Drug and Alcohol Services for Adolescents

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

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

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

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)

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

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

Adolescent Substance Abuse Treatment Self Family Education

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

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

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

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)

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

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

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

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

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

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?

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.

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

Family & Outpatient Services

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

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

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

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.

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

DSM–IV Disorders

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

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

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

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

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

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

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

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Drug and Alcohol Services for Adolescents