing disorders —symptoms of non compliance,
aggression, attention problems, destructiveness,
impulsivity, hyperactivity, and antisocial behavior (1835%)
•
Both types of disorder (38-65%)
Co-Occurring Disorders
Categories
• Disruptive disorders and mood disorders are
associated with earlier onset of use of substances
and increased substance use disorders
• Trauma/victimization in youth with SUD range from
25% for males to 75% of females (Kanner, 2004,
Dennis, 2004)
Gender Differences
Girls
•
Conduct disorder associated with SUD in both girls
and boys, but girls with this combination had the
highest Child Behavior Checklist Scores for
delinquency
•
Caregivers report more of both internalizing and
externalizing disorders 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
•
Females report significantly higher level of drug
dependence vs. abuse, (72% vs 43%) in boys
Gender Differences
Boys
•
Present more often with disruptive disorders
(ODD/CD/ADD)
•
COD referrals are more often made in juvenile justice
settings (80%)
•
In juvenile justice settings 75% of males and 50% of all
females have a co-occurring disorder
Section Two:
Systems Issues - Parallel
Treatment Systems and
Colliding Cultures
Systems Issues
Culture clash
Different philosophies 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 treatments.
Co-Occurring disorders are at the nexus of this culture
clash
Clinical Differences
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.
•
Often treatment can not begin until abstinence is
obtained
Clinical Differences
Mental Health Treatment
•
•
•
•
Reluctance to medicate individuals with a
substance use disorder
Psychological treatments offered but with no
substance abuse treatment component
Clinicians often not cross trained in SUD
Individuals with SUD often minimize or not
disclose the mental health disorder
Clinical Differences
Substance Abuse Treatment
Based on a peer relationship model
•
•
•
•
Licensure not necessary (changing)
Treatment provider often a recovering individual
Willing to disclose substance abuse history
Often reluctance to allow any medication of any
kind
Clinical Differences
Substance Abuse Treatment
• Treatment often ignores mental health problems
and focuses on substance abuse
• Providers often not cross trained in mental health
treatments
• Individuals with substance use disorders often do
not disclose the mental health disorder
Section Three:
Assessment and Treatment
of Co-Occurring Disorders:
Integrating Cultures
Assessment and Treatment 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 co-occurring disorders as
incidence is higher than realized in adolescents.
(Myers, Brown, & Ott 1995)
Assessment and Treatment of
Co-Occurring Disorders
Assessment:
• Comprehensive biopsychosocial assessment
• Assess for substance use disorder using a brief
screening tool in ALL adolescents entering system
• Follow up with a comprehensive substance use
disorder assessment for adolescents who present
with a co-morbid substance abuse disorder
• Assess for trauma/victimization
Assessment and Treatment of
Co-Occurring Disorders
Treatment:
– Incorporate empirically based treatments for co-occurring
disorders into routine practice
– Target most common co-morbidities i.e. Depression, ADHD,
PTSD, CD, Trauma/Victimization
– Medication has a place in treating co-morbid disorders,
particularly the internalizing disorders
Assessment and Treatment 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 Instruments
Screening Instruments:
•
•
•
•
Adolescent Alcohol Involvement Scale
Adolescent Drug Involvement Scale(ADIS)
Problem Oriented Screening Instrument for
Teenagers (POSIT)
Global Appraisal of Individual Needs Short Version—
(GSS) Sample attached.
Assessment Instruments
General Checklists:
•
Achenbach YSR
•
Revised Behavior Problem Checklist.
