Treating Adolescents with Co-Occurring Traumatic Stress and Substance Abuse Problems: Part One

1. Treating Adolescents with Co-Occurring Traumatic Stress and Substance Abuse Problems: Part One

2. This presentation is a result of collaboration between the members of the Adolescent Trauma and Substance Abuse Committee, part of the National Child Traumatic Stress Network.Many Thanks to La Familia and especially to:

3. Who Are We? A little about me� Socio-metric Group Introductions A little about each of you� Your name and why you are here: Where you work and your position, Your interest in adolescents, One thing you are hoping to get from today�s workshop.

4. Time to set up some appointments! Find your �Calendar Page Handout.� You need to schedule yourself for some appointments today! Please mix around the room and fill out your appointment sheets by exchanging names with someone you don�t know for each empty time space. You will meet with them later in the day, so be sure you each block out the same times!

5. Presentation Outline Morning: Surveying the Environment Description of General Issues/Your Issues Scope of the Problems/Your Problems List Challenges for System Change/Your Challenges Afternoon: Using/Adapting Tools for Success Assessment Measures Toolkit for Change Effective Treatment Interventions

6. National Child Traumatic Stress Networkwww.nctsn.org Collaboration of academic and community-based service centers aiming to raise the standard of care and increase access to services for traumatized children in the US. 2001 Congressional mandate to address childhood trauma in the U.S. Funded by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA) The NCTSN Core Data Set is a data collection effort across participating NCTSN centers, utilizing a web-based data entry system. This effort represents the first time that child trauma data has been collected in a formalized way across a diverse range of treatment centers, and it helps NCTSN meet its mission to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. The Core Data Set includes a standardized set of domains and measures, including client demographics and history, service utilization, and mental health outcomes.The NCTSN Core Data Set is a data collection effort across participating NCTSN centers, utilizing a web-based data entry system. This effort represents the first time that child trauma data has been collected in a formalized way across a diverse range of treatment centers, and it helps NCTSN meet its mission to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. The Core Data Set includes a standardized set of domains and measures, including client demographics and history, service utilization, and mental health outcomes.

7. National Child Traumatic Stress Network (NCTSN) Established the NCTSN structure: 1. A National Center to collect data and direct the Network (UCLA and Duke Cooperative) 2. Education and Service Sites Disseminate Evidence Based Practices 3. Community Treatment Sites Collect data and implement evidence based practices

8. NCTSN Mission: To raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. Integrate mental health care and trauma treatment for children and youth Integrate substance abuse treatment and trauma treatment for youth

9. First Steps to Common Understanding Consistent perspectives (what lens do we look through?) Victims vs violators Strengths vs problems Diagnoses vs impressions Common language (what words do we use in our work?) Co-morbidity vs co-occurring disorders Dysregulation vs deviant behavior Trauma/mental health/substance treatment terms These are the things we need to teach to others, so that we can all talk in the same framework of understanding. MH: diagnoses needed for billing, long term pathology, PTSD, Anxiety, Depression, SA: diagnoses needed for billing, expectation of recovery based on abstinence, relapse common, bio-psycho-social-spiritual component, ASAM Trauma: treatment based on coping with symptoms, no dsm diagnosis, symptom reduction constitutes cureThese are the things we need to teach to others, so that we can all talk in the same framework of understanding. MH: diagnoses needed for billing, long term pathology, PTSD, Anxiety, Depression, SA: diagnoses needed for billing, expectation of recovery based on abstinence, relapse common, bio-psycho-social-spiritual component, ASAM Trauma: treatment based on coping with symptoms, no dsm diagnosis, symptom reduction constitutes cure

10. Understanding the General Issues Related to Traumatic Stress in Adolescents

11. Trauma is a physical and/or emotional condition caused by environmental factors that result in physical and/or mental injuries affecting health. �Misidentified or misdiagnosed trauma-related symptoms interfere in seeking help, hamper engagement in treatment, lead to early drop-out and make relapse more likely� (Finkelstein, et.al. 2004)

12. Types of traumatic events Physical, sexual, and emotional abuse Interpersonal violence and victimization Community violence Natural disasters/terrorism Traumatic loss and grief Medical trauma Chronic and Complex trauma Other events processed as trauma (witnessed) Defining termsDefining terms

13. The body�s acute response to trauma Mental response In times of danger, the usual mental mechanisms that help us make everyday decisions are temporarily shut down. This response enables us to make more primitive responses and take quick action rather than to think carefully about the situation at hand. SURVIVAL MODE!

