STAR

1. STAR Substance Treatment & Recovery For DD Clients

2. STAR What Is it? • Chemical Dependency treatment within Seattle Mental Health, specifically for adults with developmental disabilities.

3. STAR Who gets to be a STAR? • King County Resident • Medicaid, DDD Enrolled (Department of Developmental Disabilities) • Substance Abuse Issues • 18 or older Additional mental health services are available.

4. Definition of Developmental Disability • A condition defined as mental retardation, cerebral palsy, epilepsy, autism, or another neurological or other condition (functional impairments, IQ score) that originates before 18 years of age and is expected to continue indefinitely. • W.A.C. 388-823: Determination of a developmental disability (eligibility)

5. Barriers to Treatment • Cognitive Delay • Poor communication/ interpersonal skills • Limited Peer network • Limited vocational skills • Restricted activities and exposure to world • Medical concerns TIP 29 CSAT

6. We see what we expect

7. Misconceptions/Principles • DD clients don’t use drugs • DD clients don’t have sex • DD clients don’t benefit from treatment • Maladaptive behavior rarely occurs alone and often the less difficult to manage behavior will be ignored. • The clinical interview alone is rarely diagnostic.

8. Reasons for use in DD clients • Most behaviors are done for a good reason • Acceptance into a social group • Social control –operant conditioning • Communication – attention, fear, love • Modulation of pain • Modulation of mood • Addiction/dependence

9. How to Accommodate • Simplification • Language • Activities • Developmental Level • Directive methods • Flexible methods • Involve others

10. Creating a Service Design • Maximize safety • Create and support positive self-view • Social skill development • Do not punish behaviors

11. Service Delivery • Accommodation does not mean giving special preferences - it does mean reducing barriers to equal participation in the program. People with coexisting disabilities are harmed by a provider's complicity in their avoidance of all challenges to chemical dependency. • Cross-training between CD treatment providers and agencies that work with people with disabilities, including vocational rehabilitation (VR), medical, and other professional specialists on specific disabilities, disability service providers, and disability education and advocacy organizations. • When treatment teams make the effort to accommodate individuals with coexisting disabilities, the quality of care improves for all clients. • All clients can get more out of treatment that is individualized.

12. Service Co-ordination Coordination with an agency providing case management services for people with disabilities should be a priority if those services are not provided by the substance use disorder treatment program. People with both a substance use disorder and a coexisting disability may need assistance and individualized accommodations to: • Escape from abusive situations • Learn to protect themselves from victimization • Find volunteer work or other means of gaining a sense of productivity • Develop prevocational skills such as basic grooming, dressing appropriately, using public transportation, and cooking • Learn social skills that may be missing because of both substance use disorders and disability-related problems • Learn to engage in healthy recreation • Become educated about their legal rights to accessible environments and services as well as employment • Obtain financial benefits to which they are entitled • Build new peer networks TIP 29 CSAT

13. STAR STAR services include: • Individualized stabilization services • CD assessment • CD treatment tailored to the client’s cognitive needs • Access to a wide range of fun, informative groups & therapeutic activities • Team & Case Management Support Services (Guardians, Parents, Care Providers, DDD CW, PCP) • Clients with qualifying mental health issues will be offered CNP (Community Networks Program) services - intensive case management • Psychiatric/Med management • 24/7 Crisis Services

14. STAR Groups Tuesday • 12:00 PM BASKETBALL • 2:00 PM POSITIVE LIFE • 3:00 PM SOCCER Wednesday • 2:00 PM EDUCATION/SKILLS BUILDING Thursday • 1:00 PM BUTT OUT (Smoking Cessation) • 2:00 PM EDUCATION/SKILLS BUILDING Friday • 10:00 AM MUSIC GROUP • 11:00 AM DRAMA/ROLE PLAYING • 1:00 PM BUTT OUT • 2:00 PM SOCCER

15. Groups • Include the use of visual cues, mixed media • Repetition of major points • Expressive therapy, or the practice of using movement to express feelings • Role-playing works well for persons with developmental disabilities-the process of playing a role themselves helps them to internalize it. (TIP 29 CSAT) • Games- ie. Recovery Pictionary, hangman • Music • BBQ’s – end of group cycle celebration - give each client a responsibility • Outings as rewards and as regular structured programming ie. sports events, zoo, aquarium, IMAX films • Art projects

16. Case Presentations • Dolly (Patrick) • Eric (Norman) • Gordo (Julie)

17. Dolly • Dolly: 44 y.o. female with long history of drug/alcohol abuse and dependence. Mild MR with prevalent Axis II behavior issues. Mental Health dx is Bipolar I-Mixed. • Over 300 police contacts and about 160 or so arrests. Multiple infractions in different counties. • Drug of choice is marijuana, but also developed a taste for crack. Drinks moderate amounts of alcohol.

