CoOccurring Disorders in Youth: What we know

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Co-Occurring Disorders in YouthWhat we know
How do we explore?

Presenters Win Turner, Ph.D. LADC Sharon Hunt
Ph.D. American Institutes for Research Jennifer
Frey Ph.D. Yale Program for Recovery and
Community Health
CSAT Adolescent Grant ConferenceBaltimore
Maryland, Tues 22nd, 2004
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Thank You !

• CSAT - Randy Muck, Jutta Butler
• CMHS - Diane Sondheimer, Rolando Santiago
• ORC Macro Wayne Holden, Renilo Laygo
• Chestnut Health Systems - Mike Dennis, Mark
  Godley, Susan Godley, Michelle White
• TA Partnership - Rachel Freed
• Researchers - Kimberly Hoagwood, Bruce Chorpita,
  Paula Riggs, Barbara Burns, Robert Drake
• Grantee Communities

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Co-occurring Workshop Agenda

• Epidemiology CSAT CMHS Data Set
• Describe - Who? What? Where?
• Directionality - When? How?
• Define and Grade the Knowledge Base
• Illustrate the Knowledge Base
• Illustrate Principles Practice Elements
• Discussion

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Past Problems with National Data System Dual
diagnosis is Under Reported

• Identification
• Funding
• Early Discharge Without Thorough Assessment

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CMHS National Evaluation Aggregate Data Profile
Report Grant Communities Funded from 1997 to
2000 (approximately 50 sites)
Prepared by the National Evaluation Team at
December 2003
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Demographic Characteristics and Custody Status of
Children Served
Because individuals may claim more than one
racial background, the race variable may add to
more than 100. Custody status refers to legal
status and may not reflect living arrangement.
For information on living arrangement see slide
entitled Living Arrangements at Intake.
Other includes siblings, aunts and/or uncles,
adult friend, and other caregivers.
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CYT
Cannabis Youth Treatment Experiment A
Collaborative Study of the Effectiveness of
Treatment for Cannabis Use Disorders
Sites Univ. Conn. Health Center, Farmington,
CT Operation PAR, St. Petersburg, FL Chestnut
Health Systems, Madison County, IL Childrens
Hospital of Phil., Philadelphia, PA
Coordinating Center Chestnut Health Systems,
Bloomington, IL, and Chicago, IL University
of Miami, Miami, FL University of Connecticut
Health Center, Farmington, CT
Sponsored by Center for Substance Abuse
Treatment (CSAT), Substance Abuse and Mental
Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services
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Treatment Series
CYT

• Motivational Enhancement Therapy/Cognitive
  Behavior Therapy (MET/CBT5)
• MET/CBT12 (uses Cognitive Behavior Therapy 7
  CBT7 manual)
• Family Support Network (FSN) uses MET/CBT5 and 7
  manuals PLUS FSN manual
• Adolescent Community Reinforcement Approach
  (ACRA)
• Multidimensional Family Therapy (MDFT)

Cannabis Youth Treatment Experiment
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Recent Adolescent Treatment Studies using the
same core GAIN measure

• Drug Outcome Monitoring Study (DOMS) across
  levels of care and age (adolescent, young adult,
  adult)
• 5 CSAT Cannabis Youth Treatment (CYT) grants
• 10 CSAT Adolescent Treatment Model (ATM) grantees
  
• 7 Persistent Effects of Treatment Study of
  Adolescents (PETS-A) subcontracts to follow
  adolescents out to 30 months.
• 12 CSAT Strengthening CommunitiesYouth (SCY)
  grants
• 11 RWJF Reclaiming Futures (diversion) grants
• 17 CSAT Adolescent Residential Treatment (ART)
  grants
• 2 NIAAA Assertive Aftercare Program (AAP)
  experiments
• Half dozen other evaluations of adolescent
  treatment, substance abuse prevention programs,
  or central intake using subsets of items
• Also used in over a dozen adult treatment
  studies, including CSATs co-occurring disorder
  grants and several NIAAA/NIDA grants.