14. Physical sensations When the perceived threat is gone, systems are designed to return to normal function via the relaxation response, but in our times of chronic, this often doesn�t happen enough, causing damage to the body. When the perceived threat is gone, systems are designed to return to normal function via the relaxation response, but in our times of chronic, this often doesn�t happen enough, causing damage to the body.

15. The body�s acute response to trauma Fight, flight, or freeze response: The body�s reaction to perceived threat or danger. Fight � fighting off an attacker Flight � running away from danger Freeze � going �dead� such as during rape Dissociation � out of body experiences Adrenalin and cortisol are released to give the body a burst of energy and strength Fight or flight response: The body�s reaction to perceived threat or danger. Certain hormones (adrenalin & cortisol) are released, speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing various other autonomic nervous functions, giving the body a burst of energy and strength. Originally named for its ability to enable us to physically fight or run away when faced with danger, it�s now activated in situations where neither response is appropriate, like in traffic or during a stressful day at work. Fight or flight response: The body�s reaction to perceived threat or danger. Certain hormones (adrenalin & cortisol) are released, speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing various other autonomic nervous functions, giving the body a burst of energy and strength. Originally named for its ability to enable us to physically fight or run away when faced with danger, it�s now activated in situations where neither response is appropriate, like in traffic or during a stressful day at work.

16. Trauma Reminders Linger The body�s alarm reaction can be triggered by situations that remind us of the trauma, even if we are no longer in a truly dangerous or threatening situation. These trauma reminders, or triggers might include situations that have something in common with the traumatic event, but they could also include thoughts or memories about what happened. Even when we are no longer in danger, our body�s alarm response could become activated as if we were experiencing the trauma all over again.

17. Post Traumatic Stress Disorder Re-Experiencing the traumatic event through intrusive thoughts or dreams of the event, or intense psychological distress when exposed to reminders of the event Avoidance of thoughts, feelings, images, or locations that remind the adolescent of or are associated with the traumatic event Increased arousal such as hyper-vigilance, irritability, exaggerated startle response, and sleeping difficulties

18. Additional problems associated with trauma exposure Anxiety and mood problems Negative perceptions about oneself and others Avoidance activities, such as dissociation, tension reduction activities (binging/purging, self mutilation) Somatic Complaints Interpersonal difficulties Substance abuse

19. Trauma in 2 Dimensions

20. Adolescent Development How do child development issues relate to trauma? What is �normal� development and what is �unusual� development? What areas of a teen�s life may be affected?

21. Impacts of Trauma on Teens On arousal On cognition and memory On emotions On identity and sense of self On relationships On dating and sexual development On goals and achievements

22. Adolescent Brain Development Myth that brain development stops at early childhood has been discredited Patterns of brain development extend into early adult years, age 24-25 at least Teenage brain has the potential to grow and heal through effective treatment techniques, family support, and a cessation of stressors

23. Understanding Substance Abuse Problems in Adolescents

24. Substance Abuse Is Often Hidden The earlier the onset age of drinking, the greater the risk for lifetime alcohol abuse or dependence (DeWit, Adlaf, Offord, & Ogborne, 2000). Trauma and substance abuse often co-occur. Mental health diagnoses may follow prolonged untreated trauma and substance use.

25. Definition of Addiction Addiction is a chronic, episodic, progressive disease of the brain and body characterized by periods of substance use followed by periods of abstinence. It may involve physical and/or psychological dependence on continued use, with negative impacts over a variety of areas of life. Recovery from the condition is possible, but it requires ongoing care and lifestyle change. --National Institute of Drug Abuse www.nida.nih.gov www.nida.nih.gov

26. Abuse and Dependence Substance Abuse: Use of drugs in a manner that is illegal or harmful to the individual and causes significant adverse consequences such as accidents or injuries, blackouts, legal problems, and risky sexual behavior. Substance Dependence: Continued substance abuse despite significant substance-related problems Usually includes tolerance (requiring higher doses to achieve the same effect) and withdrawal (symptoms experienced when use of the drug is discontinued)

