Drug and Alcohol Services for Adolescents

1. Drug and Alcohol Services for Adolescents Presented by Howard Dounn Phoenix House. Lake View Terrace

2. SUD Impedes Development in Adolescent Substance Abusers • Coping skills • Social/interpersonal skills • Communication skills • Identity, values consolidation • Affect identification/regulation • Self-efficacy and external locus control • Pro-social network & role models

3. Prevalence • Drug abuse/dependence: 3-9% • Alcohol abuse/dependence: 5-8% • Higher prevalence SUD reported if in juvenile justice system • Higher SUD (60-80%) if psychiatric disorder • Only 1 in 10 with SUD receive treatment, of those that do, only 25% receive enough

4. Methamphetamine Use • methamphetamine use and abuse (MA) is increasing • 1997 - annual use estimated at 2.3% amongst 12th graders – in 2003 risen to 13% • treatment admissions for MA in CA have doubled since 1992-2002, total admissions have only increased 17% • cognitive impairment, auditory hallucinations, psychological dysfunction, and suicidal impulses • chronic methamphetamine use can permanently alter brain & cognitive functioning (exposure & amount)

5. Characteristics of Youth Seeking Treatment for MA in Los Angeles • More whites and Latinos using methamphetamine than other groups • Fastest growth in rates of MA among older adolescent females compared with males • Alcohol and marijuana initiation patterns tended to occur earlier in MA • Teens are coming from drug saturated environments with exposure to parental substance abuse & associations with drug using peers Rawson,Gonzles, Obert,McCann, Brethen 2005

6. Juvenile Offenders 44% meet clinical DSM-IV criteria for substance abuse or dependence (v.7.4%) 27.8% meet criteria for addiction (v. 3.4%) 3.6% receive substance abuse treatment 80% suffer from learning disabilities 75% have mental health disorder “ Criminal Neglect: Substance Abuse, Juvenile Justice & the Children Left Behind” www.casacolumbia.org

7. Adolescent Substance Abuse Treatment Self Family Education

8. Phoenix Academies Modified Therapeutic Communities SAMSHA’s National Registry of Evidence-based Programs Office of Juvenile Justice Delinquency Prevention Model Program Drug Strategies

9. Phoenix Academies • Residential substance abuse treatment model utilizing modified Therapeutic Community Methodology • Based on the view that substance abuse is the manifestation of underlying emotional and developmental disorder • View the community as the method of incremental social learning • On-site accredited high schools in partnership with local education jurisdiction

10. Adolescent Therapeutic Community • Duration of stay (9 to 12 months) • Emphasis on education, social development & recreation • Less confrontational than adult TC – focused on growth and development needs of adolescence • More supervision & evaluation by staff members • Assessment of emotional, psychological & learning disorders • Use of psychotropic medications, as appropriate

11. Adolescent Therapeutic Community • Expanded role of family members • Behavior shaping based on introspection & self- determination & regulation • Expression of appropriate age independence & autonomy supported • Completion of phase objectives with two to three months of orientation; three to six months of primary treatment; and two to three months of re-entry; twelve months of live-out (continuing care)

12. Activities That Promote Change Five primary, distinct, yet overlapping categories of activity: • Behavior Management/Shaping • Emotional / Psychological • Intellectual and Spiritual • Vocational / Survival Skills • Biomedical Management

13. Therapeutic Community: Behavior Shaping Element • Application of Behavior Modification Theory • Rewards for positive behavior. . .Negative consequences. Three to One ratio. . . • Graduated rewards • Artful application of Dissonance Theory can increase outcome of interventions Pre-decision conflict (dissonance) = post decision commitment to the choice

14. A Hierarchy of Behavior Shaping Tools Decrease in Frequency Increase in Severity

15. Therapeutic Community:Emotional/Psychological Element • Encounter Group: Deals with the here and now. Behavior shaping • Static Group: Consistent group of peers and leader; meets over a long period of time throughout treatment experience • Probes and Marathons: Psychodrama etc., Special groups (ACA, Abuse) periodic and as needed. • One-to-One Counseling: Intimacy/Shame/Guilt/Complex Emotions • Family Counseling: Systems Treatment, Couples Counseling

16. Therapeutic Community: Intellectual/Ethical • Formal Learning: School, GED, emphasis on social competencies, basic skills. • Seminars: Great thinkers, great ideas and concepts. • Philosophy – The question of life: • Where do we come from? Why are we here? • What gives life meaning? What are our moral responsibilities? Who are our heroes? • Books: Available and openly referred to and discussed • Society: Norms – Rules – Etiquette - Manners

17. Therapeutic Community Vocational Survival Skills The Context for Lessons are the result of the Social Learning Environment • Work is the primary way we participate in community, in society. • Work as a teaching and learning tool. Value beyond end product. • All tasks have meaning. They are reality based, necessary, created by need and the environmental situation: Kitchen, meal prep, housekeeping • All Tasks include a challenge to learn something. Example: how can work teach compassion?