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Assessment Tools That Can Be Used by Parents and
Professionals

• Child Behavior Checklist (CBCL) 2-3 4-18 years
• Devereux Early Childhood Assessment Program
• Infant-Toddler Social Emotional Assessment
• Vineland Social-Emotional Early Childhood Scales
• Global Assessment Scale for Children(GASC)
• Parents Evaluations of Developmental Status
  (PEDS)
• Substance abuse survey integrating measures from
  SOC CSAT
• DSM interview for childhood disorders

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Challenge Unmet Need for Mental Health
Services
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Change in Past Month Substance Use by Age
Source Dennis, M.L., (in press). Treatment
Research on Adolescents Drug and Alcohol Abuse
Despite Progress, Many Challenges Remain.
Connections and Data from the OAS 1999 National
Household Survey on Drug Abuse
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Most Common Presenting Problems

• Missed Opportunity
• Verbal/Physical Aggressiveness
• Academic Difficulties
• Impulsivity
• Hyperactivity
• Depressed Mood
• Poor Social Skills

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Sources of Adolescent Referrals (SOC)n 12,094.
age 12 years old
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Sources of Adolescent Referrals
Source Dennis et al., in press and OAS (2000)
1998 Treatment Episode Data Set (TEDS)
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Substance Use History at Intake by Age Category
Have you ever used
Substances
11 to 14 Years Old Number of children varied
from 2,440 to 2,452. 15 to 18 Years Old Number
of children varied from 1,571 to 1,575.
Substance use information was based on self
reports from youth 11 years or older.
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Consequences of Substance Use
Source Dennis, M.L., Godley, S.H., Titus,
J.C. (1999, Fall).
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Severity is Related to Other Problems
plt.05
Source Tims et al 2002
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Prevalence Chronicity

• Co-occurring mental disorders are common and
  serious, (prevalence rates 20 - 80 depending on
  sample pool.
• Research indicates the onset of the mental
  disorder often precedes the addictive disorder.
  (Temporal order)
• The likelihood of adolescent substance use and
  dependence is strongly associated with both
• younger age of onset
• severity of emotional and behavioral problems
• True across gender and race.

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Development of comorbidity with substance abuse

• Costello (1999) n1420
• Family drug problems were the strongest
  correlates of earlier onset of SUD
• Mean onset of abuse 14.8
• Mean onset of dependence 15.1
• Disruptive behavior disorders and MDD associated
  with earlier onset of use and higher rate of
  substance abuse for both genders
• Anxiety predicted later onset of smoking

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Comorbidity Status by Age Category
(n 315)
(n 2,439)
(n 5,324)
(n 1,966)
Age Category
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DT one possible pathway to co-occurring (self,
family peers)

• Difficult To Soothe Temperament possible
  precursor to externalizing disorders. Predisposes
  a child to both a coercive parenting relationship
  and insecure attachments to parents.
• Temperament characteristics, particularly
  sensation seeking and difficult to soothe, as
  they are expressed in childhood, play an
  instrumental role in the development of
  alcoholism and related substance use disorders.
• DT toddlers more likely to experience
  abuse/neglect, family problems, develop a
  psychiatric disorder during early childhood LD,
  ADHD, ODD, CD.

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Internalizing Externalizing ()

• Internalizing-anxiety, fear, shyness, low self
  esteem, sadness and depression (30)
• Externalizing noncompliance, aggression,
  attention problems, destructiveness, impulsivity,
  hyperactivity, and antisocial behavior. (60)
• Victimization (60-80)

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Meta Analysis of 2968 Adolescents and Adults from
61 programs validates the following structure of
the Psychopathology
Source Dennis, Lennox, Funk McDermeit, under
review
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Most Frequent Diagnoses

• Oppositional Defiant/Conduct Disorders
• Attention Deficit/Hyperactivity Disorder
• Depression
• Anxiety
• Traumatic Stress
• Substance Disorder

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Markers for Risk ! (Glantz, 2002)

• Certain Psychopathologies seem to be
  significantly associated with SUD and frequently
  precede SUD
• Conduct disorder and oppositional defiance
  disorder frequently precede SUD
• ADHD combined with CD precedes SUD but ADHD alone
  is still questioned for temporal order
• Depression and bipolar disorders less clear
• Anxiety depends on subtype of the disorder
• PTSD most often precedes SUD
• Only personality disorders borderline and
  antisocial

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Multiple Co-occurring Problems By Gender
Source CSATs Cannabis Youth Treatment (CYT),
Adolescent Treatment Model (ATM), and Persistent
Effects of Treatment Study of Adolescents
(PETS-A) studies
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More risk More care

• Prognosis is worse for dd youth for many
  reasons less motivation, increased academic,
  family, and behavior problems, limited coping and
  social skills.
• Lag in important adolescent development tasks
  individuation, moral development and
  conceptualization of future family, vocational
  and educational goals.