27. Substance Use There is no �one-size fits all� approach�substance using families tend to be unique, and it usually takes longer to make change in these families. Most common substances: Alcohol Prescription medications (often misused) Marijuana Other illegal drugs And don�t forget to ask about tobacco and gambling�often these are co-addictions! Lots of information on the NCTSN website, such as: �Alcoholism is a devastating disease, affecting not only the alcoholic but also loved ones who cope with its effects on a daily basis. It is estimated that one out of every four children is exposed to some form of alcohol abuse or alcoholism in the family before the age of 18.� And the: National Association for Children of Alcoholics 11426 Rockville Pike, Suite 301 Rockville, MD 20852 NaCOA.net �Core Competencies for Social Workers in Addressing the Needs of Children of Alcohol and Drug Dependent Parents� Lots of information on the NCTSN website, such as: �Alcoholism is a devastating disease, affecting not only the alcoholic but also loved ones who cope with its effects on a daily basis. It is estimated that one out of every four children is exposed to some form of alcohol abuse or alcoholism in the family before the age of 18.� And the: National Association for Children of Alcoholics 11426 Rockville Pike, Suite 301 Rockville, MD 20852 NaCOA.net �Core Competencies for Social Workers in Addressing the Needs of Children of Alcohol and Drug Dependent Parents�

28. Impairment A hallmark of Substance Use Disorders in adolescents is impairment in psychosocial & academic functioning (Martin & Winters, 1998) Can include family conflict or dysfunction Interpersonal conflict Academic Failure

29. Triggers and Cravings A �trigger� is a stimulus which has been repeatedly associated with the preparation for, anticipation of or the use of drugs and/or alcohol. These stimuli include people, things, places, times of day, and emotional states. Substance use �craving� refers to the very strong desire for a psychoactive substance or for the intoxicating effects of that substance. Cravings include thoughts (about the urge to use), physical symptoms (heart palpitations) and behaviors (pacing) In the substance abuse treatment field, it is important to understand the nature of triggers and cravings. Because activate the �pleasure center� of the brain, there are certain strong associations made between the external or internal situations (triggers) that elicit thoughts of or intense desires for the drug (cravings) In the substance abuse treatment field, it is important to understand the nature of triggers and cravings. Because activate the �pleasure center� of the brain, there are certain strong associations made between the external or internal situations (triggers) that elicit thoughts of or intense desires for the drug (cravings)

30. Are Teen�s Really Addicted? Some are, but many who use substances do not meet the NIDA definition for addiction. The majority of teens who use substances quit their use with no formal treatment, either before adulthood or in early adulthood. Evidence Based Practices for adults often do not work well with teens! But neither do many traditional interventions! Outdoor/challenge programs, 12 step meetings, scare tactics, etc. rarely workOutdoor/challenge programs, 12 step meetings, scare tactics, etc. rarely work

31. Time for our first appointment! Check your Calendar Page and find your first appointment partner. Move around (switch chairs) so that you may meet with them for the next 8-10 minutes. Discuss the questions on the following slide. At the end of this time, we will take a morning break!

32. What are your experiences working with this population? Direct services with youth in schools or clinics? Administrative challenges in service systems? Corrections contact with youth? Family work? Recreational supervision, or employment training, or health care? HOW DO TRAUMATIZED YOUTH ACT? HOW DO SUBSTANCE USING YOUTH ACT? HOW DO THEIR FAMILIES RESPOND?

33. Morning Break 10-15 minutes

34. The connection between trauma and substance abuse

35. NCTSN Core Data Set Findings Summary Youth with co-occurring substance abuse problems and trauma exposure were more likely to meet clinical severity criteria using the UCLA PTSD-RI and the TSCC, compared to youth with trauma only. Co-occurring youth had higher Total and Externalizing CBCL scores. The percentage of adolescents with problems according to the clinician-rated �Indicators of Severity� scale was significantly greater among co-occurring youth across most domains. A higher proportion of co-occurring youth had been engaged with several service systems, including probation, child welfare, day treatment, case management, in home services, school counselor, and self help.

