Co-Occurring Disorders, Best Practices and Adolescents Webcast

Transcription

1 Co-Occurring Disorders, Best Practices and Adolescents Webcast Thursday June 26, :00 AM 12:30 PM Dial-in Number: (866) Conference Code: For technical assistance please contact Maria Lovato, MBA at or (916)

2 Co-Occurring Disorders, Best Practice and Adolescents Please if you have any questions regarding this webcast please or you can call 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 Maria Lovato at with all your questions.

3 Co-Occurring Disorders Best Practices and Adolescent Double Trouble - Early Mary Jane Alumbaugh, Ph.D

4 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 Co- Occurring Disorders Section Four: Evidence Based Mental Health Treatments for Adolescents with Co-Occurring Disorders Section Five: Recommendations

5 Section One: Co-Occurring Mental Health and Substance Use Disorders in Adolescents: The Research

6 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)

7 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

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9 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)

10 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 (18-35%) Both types of disorder (38-65%)

11 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)

12 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

13 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

14 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

15 Section Two: Systems Issues - Parallel Treatment Systems and Colliding Cultures

16 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

17 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

18 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

19 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

20 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

21 Section Three: Assessment and Treatment of Co-Occurring Disorders: Integrating Cultures

22 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)

23 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

24 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

25 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

26 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.

27 Assessment Instruments General Checklists: Achenbach YSR Revised Behavior Problem Checklist. Youth Outcome Questionnaire YOQ Youth Outcome Questionnaire Self Report YOQ- SR

28 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

29 Section Four: Evidence Based Mental Health Treatments for Adolescents with Co- Occurring Disorders

30 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

31 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

32 Evidenced Based Treatments for Co-Occurring Disorders Family Treatments Cognitive Behavioral Treatments Parenting Programs Substance Abuse Treatment Out of Home Placement

33 Evidenced Based Mental Health Treatments that have demonstrated success with Co- Occurring Disorders Adolescent Transitions Program Aggression Replacement Treatment (ART) Brief Strategic Family Therapy (BFST) Family Behavior Therapy (FBT) Functional Family Therapy (FFT)

34 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)

35 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

36 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 years of iterative research development

37 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

38 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

39 Brief Strategic Family Therapy Severe Conduct Disorder and Substance Abuse Sessions Jose Szapocznik PhD - Spanish Family Guidance Center, Center for Family Studies, University of Miami

40 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

41 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.

42 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.

43 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

44 Family Behavior Therapy Bradley Donohue, Ph.D. Associate Professor University of Nevada, Las Vegas

45 Family Therapy Functional Family Therapy (FFT) Targets Youth 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

46 Functional Family Therapy Low drop out from treatment Reduces family conflict Improves family communication Improves parenting

47 Functional Family Therapy Therapist assumes responsibility for Treatment Phases Engagement Motivation Assessment Change behavior Generalize

48 Functional Family Therapy Average duration of service is 3-4 months 8-30 sessions of direct service Full time therapist will serve families at one time Site certification and training James Alexander PhD University of Utah

49 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.

50 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

51 Integrated Treatment for Co- Occurring 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.

52 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

53 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

54 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

55 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

56 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

57 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.

58 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 henggesw@musc.edu

59 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

60 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

61 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

62 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

63 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

64 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.

65 Seeking Safety Population Adolescents ages Young adults ages Adults ages Male and Female Races: American Indian/Alaska Native, Asian American, Black or African American, Hispanic or Latino, Race/ethnicity unspecified, White.

66 Seeking Safety Outcomes Reduces Substance abuse Improved trauma-related symptoms Improved psychopathology Increased treatment retention

67 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 Lnajavits@hms.harvard.edu

68 Parenting Program Adolescent Transitions Program Outcomes Reduces Negative Parent/Child Interaction Decreases Antisocial Behavior at School Reduces Smoking at 1 Year Follow Up

69 Adolescent Transitions Program School-based Universal, Selected, Indicated Twelve Group and Four Family Meetings Social Learning Theory Skill Development

70 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

71 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

72 Parenting Program Strengthening Families Program Adapted: African American, Asian/Pacific Islander, Hispanic, Native American, Rural Families Adapted to 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

73 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.

74 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

75 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.

76 Out of Home Care Multidimensional Treatment Foster Care Targets Adolescents with Delinquency and their Families. Alternative to Group Home Placement and Incarceration

77 Evidence-based Practices Out-of- Home 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

78 Evidence-based Practices Out-of- Home 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

79 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

80 Section Five: Recommendations

81 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

82 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

83 Websites: The Cannabis Youth Treatment Protocol Motivational.interview.org

84 Co-Occurring Disorders, Best Practice and Adolescents Please if you have any questions regarding this webcast please 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 Maria Lovato at

85 The End