Thursday June 26, 2008  11:00 AM – 12:30 PM Dial-in Number: (866) 633-8010

1. Co-Occurring Disorders, Best Practices and Adolescents Webcast Thursday June 26, 2008  11:00 AM – 12:30 PM Dial-in Number: (866) 633-8010 Conference Code: 4449499285 For technical assistance please contact Maria Lovato, MBA at mlovato@cimh.org or (916) 379-5351.

2. Co-Occurring Disorders, Best Practice and Adolescents • Please if you have any questions regarding this webcast please email mlovato@cimh.org or you can call 916-379-5351 • 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 email Maria Lovato at mlovato@cimh.org with all your questions.

3. Co-Occurring DisordersBest Practices and Adolescent Mary Jane Alumbaugh, Ph.D “Double Trouble - Early”

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

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 co-occurring 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 IssuesCulture 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 hope-decreasing negativity Change – Practical, logical, research support, Generalization – Family empowerment, linkage, relapse prevention Flexible Delivery – Home, Office, School, Community-based. Individualized – Tailored - Flexible 20-25 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 24-30 Sessions Jose Szapocznik PhD - Spanish Family Guidance Center, Center for Family Studies, University of Miami

40. Family therapyFamily 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 E-mail: bradley.donohue@unlv.edu

45. Family TherapyFunctional Family Therapy (FFT) Targets Youth 11-18 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 12-15 families at one time Site certification and training James Alexander PhD – University of Utah

49. Family TherapyIntegrated 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 TreatmentICT • 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