Co-occurring Substance Use and Mental Disorders in Adolescents

1. Co-occurring Substance Use and Mental Disorders in Adolescents Integrating Approaches for Assessment and Treatment of the Individual Young Person

2. Course Outline • Introduction • Brief Overview of Co-Occurring Disorders • Framework for Integrated Treatment • Adolescent Developmental Issues • Conducting Integrated, Comprehensive Assessment • Substance Use Disorders and their relationship to co-occurring disorders • Mental Health Disorders and their relationship to co-occurring disorders

3. Course Outline cont. • Evidence-Based Strategies • Cross-System Collaboration

4. Overall Course Objectives • Create, stimulate, and facilitate an ongoing cross-system and stakeholder dialogue regarding adolescent co-occurring disorders • Identify both current evidence-based treatments for CODs and promising alternative therapeutic strategies. • List core program elements needed to provide effective integrated interventions.

5. Objectives, con’t • Review the uniqueness of the adolescent developmental process and differentiate it from that of adults • Examine possible relationships between SUD and other mental disorders. • Explore integrated and collaborative treatment approaches for co-occurring disorders. • Identify barriers and solutions for systems change.

6. Module 1 Brief Overview of Co-Occurring Disorders and Adolescents

7. Goal Provide information to support growing understanding about the nature of co-occurring disorders

8. Objectives • Discuss the association between substance abuse and psychiatric illness. • Describe general statistics and trends among the adolescent population.

9. Evolving Field of Co-Occurring Disorders (SAMHSA, TIP 42) • Early association between depression and substance abuse • Growing evidence of links and impact on course of illness • Growing evidence that substance abuse treatment can be beneficial

10. Evolving - con’t • Co-Occurring • Replaces dual diagnosis • New Models and Strategies • Physical Health Integration • Recovery Oriented Systems of Care

11. Adolescents with SUD. . .(Meyers et al) • Are largely undiagnosed • Are distributed across diverse health & social service systems • Have been adjudicated delinquent; • Have histories of child abuse, neglect and sexual abuse; • Have high co-morbidity with psychiatric conditions;

12. Facts about Co-Occurring Disorders – con’t • 43% receiving mental health services had been diagnosed with a co-occurring SUD. • CMHS (2001)national health services study • Among 12-17 year olds who had major depressive episode in past year, 38% had used illicit drugs • National Survey on Drug Use and Health, 2005 • 62% of males and 82% of females entering SUD treatment had a co-occurring psychiatric disorder. • SAMHSA/ CSAT 1997-2002 study • 75-80 % of adolescents receiving inpatient substance abuse treatment have a coexisting mental disorder • NMHA, 2005

13. Co-Occurring and Juvenile Justice • Nearly two-thirds of incarcerated youth with SUD have at least one other mental health disorder. • As many as 50% of substance abusing juvenile offenders have ADHD. • Among incarcerated youth with SUD, nearly 33% have a mood or anxiety disorder. • Those exposed to high levels of traumatic violence might experience symptoms of posttraumatic stress as well as increased rates of substance abuse.

14. Traumatic Victimization • 40 – 90% have been victimized • 20-25% report in past 90 days, concerns about reoccurrence • Associated with higher rates of • substance use • HIV-risk behavior • Co-occurring disorders

15. Implications for Practice • Systematically screen • Train staff how to respond • Incorporate information into placement decisions • Addressing victimization is complex • Person may be victim and abuser • Track victimization in diagnosis and for program planning • Address staff concerns

16. Sources of Adolescent Referrals Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS)

17. Level of Care at Admission Source: Dennis, Dawud-Noursi, Muck & McDermeit, 2002 and 1998 Treatment Episode Data Set (TEDS)

18. Multiple Co-occurring Problems Are the Norm and Increase with Level of Care Source: CSAT’s Cannabis Youth Treatment (CYT), Adolescent Treatment Model (ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) studies

19. Module 2 Framework for Integrated Treatment

20. Goal • Compare traditional treatment models for co-occurring disorders with the more current integrated treatment model.

21. Objectives • Discuss the disadvantages of sequential and parallel models. • List the six guiding principles for integrated treatment. • Describe the critical components in the delivery of services. • List the 4 levels of program capacity • Discuss the components for fully integrated treatment.

22. Traditional Approaches • Sequential • One disorder then the other • Parallel • Treated simultaneously by different professionals

23. Integrated Treatment: Definition • Treatment interventions for COD are combined within the context of a primary treatment relationship or service setting. • Actively combining interventions intended to address substance abuse and mental disorders in order to treat both, related problems, and the whole person more effectively. SAMHSA, TIP 42

24. Six Guiding Principles for Integrated Treatment (samhsa, 2005) • Employ a recovery perspective • Adopt a multi-problem viewpoint • Develop a phased approach to treatment • Address specific real-life problems early in treatment • Plan for cognitive and functional impairments • Use support systems to maintain and extend treatment effectiveness

25. Provide access Complete a full assessment Provide appropriate level of care Achieve integrated treatment Treatment planning and review Psychopharmacotherapy Provide comprehensive services Supportive and Ancillary Wrap Services Ensure continuity of care Extended Care, Halfway Homes and other Residence Alternatives Delivery of Services(samhsa, TIP 42)

