Course Outline

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 • Current Best Practices • Adolescent Developmental Issues • Conducting Integrated, Comprehensive Assessment • Substance Use Disorder and its relationship to co-occurring disorders • Mental Health Disorders and their relationship to co-occurring disorders

3. Course Outline continued • Evidence-Based Strategies • Alternative Therapeutic 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, continued • 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 (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 • Treatment modifications can enhance effectiveness

10. Evolving Field of Co-occurring Disorders (TIP 42) cont. • Co-occurring - Replaces dual diagnosis • Bi-Directional - ASAM - AACP • New Models and Strategies

11. Adolescents with SUD... • 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 • 43% of adolescents receiving mental health services had been diagnosed with a co-occurring SUD. - CMHS (2001) national health services study • 13% of adolescents with significant emotional and behavior problems reported alcohol and drug dependence. - SAMHSA 1994-96 National Household Survey • 62% of adolescent males and 82% of adolescent females entering SUD treatment had a significant co-occurring emotional/psychiatric disorder. - SAMHSA/ CSAT 1997-2002 study • 75-80% of adolescents receiving inpatient substance abuse treatment have a co-existing mental disorder

13. Co-occurring Disorders and Juvenile Justice • Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder. • As many as 50% of substance abusing juvenile offenders have ADHD. • Among incarcerated youth with substance use disorders, nearly one third 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 behaviors - 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-Nourski, Muck & McDermeit, 2002 and 1995 Treatment Episode Data Set (TEDS)

17. Level of Care at Admission Source: Dennis, Dawud-Nourski, Muck & McDermeit, 2002 and 1995 Treatment Episode Data Set (TEDS)

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

19. Module 2 Best Practice Model to Provide Treatment for Co-occurring Disorders

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 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.

24. Six Guiding Principles (SAMHSA, TIP 42)) • 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. Delivery of Services • Provide access • Complete a full assessment • Provide appropriate level of care • Achieve integrated treatment - Treatment Planning and Review - Psychopharmacology • Provide comprehensive services - Supportive and Ancillary Wrap Services • Ensure continuity of care - Extended Care, Halfway Homes and other Residence Alternatives

26. Achieving Integrated Treatment • Beginning: Addiction only • Intermediate: COD capable • Advanced: COD enhanced • Fully Integrated

27. Vision of Fully Integrated Treatment • 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.

28. Vision of Fully Integrated Treatment (continued) • The focus is on preventing anxiety rather than breaking through denial. • Emphasis is placed on trust, understanding, and learning. • Treatment is characterized by a slow pace and a long-term perspective. • Providers offer stagewise and motivational counseling.

29. Vision of Fully Integrated Treatment (continued) • 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.

30. MODULE 3: ADOLESCENT DEVELOPMENT

31. Goal: To provide critical information regarding this complex developmental period in order to gain essential understanding of the myriad influences and issues that define the adolescent population.

32. 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

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

34. 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) • Shift from Parental / Family authority to Peer Group authority • Moral Development (Kohlberg, Kagan, Bandura, Gilligan) • Transition and Transformation - The road to Adulthood

35. Physical Adolescent Developmental Changes (Early, Middle & Late) • 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 and drives • Brain maturation

36. 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 ones thinking) • Egocentricity (Early-Middles)

37. Social Changes • Family authority versus Peer Authority • Onset of parent / child conflict (Ex. Backtalk) • Challenges to parental knowledge and rules • Comparisons to “Everyone else’s Parents” • Increased Demands for the “right” fashion trend(s) • Apparent disregard for once held family values/priorities in favor of peer values and priorities

38. Characteristic Behaviors and Attitudes • Role Experimentation • Practicing • Questioning & Challenging • Peer bonding • Here & Now focus • Sense of Invulnerability

39. Challenges to “Normal” Adolescent Development • Genetic Vulnerabilities / Predispositions / Risk Factors - Family History of: • Substance Use Disorders • Psychiatric / Psychological Disorders • Learning and/or Attentional Disorders • Other Cognitive/Developmental Disorders

40. Challenges - continued • Environmental Vulnerabilities / Risk Factors • Parent / Family / Caretaker Dysfunction • Inconsistency / Instability • Lack of Clear Values, Expectations and Boundaries • Absence / Uninvolved • Over Involvement / Over Indulgent • Frequent Relocation

41. Challenges - continued • Environmental Vulnerabilities / Risk Factors - Trauma • Abuse / Neglect / Sexual Abuse /Incest • Sexual Assault / Date Rape • Loss - Medical Illness - Active Addiction / Psychiatric Disturbance - Poverty / Wealth - Single Parent Homes

42. Mental Health and Substance Abuse Affect Maturation • Low frustration tolerance • Lying to avoid punishment • Hostile dependency • Limit testing • Persists into later adolescence

43. Maturation - continued • Alexithymia - Unable to verbalize/soothe self • Present tense only - Past-future tense diminished • Rejection sensitivity - Dualistic - Categorical - Right-wrong

44. Summary of Adolescent Development • Adolescence is a profound period of developmental transformation • Adolescence is defined by fundamental Biopsychosocial state changes • Successful navigation toward young adulthood requires sufficient accomplishment of a number of specific developmental tasks associated with the fundamental changes • Each adolescent represents a unique combination of Biopsychosocial competencies, resiliencies, vulnerabilities and challenges

45. Summary - continued The potential to meet, negotiate, work through, adapt and emerge successfully is greatly influenced by presence or absence of: - Strong family ties/support - Education - Formal and Informal - Clear and consistent values - Moral development - extending the capacity for ethically directed choices and behavior - Spiritual centeredness as it is individually conceptualized and understood Adolescents struggling with Co-Occurring Disorders issues face a significantly more difficult set of issues and challenges in meeting the necessary developmental tasks

46. Module 4: Substance Abuse

47. Goal: Provide an overview of salient factors involved in diagnosing adolescent substance use disorders.

48. Objectives • Describe 5 risk factor categories that put adolescents at increased risk for substance use. • Discuss the importance of applying adolescent specific criteria to a substance use diagnosis. • List the DSM IV diagnostic criteria

49. Assumptions (Estroff M.D., 2001) • Substance abuse disorders represent primary disease processes. • The onset of each adolescent substance abuse disorder can precede, coincide with, or follow the development of other physical and psychiatric disorders • Alcohol and drug abuse can mimic and interact with all mental illnesses. • These substance abuse disorders disrupt normal adolescent development.

50. Neurological Effects of Substance Use • Chemical changes in neurotransmitters • Physical effects • Affective responses