•
Youth Outcome Questionnaire YOQ
•
Youth Outcome Questionnaire Self Report YOQ- SR
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)
Substance Abuse Subtle Screening Inventory-SASSI
Section Four:
Evidence Based Mental
Health Treatments for
Adolescents with CoOccurring 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
Evidenced Based Mental
Health Treatments
• Evidenced Based Treatments:
•
•
•
•
•
Hold promise for improving outcomes
Have different levels of support
Target specific populations/specific outcomes
Implemented with fidelity to ensure outcomes
Implementation/fidelity/model adherence: A robust
process
• Practitioner is responsible for engagement
Evidenced Based Treatments
for Co-Occurring Disorders
•
•
•
•
•
Family Treatments
Cognitive Behavioral Treatments
Parenting Programs
Substance Abuse Treatment
Out of Home Placement
Evidenced Based Mental Health
Treatments that have
demonstrated success with CoOccurring Disorders
•
•
•
•
•
Adolescent Transitions Program
Aggression Replacement Treatment (ART)
Brief Strategic Family Therapy (BFST)
Family Behavior Therapy (FBT)
Functional Family Therapy (FFT)
Evidence-Based Mental Health
Programs that have demonstrated
Success with Co-Occurring
Disorders
•
•
•
•
•
•
•
Motivational Interviewing
Multidimensional Family Therapy (MDFT)
Multidimensional Treatment Foster Care (MTFC)
Multisystemic Therapy (MST)
Seeking Safety
Strengthening Families
Integrated Co-Occurring Treatment (ICT)
Common Characteristics of
Family Therapies
• Family change is necessary for child success
• Multidimensional approach
• Individual, Family, Peers, School/Other Institutions,
Community
• Time Limited Brief – 1mo. to 1 yr.
• Targeted-Problem Focused
• Effect child by impacting family interactions & structure
• Present focused & pragmatic
Common Characteristics of
Family Therapies
• Utilize other empirically supported approaches
• Sequenced treatment – i.e. Phases/Stages
• Engagement Strategies - Increasing hopedecreasing negativity
• Change – Practical, logical, research support,
• Generalization – Family empowerment, linkage,
relapse prevention
• Flexible Delivery – Home, Office, School, Communitybased.
• Individualized – Tailored - Flexible
• 20-25 years of iterative research development
Family Therapy
Brief Strategic Family Therapy
(BSFT)
• Targets child/adolescents 8-17 years exhibiting, or at risk
of behavior problems including substance abuse
• Improve Child’s Behavior by Improving Family
Interactions
Brief Strategic Family Therapy
Outcomes
• 42% Reduction Behavior Problems
• 75% Reduction Marijuana use
• 58% Reduction Association with Antisocial Peers
• 75% Client Retention
• Reduces Recidivism
• Improves Family Relationships
Brief Strategic Family Therapy
• Severe Conduct Disorder and Substance Abuse 24-30
Sessions
• Jose Szapocznik PhD - Spanish Family Guidance
Center, Center for Family Studies, University of Miami
Family therapy
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.
• Participants attend sessions with parent/guardian
Family Behavior Therapy
• 90 min. weekly sessions gradually decrease to 60 min.
monthly with participants progress in therapy
• Behavioral contracting to establish an environment that
facilitates reinforcement for performance of behaviors that are
associated with abstinence from drugs
• Implementation of skill-based interventions to assist in
spending less time with individuals and situations that involve
drug use and other problem behaviors.
• Skills training to assist in decreasing urges to use drugs and
other impulsive behavior problems
• Communication skills training to assist in establishing social
relationships with others who do not use substances and
effectively avoiding substance abusers.
Family Behavior Therapy
•
•
•
•
•
•
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
•
•
•
•
•
•
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
• Bradley Donohue, Ph.D. Associate Professor
• University of Nevada, Las Vegas
– E-mail: bradley.donohue@unlv.edu
Family Therapy
Functional Family Therapy
(FFT)
• Targets Youth 11-18 yrs at risk/ presenting behavior
problems, substance abuse, conduct disorder
• Demonstrates strong outcomes
• Reduces recidivism from 25-60%
• Reduction in violent behavior
• Reduces siblings’ entry into high risk behaviors
Functional Family Therapy
• Low drop out from treatment
• Reduces family conflict
• Improves family communication
• Improves parenting
Functional Family Therapy
• Therapist assumes responsibility for Treatment
Phases
• Engagement
• Motivation
• Assessment
• Change behavior
• Generalize
Functional Family Therapy
• Average duration of service is 3-4 months
• 8-30 sessions of direct service
• Full time therapist will serve 12-15 families at one time
• Site certification and training
• James Alexander PhD – University of Utah
Family Therapy
Integrated Co-Occurring Treatment
Model (ICT)
• Four main areas of focus
• Basic needs and safety
• Individual functioning
• The family system
• Community connections and supports
• Integrated Co-Occurring Treatment Model is a home
based intervention using system of care service philosophy
but adapted to youth with co-occurring disorders.