27. Beginning Addiction Only Intermediate COD capable Advanced COD Enhanced Achieving Integrated Treatment

28. Integrated Clinical Practice • Shared decision making • A focus on the person’s natural environment • Establishing a strong therapeutic relationship to engage and retain clients • Recognition that treatment involves a long-term process • A broad perspective in which life habits are modified

29. Intermediate:Co-Occurring Capable • Each program designs its policies, procedures, screening, assessment, program content, treatment planning, discharge planning, interagency relationships, and staff competencies to routinely provide integrated co-occurring disorder services to the individuals and families with co-occurring disorders who are routinely presenting for care in their program, within the context of the program’s mission, design, licensure, and resources. (Minkoff and Cline)

30. Fully Integrated TreatmentAdapted from Drake et al. 1998 • One program that provides treatment for both disorders. • Mental and substance use disorders are treated by the same clinicians. • The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders.

31. Fully Integrated - con’t • Supportive clinicians are readily available. • 12-Step groups are available to those who choose to participate and can benefit from participation. • Neuroleptics and other pharmacotherapies are indicated according to clients' psychiatric and other medical needs

32. Principles of Recovery • Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life (CSAT, 2007)

33. Module 3 Adolescent Development

34. Goal • To provide clinical information on this complex developmental period in order to gain essential understanding of the myriad of influences and issues that define the adolescent population.

35. Objectives • Describe “normal” and “maladaptive” adolescent development • Discuss developmental theories regarding separation/individuation and moral development • List major stages and tasks of adolescence • List key aspects of biopsychosocial issues and changes • Demonstrate increased empathic understanding of adolescents

36. GET OUT OF MY LIFE!!! …But first could you…. You call this NORMAL!

37. Adolescence: A “Normal” Developmental Perspective • Puberty and physiological change (Tanner) • Separation/individuation (Mahler, Blos) • Identity formation and autonomy (Erickson) • Cognitive development-Formal Operational Thinking (Piaget) • Moral development (Kohlberg, et. al.) • Transition and transformation-The Road to Adulthood

38. Hormonal & Growth Changes Acne Menstruation Breast Development Shape Changes Spontaneous Erection Nocturnal Emissions Voice Changes (cracking) Body Odor Rapid Growth Disproportionate Growth Emergence of sexual feelings Brain Maturation Physical Adolescent Development Changes (Early, Middle & Late)

39. Terminology and Descriptions Source: Prairierlands ATTC: A Provider’s Introduction to Substance Abuse for Lesbian, Gay, Bisexual and Transgender Individuals. (2007). Bisexual Transgender Questioning Queer Intersex • Sex • Gender/Gender Role • Sexual Orientation • Gender Identify • Lesbian • Gay

40. Special Issues For LGBTQ Youth • LGBTQ Youth of Color • Integrating their sexual, racial & ethnic identities • Interacting with three separate communities • Managing stigmatized identities • All LGBTQ Youth • Higher risk for depression, suicide, substance abuse • Homelessness • Risk for exploitation • Homeless youth - health and social risks Source: Prairierlands ATTC: A Provider’s Introduction to Substance Abuse for Lesbian, Gay, Bisexual and Transgender Individuals. (2007).

41. Welcoming LGBTQ Youth • Be open to listening • Maintain confidentiality of youth’s sexual orientation or gender • Be skillful in handling disclosure • Display culturally diverse posters, books, symbols, etc • Follow the youth’s lead • Encourage expression of feelings - Explore beliefs • Know the resources

42. Adolescent Brain Development • A period of profound brain maturation

43. A New Understanding • We thought brain development was complete by adolescence • We now know….maturation is not complete until about age 24!!! Source: Prairierlands ATTC: A Provider’s Introduction to Substance Abuse for Lesbian, Gay, Bisexual and Transgender Individuals. (2007).

44. Emerging Science • 1990s provided an information explosion due to brain imaging techniques that produced windows to observe brain development & effects of substance on the brain • In effect, the teen brain remains “under construction” longer than we had previously thoughts Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

45. Construction Ahead During late childhood, neurons increase their number of connections But some of these connections are pruned off starting at age 11 ½ for girls and age 12 for boys Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

46. Pruning Takes Brain Capacity When the pruning is complete, the brain is faster and more efficient. But…during the pruning process, the brain is not functioning at full capacity. Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

47. Pruning starts at the back of the brain…and moves to the front JUDGEMENT is the last to develop! Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

48. Age 24 Ahhh….Balance, Finally! Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

49. New Insights • Why teenagers take risks and show poor judgment • How teenagers may be highly vulnerable to drug abuse Source: Southern Coast ATTC: Co-Occurring Substance Use and Mental Health Disorders in Adolescents: Building a Foundation for Quality Care. (2009).

50. Cognitive (Thinking) Changes • Shift from “Concrete to Formal Operational” thinking capacity with the emergence of abstract and conceptual processes • Omnipotence & Omniscience (Terminal Uniqueness) • Meta-Cognition (the ability to think about one’s thinking) • Egocentricity (Early-Middles)