Co-occurring Substance Use and Mental Disorders in Adolescents:Integrating Approaches for Assessment and Treatment of the Individual Young Person
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
Course Outline continued • Evidence-Based Strategies • Alternative Therapeutic Strategies • Cross-System Collaboration
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.
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.
Module 1 Brief Overview of Co-occurring Disorders and Adolescents
Goal: Provide information to support growing understanding about the nature of co-occurring disorders.
Objectives: • Discuss the association between substance abuse and psychiatric illness • Describe general statistics and trends among the adolescent population
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
Evolving Field of Co-occurring Disorders (TIP 42) cont. • Co-occurring - Replaces dual diagnosis • Bi-Directional - ASAM - AACP • New Models and Strategies
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;
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
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.
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
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
Sources of Adolescent Referrals Source: Dennis, Dawud-Nourski, Muck & McDermeit, 2002 and 1995 Treatment Episode Data Set (TEDS)
Level of Care at Admission Source: Dennis, Dawud-Nourski, Muck & McDermeit, 2002 and 1995 Treatment Episode Data Set (TEDS)
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
Module 2 Best Practice Model to Provide Treatment for Co-occurring Disorders
Goal: Compare traditional treatment models for co-occurring disorders with the more current integrated treatment model.
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.
Traditional Approaches • Sequential - One disorder then the other • Parallel - Treated simultaneously by different professionals
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.
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
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
Achieving Integrated Treatment • Beginning: Addiction only • Intermediate: COD capable • Advanced: COD enhanced • Fully Integrated
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.
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.
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.
MODULE 3: ADOLESCENT DEVELOPMENT
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.
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
GET OUT OF MY LIFE!!!... But first could you... You call this NORMAL!
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
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
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)
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
Characteristic Behaviors and Attitudes • Role Experimentation • Practicing • Questioning & Challenging • Peer bonding • Here & Now focus • Sense of Invulnerability
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
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
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
Mental Health and Substance Abuse Affect Maturation • Low frustration tolerance • Lying to avoid punishment • Hostile dependency • Limit testing • Persists into later adolescence
Maturation - continued • Alexithymia - Unable to verbalize/soothe self • Present tense only - Past-future tense diminished • Rejection sensitivity - Dualistic - Categorical - Right-wrong
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
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
Module 4: Substance Abuse
Goal: Provide an overview of salient factors involved in diagnosing adolescent substance use disorders.
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
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.
Neurological Effects of Substance Use • Chemical changes in neurotransmitters • Physical effects • Affective responses