36. Rates of traumatic stress and substance abuse problems among adolescents High prevalence in adolescents Lifetime substance abuse rates (10-32%) Younger ages of onset and initiation Adolescents are at risk for interpersonal violence and victimization 25% of children and adolescents will experience a traumatic event by age 16 Rates of SUD-PTSD comorbidity- 3.6% - 47% Traumatic stress and substance abuse are common problems in adolescents. However, there is little coordination between mental health and substance abuse service systems. Traumatic stress and substance abuse are common problems in adolescents. However, there is little coordination between mental health and substance abuse service systems.

37. Prevalence of trauma and substance abuse in youth Traumatic stress and substance abuse problems frequently co-occur among adolescents Epidemiological studies show the overall rates of co-occurrence of PTSD and substance abuse can range from 13.5% to 29.7% 1 However, the co-occurrence is even greater in treatment settings, with rates highest among females: Lifetime prevalence rates of trauma exposure: 71-80% 2, 3. Lifetime prevalence rates of PTSD 24.3% -45.3% 2 Current prevalence rates of PTSD: 14%- 40.0% 2, 4

38. Traumatic stress and substance abuse Adolescents who have experienced a traumatic event may turn to substances in efforts to cope with their distress, as a way to numb their emotions Substance using youth engage in risky activities that can also lead to experiencing traumatic events, and they may be less able to cope

39. Which came first?

40. Does it matter?

41. Why are the risks greater for adolescents? Interference with many physiological processes that can destabilize mood (depression, aggression, violence, and suicide). Decision-making abilities are not fully developed Since the teenage brain is still growing and changing, alcohol and drug use at an early age have a greater potential to disrupt normal brain development The most affected brain regions include 1) the hippocampus, which is related to learning and memory, and 2) the prefrontal cortex, responsible for critical thinking, planning, impulse control, and emotional regulation (DeBellis, Narasimhan, Thatcher, Keshavan, Soloff, & Clark, 2005; Nagel, Schweinsburg, Phan, & Tapert, 2005; Zeigler, Wang, Yoast, Dickinson, McCaffree, Robinowitz, et al., 2005). Drug and alcohol use interferes with many physiological processes and can destabilize mood. Thus, adolescent substance use is associated with higher rates of depression, aggression, violence, and suicide (Diamond, Panichelli-Mindel, Shera, Dennis, Tims, & Ungemack, 2006). Because teens� decision-making abilities are not fully developed, they are more likely to engage in risky behavior such as driving while under the influence (Giaconia, Reinherz, Paradis, & Stashwick, 2003). The earlier the onset age of drinking, the greater the risk for lifetime alcohol abuse or dependence (DeWit, Adlaf, Offord, & Ogborne, 2000).Since the teenage brain is still growing and changing, alcohol and drug use at an early age have a greater potential to disrupt normal brain development The most affected brain regions include 1) the hippocampus, which is related to learning and memory, and 2) the prefrontal cortex, responsible for critical thinking, planning, impulse control, and emotional regulation (DeBellis, Narasimhan, Thatcher, Keshavan, Soloff, & Clark, 2005; Nagel, Schweinsburg, Phan, & Tapert, 2005; Zeigler, Wang, Yoast, Dickinson, McCaffree, Robinowitz, et al., 2005). Drug and alcohol use interferes with many physiological processes and can destabilize mood. Thus, adolescent substance use is associated with higher rates of depression, aggression, violence, and suicide (Diamond, Panichelli-Mindel, Shera, Dennis, Tims, & Ungemack, 2006). Because teens� decision-making abilities are not fully developed, they are more likely to engage in risky behavior such as driving while under the influence (Giaconia, Reinherz, Paradis, & Stashwick, 2003). The earlier the onset age of drinking, the greater the risk for lifetime alcohol abuse or dependence (DeWit, Adlaf, Offord, & Ogborne, 2000).

42. Common patterns observed in populations with trauma and substance abuse problems To understand that connection further, lets imagine what happens to a traumatized adolescent when she encounters specific triggers. To understand that connection further, lets imagine what happens to a traumatized adolescent when she encounters specific triggers.