• Integrated treatment approach a single provider
addresses both the mental and the substance abuse needs
of the adolescent.
Integrated Co-occurring
Treatment
ICT
• ICT utilizes a stage wise approach, (engagement,
persuasion, active treatment and relapse prevention)
• Uses motivational interviewing to facilitate readiness for
change. The provider also assesses the family’s
readiness and stage of change, as well as the
community’s readiness to receive the youth into the
community.
• Intensive service delivery is consistent with philosophy of
home-based intervention
• Flexible work hours to meet on call availability 24/7
Integrated Treatment for CoOccurring Disorders
• Time limited 4 to 6 months
• Small case loads
• Collaborative relationships with other child/family serving
systems
• Advocacy and system navigation
• Comprehensive mix of treatment/case management
• Provision of services where youth and family live and
function
• Helen K. Cleminshaw , Richard Shepler : Center for
Family Studies , The University of Akron.
Family Therapy
Multidimensional Family Therapy
MDFT
• Targets Adolescents (11-18 years) with drug and
behavior problems.
• Outcomes include improvements in:
• Rates of drug Use {42%-70% abstinent at followup}
• Behavior Problems
• School Performance
• Family Functioning
Multidimensional Family Therapy
• School Improvement
• Attend/Passing grades:
– 43% MDFT - 17% Family Group Therapy - 7%
Group Tx
• Improves Family Functioning
• Less conflict/More cohesion
• Prevention Outcomes
• Improves MH Symptoms
• 30-80% reductions Depression, Anxiety, Conduct
• Stronger outcomes w/Co-Occurring conditions
compared to CBT
• Lower Recidivism & Association w/Delinquent Peers
Multidimensional Family Therapy
• Superior outcomes to 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
Family Therapy
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.
 Wraparound approach
Multisystemic Therapy
Intensive Family / Community Based Treatment
• Targets chronic, violent, or substance abusing
offenders at high risk of out of home placements,
and their families
• Outcomes:
» Decrease in Substance Use and
Psychiatric Symptoms
» 25-70% Reduction Arrest Rates
» 47-64% Reduction Out of Home Placement
» Improves Family Functioning
» Improved School Performance
Multisystemic Therapy
• Interventions aim to :
•
•
•
•
•
•
•
Improve Caregiver discipline practices
Enhance family affective relationships
Decrease association with deviant peers
Increase association with prosocial peers
Improve school/vocational performance
Prosocial recreational outlets
Develop indigenous support network – family, friends,
neighbors, etc.
Multisystemic Therapy
• 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: henggesw@musc.edu
Characteristics of Cognitive
Behavioral Treatments
• Cognitive Behavioral Therapy is a general term for
treatments based on the premise that thoughts influence
behavior.
• CBT is briefer and time-limited.
• It is highly instructive in nature and makes use of
homework.
• The fundamental premise is that people can learn
to think differently and act on that learning.
• CBT is structured and directive.
• Many of the treatments listed use both family therapy
techniques and CBT or other techniques
Cognitive Behavioral
Aggression Replacement Training
(ART)
• Assumes aggression is related to
• Weak or absent personal, interpersonal and socialcognitive 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 Arnold Goldstein, Eva Feindler
Cognitive Behavioral Therapy:
ART-Anger Control Training
Eva Feindler PhD
• 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 - Skillstreaming
Barry Goldstein PhD
•
•
•
•
•
•
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
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
Cognitive Behavioral
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
• 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
Parenting Program
Adolescent Transitions Program
• Outcomes
– Reduces Negative Parent/Child Interaction
– Decreases Antisocial Behavior at School
– Reduces Smoking at 1 Year Follow Up
Adolescent Transitions Program
• School-based Universal, Selected, Indicated
• Twelve Group and Four Family Meetings
• Social Learning Theory – Skill Development
Parent Training
Adolescent Transitions Program
• Outcomes
• Reduces Negative Parent/Child Interaction
• Decreases Antisocial Behavior at School
• Reduces Smoking at 1 Yr Follow Up
• Thomas Dishion PhD, Kate Kavanaugh PhD – University of Oregon
Parenting Programs
Strengthening Families Program
•
•
•
•
Parenting Program
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
Parenting Program
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
• Karol Kumpfer PhD – University of Utah
Substance Abuse
Treatment Motivational Enhancement
Therapy and Cognitive Behavioral Therapy
for Adolescent Cannabis Users: 5 or 7
Sessions,
• Substance abuse treatment protocol tested with
Cannibis abusers but can be used with other SUD.