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Supports for integration

• Unrecognized mental health disorders reduce
  engagement, retention and completion
• Untreated co-morbid disorders persist after
  recovery ADHD, Mood Disorders
• After recovery form SUD, depression in youth is
  much more likely to persist compared to adults.
• Recent controlled trials indicate that tx of
  comorbid disorders alone is not likely to
  significantly reduce substance use or induce
  abstinence in dd adolescents.

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Juvenile Delinquency at Intake, 6 Months, and 12
Months by Comorbidity Status
On Probation
No Comorbidity Sample n 574. Comorbidity w/o
Substance Use Sample n 663. Comorbidity w/
Substance Use Sample n 87.
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What is evidence based?

• American Psychological Association-Task Force on
  Psychological Intervention Guidelines and Div 12
  Task Force on Promotion and Dissemination of
  Psychological Procedures (Chambliss et al. 1996)
• Developed a template for evaluating the degree of
  internal and external validity of outcome studies
• Concluded the strongest designs were group
  designs involving active control groups (best
  rule out alternative explanation of effects) and
  random assignment to conditions.
• The randomized clinical trial was thus considered
  to be a gold standard for psychotherapy
  research.

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Other Definitions of EBT or EBP

• APA Clinical Child and Adolescent Division (1998)
  also defined Well Established, Probably
  Efficacious
• Stage model for Behavioral Therapy Research
• (Onken et al. 1997) 1) Tx Dev 2) RCT 3) Settings
• SAMHSA Model Programs - Promising, Effective and
  Model
• Hoagwood Strong, Moderate, Mixed
• Chorpita Best, Good, Some, None, Known Risk
• Evidence Based Practice Best Practice

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Child and Adolescent Division

• Well established
• At least two well-conducted group-design studies
• Or a large series of single case design
  experiments
• Conducted by at least two investigators
• Probably Efficacious
• An intervention tested by a single investigator

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Additional Criteria

• treatment manual
• sample characteristics must be clearly specified
• evidence of uniform training and adherence
  procedures maintained
• clinical samples of youth are appropriate
  candidates tests of clinical significance of
  outcomes
• inclusion of functioning outcomes in addition to
  symptoms
• assessment of long-term outcomes well beyond
  treatment termination

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SAMHSA defines evidence-based prevention programs
in one of three categories

• Promising Programs
• Effective Programs
• Model Programs
• Programs are scored by teams of researchers on 15
  criteria of scientific soundness. A few include
  Theory, Fidelity, Evaluation, Outcome,
  Replications, Culture/Age Appropriate etc.
• Scored on all variables with a caveat
  Integrity and Utility
• National Registry of Effective Prevention
  Programs (NREPP)

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Promising Programs

• Implemented and evaluated sufficiently and are
  considered to be scientifically defensible.
• Promising Programs must score at least 3.33 on
  the 5-point scale on parameters of Integrity and
  Utility.

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Effective Programs

• Well-implemented, well-evaluated programs that
  produce a consistent positive pattern of results
  (across domains and/or replications).
• These programs must score at least 4.0 on a
  5-point scale on Integrity and Utility.

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Model Programs

• Well-implemented, well-evaluated programs,
  meaning they have been reviewed by the National
  Registry of Effective Programs (NREP) according
  to rigorous standards of research.
• Developers, whose programs have the capacity to
  become Model Programs, have coordinated and
  agreed with SAMHSA to provide quality materials,
  training, and technical assistance for nationwide
  implementation.
• Model Programs score at least 4.0 on a 5-point
  scale on Integrity and Utility.

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Model Programs affect both SA MH

• Brief Strategic Family Therapy (BSFT) also Family
  Effectiveness Training (FET)
• Jose Szapocznik, Ph.D.
• 42 improvement in acting out behavior problems
• 75 in marijuana use
• 58 reduction in association with antisocial
  peers
• retained over 75 of youth in program

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Multisystemic Therapy (MST)

• Henggeler (1991)
• Decreased adolescent substance use, decreased
  adolescent psychiatric symptoms, reduced long
  term re-arrest rates (25-75), reduced long term
  out of home placement (47-64), improved family
  relations and functioning, increased mainstream
  school attendance, cost savings.