43. Pathways to the link between SUD and PTSD in adolescents High risk behaviors - those with SUDs are more likely to experience traumas that result from risky behavior Susceptibility - those with SUDs may have less ability to cope with traumatic events Self medication - develop problems with SUDs to manage PTSD or other negative emotional states (depression/anxiety) There are 3 ways in which PTSD and substance use disorders can be temporally related. Substance use and SUD increase risk for exposure to traumas because substance users may engage in risky behaviors that enhance the likelihood of experiencing traumas For some adolescents (45-66%) SUD s precede onset of traumas (Clark et al 1997; Giaconia et al 2000; Perkonigg et al 2000) Adolescents with SUD are significantly more likely than non-SUD youth to have experienced traumas involving harm to themselves (2-5 times more likely) and traumas that entail witnessing harm to others (3-5 times more likely), traumas that might plausibly result from engaging in risky behavior (Clark et al 1997; Giaconia et al 2000; Perkonigg et al 2000) Direct link between alcohol use and risky behaviors where adolescents may get hurt: Giaconia et al 2000: 75% of adol with lifetime SUD acknowledged that they had been under the influence of alcohol or drugs in situations where it increased their chances of getting hurt.; CDC 2000: risky behaviors associated with use included hitchhiking, walking in unsafe neighborhoods, driving after usung alcohol or drugs Substance use increases the likelihood of developing PTSD following trauma because it interferes with an individual�s ability to cope effectively with the trauma Indirect evidence: After controlling for exposure to trauma, adol with SUD continued to be at greater risk (2 times more likely) for developing PTSD following trauma than their peers without SUD Giaconia 2000. Researchers suggested that extensive psychosocial impairments found in adol with SUDs support the view that youth with SUD may lack the skills needed to cope with trauma and its aftermath. Self medication hypothesis: substance use begins after the onset of traumas or PTSD in an attempt to manage the distressing symptoms associated with traumas or PTSD Partial support: For at least some of the adolescents studied, the onset of SUD followed the onset of trauma (25-76%) and occurred after the onset of PTSD (14-59%) Clark et al 1997; Deykin & Buka 1997; Giaconia et al 2000; Perkonigg et al 2000). There was no direct evidence that this temporal pattern reflected the adolescents attempts to self medicateThere are 3 ways in which PTSD and substance use disorders can be temporally related. Substance use and SUD increase risk for exposure to traumas because substance users may engage in risky behaviors that enhance the likelihood of experiencing traumas For some adolescents (45-66%) SUD s precede onset of traumas (Clark et al 1997; Giaconia et al 2000; Perkonigg et al 2000) Adolescents with SUD are significantly more likely than non-SUD youth to have experienced traumas involving harm to themselves (2-5 times more likely) and traumas that entail witnessing harm to others (3-5 times more likely), traumas that might plausibly result from engaging in risky behavior (Clark et al 1997; Giaconia et al 2000; Perkonigg et al 2000) Direct link between alcohol use and risky behaviors where adolescents may get hurt: Giaconia et al 2000: 75% of adol with lifetime SUD acknowledged that they had been under the influence of alcohol or drugs in situations where it increased their chances of getting hurt.; CDC 2000: risky behaviors associated with use included hitchhiking, walking in unsafe neighborhoods, driving after usung alcohol or drugs Substance use increases the likelihood of developing PTSD following trauma because it interferes with an individual�s ability to cope effectively with the trauma Indirect evidence: After controlling for exposure to trauma, adol with SUD continued to be at greater risk (2 times more likely) for developing PTSD following trauma than their peers without SUD Giaconia 2000. Researchers suggested that extensive psychosocial impairments found in adol with SUDs support the view that youth with SUD may lack the skills needed to cope with trauma and its aftermath. Self medication hypothesis: substance use begins after the onset of traumas or PTSD in an attempt to manage the distressing symptoms associated with traumas or PTSD Partial support: For at least some of the adolescents studied, the onset of SUD followed the onset of trauma (25-76%) and occurred after the onset of PTSD (14-59%) Clark et al 1997; Deykin & Buka 1997; Giaconia et al 2000; Perkonigg et al 2000). There was no direct evidence that this temporal pattern reflected the adolescents attempts to self medicate

44. The role of stress Initiation of use Continuation of use Relapse Stress has often been associated with reasons people give for starting to use drugs and alcohol in the first place, deciding to continue use, or return to unhealthy drug use patterns after a period of abstinence. If we magnify that relationship, imagine how much stronger the connection could be between traumatic stress and substance abuse. Stress has often been associated with reasons people give for starting to use drugs and alcohol in the first place, deciding to continue use, or return to unhealthy drug use patterns after a period of abstinence. If we magnify that relationship, imagine how much stronger the connection could be between traumatic stress and substance abuse.