• These brief treatments can be transposed easily to the
mental health setting.
Substance Abuse Treatment
•
•
•
•
•
•
Manualized treatment protocols
Five or seven sessions
Combines motivational enhancement and cognitive behavioral treatment.
Sampl, S., & Kadden, R. (Free)
Cannabis Youth Treatment Series
SAMSHA
Substance Abuse Treatment
Motivational Interviewing
• Engagement in Treatment -- Readiness for Change
• Based on a theory of stages of change. Motivational Interviewing is
a directive, client centered counseling style for eliciting behavior
change by helping clients to explore and resolve ambivalence. It is
focused and goal directed.
– Stage One—Pre-contemplation Stage—Not thinking about
making a change
– Stage Two- Contemplation State- Unsure about what to do—
often want to change, but want to stay the same
– Stage Three- Action Stage—People begin to implement their
“change plans”
– State Four- Maintenance Stage-People try to sustain the
changes.
Out of Home Care
Multidimensional Treatment
Foster Care
• Targets Adolescents with Delinquency and their Families.
• Alternative to Group Home Placement and Incarceration
Evidence-based Practices – Out-ofHome Care
Multidimensional Treatment Foster Care
Outcomes
• Fewer arrests (less than half the rate of the control
group)
• Fewer days incarceration and group home placement
• Greater completion of treatment - fewer AWOLs
• Improved school performance
• Less hard drug use
• Improved emotional well being
Evidence-based Practices – Out-ofHome Care
Multidimensional Treatment Foster Care
• Youth is placed in a Therapeutic Foster Home
– One youth per home
– 24/7 support for foster parent and natural parents
• Youth receive weekly individual therapy with focus on
developing effective:
– Problem solving skills-Social skills-Emotional regulation
skills
• Foster Parent and Team Meetings Weekly
• Parent Daily Report – Child Behavior / Foster Parent Stress
• Parents attend weekly family therapy with focus on effective
parenting and family management
Evidence-based Practices –
Multidimensional Treatment
Foster Care
• Public school, with daily monitoring of attendance
and performance
• Strict Adherence to Roles: Foster Parent, Care
Manager, Individual Therapist, Family Therapist,
Skills Trainer, Recruiter/Caller
• Patricia Chamberlain PhD – Oregon Social Learning
Center
Section Five:
Recommendations
Recommendations
•
•
•
Assessment format that includes standardized SUD
instruments, screening & comprehensive when
indicated:
•
GAIN-Short Form
•
Adolescent Diagnostic Interview (ADI)
Family Treatment Programs
•
Integrated Community Treatment
•
Multidimensional Family Treatment
•
Multisystemic Therapy
Preventive Program
•
Strengthening Families
Recommendations
• Out of Home Care
• Multidimensional Treatment Foster Care
• Social Skills Training
• Aggression Replacement Therapy
• Substance Abuse Treatment
• Motivational Interviewing
• Motivational Enhancement and Cognitive
Behavioral Therapy (5 or 7 sessions)
• Trauma Treatment Therapy
• Seeking Safety
Websites:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
http://www.nida.nih.gov/
www.kap.samhsa.gov The Cannabis Youth Treatment Protocol
http://coce.samhsa.gov/products
http://www.healthfinder.gov
http://www.kap.samhsa.gov/products/manuals/tips/index
http://www.ndri.org/search/search.
http://www.ncmhjj.com/resource_kit
http://mentalhealth.samhsa.gov/publications/allpubs
http://www.ncbi.nlm.nih.gov/books
http://www.vera.org/publications/publications
http://www.motivationalinterview.org/
http://www.mid-attc.org/
http://www.seekingsaftey.org
http://www.unlv.edu/centers/achievement
http://www.fftinc.com
http://www. Motivational.interview.org
Co-Occurring Disorders, Best
Practice and Adolescents
• Please if you have any questions regarding this
webcast please email mlovato@cimh.org
• To unmute your phones by pressing #6 once the
training has ended. Thank you for your
participation.
• All questions will be answered at the end, so
please email Maria Lovato at mlovato@cimh.org
The End