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Kimberly Hoagwoods, 2003 Menu

• Developed from multitude of literature reviews
  and research on child psychopathology.
• Not co-occurring focused but contains the
  treatment evidence grade for specific disorders.
• Recommends a modular approach to co-occurring
  treatment intervention ..can be used to extract
  modules.
• To deliver the protocol must refer to manual

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Prevalence of Common Co-morbid Disorders and
Impact of Treatment on Adolescents with a
Substance Abuse DisorderRiggs, 2003
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Prevalence of Common Co-morbid Disorders and
Impact of Treatment on Adolescents with a
Substance Abuse DisorderRiggs, 2003
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Prevalence of Common Co-morbid Disorders and
Impact of Treatment on Adolescents with a
Substance Abuse DisorderRiggs, 2003
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Prevalence of Common Co-morbid Disorders and
Impact of Treatment on Adolescents with a
Substance Abuse DisorderRiggs, 2003
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Prevalence of Common Co-morbid Disorders and
Impact of Treatment on Adolescents with a
Substance Abuse DisorderRiggs, 2003
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DD Treatment Research (Drake, 2003)

• After twenty years of development and research,
  dd services for adult clients with severe
  mental illness are emerging as an evidence based
  practice.
• Comprehensive long-term staged approach to
  recovery
• Assertive outreach
• Motivational interventions
• Skill Training Support to meet Functional Goals
• Cultural Sensitivity and Competence

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Approach for adapting manuals for youth treatment
(Hoagwood Burns, 2003)

• Define
• Core and optional skill training sessions
• Guidelines for choosing optional modules
• Optional modules that allow therapists to address
  the needs of the adolescent and family
• Model of parent/family involvement
• Confidentiality parameters that need to be
  addressed

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Integrated Treatment for SUD/PTSD

• Phased approach treatment in stages
• Same clinician or clinical team provides
  treatment for both disorders at the same time
• Two manualized programs Substance Dependence
  Posttraumatic Stress Disorder Therapy Seeking
  Safety
• Development of positive coping skills and
  improved functioning
• Increase in sense of control and influence of
  substance use on trauma symptoms

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Modifications for Youth SUD/PTSD (Burns
Hoagwood, 2003)

• Extensive involvement of parents or guardians
• Provision of services in age-specific settings
• Greater emphasis on peer, family and school
  outcomes
• Modification of stage-wise timing, CBT
  strategies, exposure therapy, and skill building
  to facilitate development
• Measures of global assessment of functioning
  (GAF) must be age specific including family,
  peer, academic relations
• Additional disorders need attention

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Riggs, 2003 Exemplary Program Components

• Comprehensive, systematic evaluation to identify
  problems and treatment needs in multiple domains,
  including psychiatric co-morbidity
• Use of empathic, supportive, motivation-enhancing
  techniques to improve alliance, engagement, and
  retention
• Use of behavioral techniques informed by urine
  toxicology results to promote and shape desired,
  pro-social behaviors and discontinuation of drug
  use and other problem behaviors

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Exemplary Program Components

• Use of cognitive-behavioral and skills-building
  techniques delivered in an individual or group
  format to enhance adolescents self-efficacy,
  problem solving, decision-making, communication,
  anger management, mood regulation, coping, and
  relapse prevention skills. These techniques are
  often used to help adolescents anticipate and
  avoid high-risk situations and identify triggers
  for drug use, decrease association with
  drug-using peers, and encourage involvement in
  enjoyable, pro-social activities incompatible
  with drug use

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Exemplary Program Components

• Involvement of the family in an adolescents
  treatment, emphasizing enhancement of parental
  monitoring and behavioral management skills and
  use of restructuring interventions to correct
  dysfunctional patterns of interaction,
  relationships and behaviors to improve overall
  family functioning
• Emphasis on relapse prevention and the need for
  continuing care, including development of
  specific plans to manage relapse
• Focus on adequate training and ongoing staff
  development activities for counselors and program
  specialists

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Exemplary Program Components

• Emphasis on providing developmentally appropriate
  interventions, often including specialized
  program components such as gender-specific or
  culture-specific programming
• Focus on evaluating treatment outcomes
• Emphasis on the importance of integrating the
  assessment and treatment of co-morbid psychiatric
  disorders with substance abuse treatment.