45. �Impairment� Inability to meet major role obligations Leading to reduced functioning in one or more areas of life Risk taking behavior Increase in the likelihood of legal problems due to possession Exposure to hazardous situations

46. Impact of SUD and PTSD on psychosocial functioning Psychological, physical and social functioning Less life satisfaction, greater anxiety, more health complaints, less social competence (Cark & Kirisci, 1996 ) Poorer self esteem, more interpersonal problems, lower grades (Reinherz, et al., 1993) Role functioning Poorer academic achievement and more school adjustment difficulties (Cark & Kirisci, 1996 ) Poor school performance and course failure (Reinherz, et al., 1993) III. Impact of comorbid SUD-PTSD on Psychosocial functioning Given the rates of comorbidity and the strong link between trauma and substance abuse, we ask ourselves Key questions: Is this comorbidity associated with greater impairments than either disorder alone Specific types of psychosocial impairments associated with this comorbidity PTSD Problems adverse effects in several areas of psychological, physical, and social functioning, including less life satisfaction, greater anxiety, more health complaints, less social competence SUD Problems deficits in role functioning, reflecting poorer academic achievement and more school adjustment difficulties Comorbid SUD PTSD: wider range of impairments than SUD alone, combination of deficits of SUD and PTSD In fact, comorbid trauma and sa adol fare worse in SA tx trials than sa alone (CYT)III. Impact of comorbid SUD-PTSD on Psychosocial functioning Given the rates of comorbidity and the strong link between trauma and substance abuse, we ask ourselves Key questions: Is this comorbidity associated with greater impairments than either disorder alone Specific types of psychosocial impairments associated with this comorbidity PTSD Problems adverse effects in several areas of psychological, physical, and social functioning, including less life satisfaction, greater anxiety, more health complaints, less social competence SUD Problems deficits in role functioning, reflecting poorer academic achievement and more school adjustment difficulties Comorbid SUD PTSD: wider range of impairments than SUD alone, combination of deficits of SUD and PTSD In fact, comorbid trauma and sa adol fare worse in SA tx trials than sa alone (CYT)

47. Impact of comorbid SUD-PTSD on psychosocial functioning III. Impact of comorbid SUD-PTSD on Psychosocial functioning Given the rates of comorbidity and the strong link between trauma and substance abuse, we ask ourselves Key questions: Is this comorbidity associated with greater impairments than either disorder alone Specific types of psychosocial impairments associated with this comorbidity PTSD Problems adverse effects in several areas of psychological, physical, and social functioning, including less life satisfaction, greater anxiety, more health complaints, less social competence SUD Problems deficits in role functioning, reflecting poorer academic achievement and more school adjustment difficulties Comorbid SUD PTSD: wider range of impairments than SUD alone, combination of deficits of SUD and PTSD In fact, comorbid trauma and sa adol fare worse in SA tx trials than sa alone (CYT)III. Impact of comorbid SUD-PTSD on Psychosocial functioning Given the rates of comorbidity and the strong link between trauma and substance abuse, we ask ourselves Key questions: Is this comorbidity associated with greater impairments than either disorder alone Specific types of psychosocial impairments associated with this comorbidity PTSD Problems adverse effects in several areas of psychological, physical, and social functioning, including less life satisfaction, greater anxiety, more health complaints, less social competence SUD Problems deficits in role functioning, reflecting poorer academic achievement and more school adjustment difficulties Comorbid SUD PTSD: wider range of impairments than SUD alone, combination of deficits of SUD and PTSD In fact, comorbid trauma and sa adol fare worse in SA tx trials than sa alone (CYT)