18. Dead Man Walking • In jail on possession charges • Released to streets • Visits SMH and/or mom for money, clothes etc • Hits the streets, runs crack for dealers, gets stoned • Gets arrested for possession • Loops over and over

19. Safety • Legal • Behavior • Basic Needs/Self-Care • Community Living/Recreational • Interpersonal/Social • Productivity • Physical/Medical • Family • Emotional/Psychological • Spiritual/Cultural • Cognitive

20. STAR • Unique needs • Assessment changes (erik??) • Membership benefits

21. Underlying Affective Illness Affective Chemical due to Illness Dependency CD issues

22. The Underpinnings: Developmental abnormalities predispose to Affect Disorders and potential for Addiction. Normal Body and Brain Development is: • Controlled by multiple systems “Attachment is the beginning.” (biological and social) • Responsive to/dependent on experiences (which cannot happen with inadequate attachment chemistry or inadequate caregiver) • Dependent on age/stage • ( critical periods) • Modifiable throughout life ( neuroplastic) • Normally fluctuate in a healthy mixed mood or well modulated shifting mood (bipolar pattern?) affected by circadian rhythm, seasonal variation. This becomes extreme with inadequate synapses +/- trauma in the Developmentally Disabled. • Drugs of abuse replicate positive attachment chemistry, but damage synapses further. • The most common damage is Bipolar Disorder.

23. There are critical times when negative experiences are more likely to have serious & sustained effects • Exposure to trauma, abuse, & neglect can interfere with brain development at any age, but most severe at younger ages. • Quality of care & security of attachment affect capacity for empathy, emotional regulation, & behavior control and therefore protect against the potential damage of poorly timed trauma. • Developmentally delayed individuals are often lacking in attachment related brain structure ( synaptic connectivity) and/or chemistry, therefore prone to attachment disorders, PTSD, and disinhibition.

25. Ghaemi, Ko, Goodwin Can J Psychiatry 2002 (website link) Bipolar “Soft Signs” • Fam Hx Bipolar • Hyperthymic Personality • Onset < Age 25 • Repeated Episodes • Depressions “Atypical” • Brief Episodes • Psychosis • Post-partum Depression • 3 or More Antidepressants • Loss of Response • Hypomania on AD’s

26. Differential Diagnosis:What else looks like bipolar disorder? • Mood: thyroid, normal • Attention: sleep deprivation, ADHD • Anxiety: Generalized Anxiety, PTSD, all • Substance Abuse: uppers, downers • Personality Disorder: Cluster B (dramatic) • Psychosis: schizophrenia, substance use • Delirium: medical illness, medications Think Treatment Mimic? Comorbid? Component?

27. TREATMENT? • Default should be mood stabilizers, not antidepressants. • Mood stabilizers are neuroplastic and neuroprotetive, and anti kindling agents. • Antidepressants can induce mania or rapid cycling, whereas mood stabilizers rarely do so. • Mood stabilizers are helpful in addressing Substance withdrawal, so may also reduce unpleasant symptoms and enhance recovery. • Direct and indirect regulation of GABA without substituting another addictive substance.

28. STAR Contact Us Schedule an intake: SMH Access/Admission’s office @ 206-302-2300. 2 SMH locations - Capital Hill & Tukwila STAR assessment & enrollment will usually occur within a week. Urgent care is offered on an as needed basis. In a crisis? SMH DD Crisis line at 1-888-435-7056 Client contact information will initiate a follow up within 72 hours. If you would like to know more about STAR services please contact • Rick Tabor at 206-302-2372 • David O’Neal 206.302.2370

29. QUESTIONS??? • Meredith A. Fine, MD • Community Network Program • Sound Mental Health • meredithf@smh.org