18. Therapeutic Community Vocational Survival Skills • Move from the simple to the complex. • Emphasis on attitude as a prerequisite for acquiring skill • Reward (hierarchical movement) is dependent on task completion with caring and effort relevant to individual capacity – “Pride and Quality” • Through tasks we explore and develop pro-social behaviors, values, attitudes and ethics.

19. Emotional Cartography • Integration of 12 week structured exploration of emotions • Precedes encounter group work • Preliminary measurement of resident response to emotional competence training includes: • Decrease in emotional confusion • Decrease in impulsivity, inability to focus, etc • Increase in retention

20. Family & Outpatient Services

21. Tasks of the Family Program • Decrease guilt • Increase autonomy • Identify what didn’t work • Learn new skills that might help • Support each other in the struggle to grow

22. Elements of Family Programs • Family Systems Counseling • Define family roles • Identify problem areas • Realign family members in supportive functional relationships • Parent Education • Current, useful information: Substance use, signs and symptoms, common drugs of abuse • Intervention via: didactic information, practice opportunities

23. Elements of Family Programs • Family Association: • Self-help peer support • Skills practice • Support to the program

24. Enhancing Resilience & the “Normal” If we want to help vulnerable youngsters….focus on protective processes that change trajectories from risk to adaptation. Rutter et al 2000; Werner 1993 • incremental growth & development • explore the impact of adversities • decrease negative chain reactions • increase self esteem and self efficacy • open up opportunities – expose to new ideas • connect & use existing community resources Both with adolescents and their guardians.

25. Co-occurring Disorders Are Common In Youth with SUD • anxiety disorders • post traumatic stress disorder • depressive disorders • attention deficit & hyperactivity disorders • attachment disorders • eating disorders • sexual and physical abuse

26. DSM–IV Disorders

27. Co-Occurring Capability and Program Practices • SA/MH screening and assessment • Integrated treatment planning and service • Full service partnerships through age 25 • Youth development and leadership models • Multi-dimensional & multi-disciplinary team • Relapse prevention model of recovery • Culturally sensitive

28. Integrated Treatment of SUD and Comorbidity • Comorbidity is rule not exception • Predictive of poorer treatment outcomes • Most teens not treated concurrently • Treating one disorder doesn’t treat the other • Research and clinical consensus supports integrated treatment

29. Barriers to Integrated Treatment • Funding agencies have not implemented integrated treatment – funding stream & licensing barriers • Critical shortage clinicians w/ experience & training • Exclusion from efficacy trials • little known about interactions drugs/ medications • adolescents first referred to SA treatment • treatment of psychiatric disorder contingent on Successful SUD treatment & stable abstinence prior to pharmacotherapy for comorbidity • Separate funding streams dis-incentive integrated & coordinated care

30. Early Peer-Supported Relapse Prevention & Continuing Care • Strong Transition Phase of Treatment with increased independence and autonomy (Re-Entry Phase) • Emphasize relapse & how to handle it not failure • Develop detailed plan for relapses and intensification of treatment until re-stabilized • Family education and involvement – positive adult mentors • Involve in pro-social activity, incompatible with drug use while in treatment • Establish coordinated continuing care plan for all problem domains which is initiated during active treatment phase • Involve in positively reinforcing; incompatible drug use; positive peers • Maintain contact and establish mechanism for early treatment re-entry when lapses occur

31. client family community organizations program systems Barriers to Treatment for Troubled Youth

32. Fragmented and conflicting mission and goals between referral, funding and oversight agencies

33. Early Engagement • Motivational interviewing • Slower presentation of information • Involve parents/guardians early • Focus on opportunity to correct educational deficits • Build ties to program through big brother/sister • Early intensive case management – weekly contacts with family members & probation from beginning • Stay in contact with family and probation officers if drop out occurs (encourage return to treatment) • Parent orientation and education • Assessment-assessment-assessment

34. Phoenix House Fashion Awards