48. The Cycle of Trauma and Substance Abuse Use of substances may cause a host of physical, mental, legal and/or social problems for adolescents while failing to provide any long-term relief from their trauma-related emotional distress. Childhood trauma exposure increases risk for later substance use, criminal activity, other anxiety disorders, etc. Adolescents with SUD�s are at special risk of experiencing traumas most likely to result in PTSD, including violent victimization (physical or sexual assault) and witnessing harm to others. Traumatic stress can cause individuals to experience severe emotional distress, and autonomic arousal. After undergoing even just one traumatic event, many people are no longer the same. In the absence of strong coping skills, it is not surprising that adolescents may turn to substance abuse as a way to manage emotional dysregulation and make maladaptive coping attempts to avoid/mask distress with a substance-induced state. Substance abuse for this population, as with many of the folks with co-occurring psychiatric illnesses, begins as a means to cope, but as we all know, substance use is associated with a lot of problems and is not really going to help with trauma related symptoms, but exacerbate them. Traumatized youth are often part of unstable environments and are likely to continue to experience distress and trauma. Getting involved in substance use also puts them at risk for further exposure, due to involvement with deviant peers, etc So the cycle continues More severe and diverse clinical problems When problems are treated separately, youth are more likely to relapse and revert to previous maladaptive coping strategies.Childhood trauma exposure increases risk for later substance use, criminal activity, other anxiety disorders, etc. Adolescents with SUD�s are at special risk of experiencing traumas most likely to result in PTSD, including violent victimization (physical or sexual assault) and witnessing harm to others. Traumatic stress can cause individuals to experience severe emotional distress, and autonomic arousal. After undergoing even just one traumatic event, many people are no longer the same. In the absence of strong coping skills, it is not surprising that adolescents may turn to substance abuse as a way to manage emotional dysregulation and make maladaptive coping attempts to avoid/mask distress with a substance-induced state. Substance abuse for this population, as with many of the folks with co-occurring psychiatric illnesses, begins as a means to cope, but as we all know, substance use is associated with a lot of problems and is not really going to help with trauma related symptoms, but exacerbate them. Traumatized youth are often part of unstable environments and are likely to continue to experience distress and trauma. Getting involved in substance use also puts them at risk for further exposure, due to involvement with deviant peers, etc So the cycle continues More severe and diverse clinical problems When problems are treated separately, youth are more likely to relapse and revert to previous maladaptive coping strategies.

49. Needs/Barriers of youth with traumatic stress and substance abuse Emotional and behavioral dysregulation Coping deficits Family strain Environmental stress Academic difficulties Health problems Involvement with multiple service systems (juvenile justice, social services, mental health, substance abuse, special education)

50. Shared risk factors for youth substance use and trauma (child abuse & neglect, victimization)

51. Known Protective Factors Individual Positive coping strategies (good decision-making skills, assertiveness, and cognitive mastery) Effective mechanisms in managing temptations Family Strong sense of attachment to parents. Parental attitudes about substance use School Bonding with school Having a strong commitment to doing well There are many known risk and protective factors associated with substance abuse that cut across a number of domains in teenager�s lives. Knowing these factors can help us identify youth in need, provide needed support, and specifically make some of these factors the target of treatmentThere are many known risk and protective factors associated with substance abuse that cut across a number of domains in teenager�s lives. Knowing these factors can help us identify youth in need, provide needed support, and specifically make some of these factors the target of treatment

52. Family Matters: Substance Abuse and The American Family Half of all children (35.6 million) in the U.S. live in a household where a parent or other adult uses tobacco, drinks heavily or uses illicit drugs. 12.7% of children under age 18 (9.2 million) live with a parent or other adult using illicit drugs. 23.8% of children under age 18 (17 million) live with a parent or other adult who is a binge or heavy drinker. --National Center on Addiction and Substance Abuse at Columbia University (CASA); White Paper, March 2005

53. Helping people in recovery understand the range of possible connections between trauma and substance abuse is a key process in integrated services.� (Finkelstein, et.al, 2004)

54. Treating Traumatized, Substance Using Youth: Our Current System

55. Substance Abuse and Mental Health Fields Systems have traditionally developed independently from one another Systems are evolving and making innovations, and system integration for youth with co-occurring disorders is slowly developing Separate funding streams Different reimbursement rates Unidimensional view of needs Problem-focused vs. youth/family focused

56. Service FragmentationHow did it happen? Funding, training, credentialingFunding, training, credentialing

59. Addressing Trauma and Substance Abuse Needs No Care Access to one Type of Care Sequential Care Parallel Care Coordinated Care Integrated Care The Higher the Severity the greater the need to integrate care

60. �it is the constellation of coordinated interventions � generally several evidence-based interventions used in combination to meet individual client needs, and delivered by the same clinicians working in one setting � that constitutes the evidence-based practice known as integrated treatment for co-occurring disorders.� (Report to congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders, 2002, Pg57)

61. Challenges/Barriers for SA and Public MH fields Not enough resources of even one type of service Not all communities have a continuum of care (Not having anything to integrate) Systems that may not have reimbursement systems that foster the use of evidence-based practices

62. Challenges/BarriersSA and Public MH Field Difficulty retaining staff, training staff Specialty areas do not attract many people Not a great deal of stability in programs or funding Lack of qualifications to use more sophisticated clinical and therapeutic skills (can they address trauma? Substance abuse? )

63. Challenges/Barriers What can SA and MH staff realistically do? The process of becoming trauma-informed takes time and effort Lack of incentives for programs to become more trauma or substance abuse informed Clinicians in each field may know about SA/TS but can�t do much to address both problems: unidimensional view due to system issues

64. Reality Assessment: When information is collected (if collected) programs do not do much with information Substance abuse and community mental health services often do not address issues of trauma Behaviors/needs are not usually seen from a trauma perspective. Mental Health programs may emphasize a medical model

65. Reality Waiting lists Passive referrals (create no change) Parallel care is not a possibility sometimes Ratios of population to Mental Health Professionals or medication prescribers Private Providers are not usually trauma informed

66. Time for Your Second Meeting! Find your second appointment! Working together, you can each make a list of the challenges and barriers you perceive in your current work system. Also, brainstorm some ways to decrease those difficulties, and make a second list of suggestions you could try at work.

67. Ready to Share? Any volunteers who want to share their challenges and the ways they might approach them? Any audience feedback? What sorts of technical assistance might be needed to help this situation? What is one thing that can be done immediately to create change?

68. Ideally Understanding the complexity of needs TS/SA youth present Integrated care in one single trauma and substance abuse-informed system, preferably by one provider or one clinical team Seamless access to a wide array of services including psychiatric care

69. Ideally Ability to guide implementation of evidenced-based practices tailored to the unique needs youth and families Intensive Case Management to coordinate care across multiple systems Closely Coordinated Care in Substance Abuse and Trauma informed systems

70. Recommendations Cross Training In mental health and substance abuse Screening and Assessment tools that identify needs in both areas Focus on Fidelity Access Available Resources Make a decision to become trauma-informed

71. Recommendations Dissemination of Evidence-based practices Fostering a consistent movement towards use of evidence-based practices and trauma information Ability of providers to organize multiple services across multiple systems.

72. Recommendations Becoming Trauma-Informed Trauma as a defining and organizing experience Create an open and collaborative relationship between providers and youth/families, placing priority of their safety, choice and control Integrate understanding of trauma and substance abuse throughout the program in order that staff recognize the multiple and complex interactions Ensure physical and emotional safety Becoming aware of trauma EBT�s and trauma resources Address comprehensive needs

73. Recommendations Give staff the ability to address trauma even if only addressing safety, psycho-education stress-management, etc. Develop Partnerships Integrate available services Increase communication between providers Develop local solutions

74. Progress in the SA Field Developmentally appropriate treatment approaches and materials Manual-guided treatment interventions Improved assessment tools and procedures that include screening for mental health disorders States are now requiring the use of substance abuse �evidence-based� treatment approaches Movement towards addressing co-occurring disorders

75. The Substance Use Treatment System American Society of Addiction Medicine ASAM is an EBP that has helped standardize substance abuse treatment across the nation Standards used at assessment to determine the type of treatment referral Also used during treatment for goal planning and completion, and discharge information

76. Treating Co-Occurring Disorders This is the term used by the substance use system to refer to mental health, trauma, or psychiatric diagnoses that occur together with substance use. These disorders take longer to treat and present additional challenges to either the mental health or substance use treatment systems.

77. Despite progress in our fields, our systems are not always conducive to integration!

79. �Your Mission Should You Choose to Accept�

80. Contact Information Lucy Zammarelli, MA Director of Adolescent and Mental Health Services Willamette Family, Inc. 687 Cheshire Ave. Eugene, OR 97402 lucyz@wfts.org 541-343-2993